Femoral shortening in correction of congenital knee flexion deformity with popliteal webbing

Severe knee flexion deformity with popliteal webbing or pterygium is considered to be uncorrectable. The soft tissues and, in particular, the main nerves and vessels are short relative to the bone. Femoral shortening was used in correction of such a deformity in a child with arthrogryposis. The operative procedure is described. Femoral shortening should be considered as an aid to correction of any severe knee flexion deformity.     

The current role of structural grafts and cages in revision arthroplasty of the hip

Treating large segmental acetabular defects that comprise more than 50% of the acetabulum is one of the most difficult challenges in revision arthroplasty of the hip. One of the surgical options is a structural acetabular allograft. Unless these allografts are protected by a cage that extends from ilium to ischium, there is an unacceptable incidence of graft failure. The cage allows reconstruction at the correct anatomic level. It provides a scaffold for bone grafting (structural and morsellized). The use of cement to stabilize the cup allows the surgeon to adjust the cup position independent of the cage. The current generation of cages does not provide biologic fixation and with time may loosen or fracture. Recent experience with a combination of a trabecular metal shell protected by a cage may offer a more favorable environment for bone grafting with permanent biologic fixation of the cup cage construct.     

The use of allograft as a bone graft substitute in patients with congenital spine deformities

The purpose of this study was to determine the safety and efficacy of using allograft bone as a substitute for iliac crest bone graft when treating pediatric patients with congenital spine deformities. We performed a retrospective review of 107 pediatric patients who underwent instrumentation and arthrodesis using allograft for congenital spine deformity between 1995 and 2002. Pseudoarthrosis was defined as implant failure, a clear radiographic pseudoarthrosis, or any loss of correction more than 10 degrees from the immediate postoperative radiographs to the final follow-up radiographs. The pseudoarthrosis rate in this series was 2.8%, and the infection rate was 0.9%. We conclude that freeze-dried corticocancellous allograft is a safe and effective alternative to iliac crest bone graft in this patient population.     

Treatment of Spinal Tuberculosis by Debridement,Interbody Fusion and Internal Fixation via Posterior Approach Only

Surgical treatment for spinal tuberculosis includes focal tuberculosis debridement, segmental stability reconstruction, neural decompression and kyphotic deformity correction. For the lesions mainly involved anterior and middle column of the spine, anterior operation of debridement and fusion with internal fixation has been becoming the most frequently used surgical technique for the spinal tuberculosis. However, high risk of structural damage might relate with anterior surgery, such as damage in lungs, heart, kidney, ureter and bowel, and the deformity correction is also limited. Due to the organs are in the front of spine, there are less complications in posterior approach. Spinal pedicle screw passes through the spinal three‐column structure, which provides more powerful orthopedic forces compared with the vertebral body screw, and the kyphotic deformity correction effect is better in posterior approach. In this paper, we report a 68‐year‐old male patient with thoracic tuberculosis who underwent surgical treatment by debridement, interbody fusion and internal fixation via posterior approach only. The patient was placed in prone position under general anesthesia. Posterior midline incision was performed, and the posterior spinal construction was exposed. Then place pedicle screw, and fix one side rod temporarily. Make the side of more bone destruction and larger abscess as lesion debridement side. Resect the unilateral facet joint, and retain contralateral structure integrity. Protect the spinal cord, nerve root. Clear sequestrum, necrotic tissue, abscess of paravertebral and intervertebral space. Specially designed titanium mesh cages or bone blocks were implanted into interbody. Fix both side rods and compress both sides to make the mesh cages and bone blocks tight. Reconstruct posterior column structure with allogeneic bone and autologous bone. Using this technique, the procedures of debridement, spinal cord decompression, deformity correction, bone grafting, and internal fixation can be completed with only one incision and surgical position, and the deformity correction efficiency is higher than anterior surgery.     

Radiographic assessment of anterior titanium mesh cages

Carbon fiber and titanium cage implantation for anterior column support during spinal fusions is an alternative to the use of more traditional structural allografts and autografts. The authors report instrumentation and cage failure for patients who underwent spinal fusion with structural titanium mesh cages implanted into the anterior column a minimum of 2 years after surgery. They wanted to determine whether plain radiographic techniques can be used to critically assess disk space and corpectomy fusions after implantation of these radioopaque cages. Fifty patients having undergone spinal fusions using structural titanium mesh cages in the anterior column had 99 anterior levels fused with at least 1 (maximum of 2) titanium mesh cage, resulting in a total of 131 cages used. The cages were examined for evidence of settling, migration, or failure. The anterior and posterior instrumentation was assessed for evidence of failure, and the spine was examined for evidence of successful fusion. Radiographic cage settling (>2 mm) into the vertebral body end plates was observed, but cage migration or failure were not. An average lordotic correction of 10 degrees was observed, with loss of correction into kyphosis from immediately after operation to final follow-up averaging 2 degrees. As an average of all reviewers, using a strict radiographic fusion assessment, definite or probable anterior fusion was graded at 81% of the levels, probably not or no at 5% of the levels, and could not be assessed at 14% of the levels. Definite or probable posterior fusion as an average of all reviewers was graded at 44% of the posterior fusion levels, questionable at 4%, no at 5%, and could not be assessed at 47%. The use of anterior-only, posterior-only, or anterior and posterior instrumentation with structural titanium mesh cages in the anterior spine along with proper autogenous bone grafting techniques provided anterior column support with a low rate of radiographic complications. Acceptable anterior spinal fusion rates, as assessed by a consensus agreement of reviewers, were observed primarily by evaluation of the fusion mass around the cages (extracage fusion), because intracage fusion was difficult to assess.     

Radiological analysis of titanium mesh cages used after corpectomy in the thoracic and lumbar spine: minimum 3 years' follow-up

This study analyses radiological outcome of titanium mesh cages used for anterior column support following corpectomy in the thoracic and lumbar spine in 34 patients with a minimum three-year follow-up. The aim of the study was to assess the complications and radiological outcomes of patients with structural cages implanted into the anterior column. Titanium mesh cages for the anterior column became popular for anterior column reconstruction following discectomy and corpectomy. Few clinical studies are published assessing their efficacy as a structural graft after corpectomy and factors for the development of settling and correction loss are not investigated enough. Thirty-four patients with minimum 3-year follow-up were analysed radiologically for correction achievement, cage settling and fusion inside the mesh cage. The effect of fixation technique, anatomical localisation and diagnosis for the development of settling were analysed. Measurements of preoperative and early postoperative local kyphotic angle revealed that a mean correction of 27 degrees (range: 8 to 60) was obtained. While no dislodgement or fracture of titanium mesh cages was observed, there was a mean correction loss of 4 degrees and settling (> 2 mm) was noted in 6 patients. Short posterior and only anterior instrumentation systems were associated with settling. The anatomical location and diagnosis did not affect the development of cage settling. Following corpectomy and mesh cage implantation, isolated anterior fixation or short posterior fixation do not provide enough stability, and correction loss and settling can occur.     

Vertebral body resection and lumbar corpectomies

Corpectomies in the lumbar spine are unique operations with important and well-deserving nuances that determine their ultimate safety and efficacy. Lumbar vertebral resections are indicated in deformity and non-deformity settings. For deformities, they are reserved for those that are severe and rigid. Infections, fractures, and tumors that compromise the weight-bearing capacity of the anterior and middle columns of the spine are also indicated for lumbar vertebrectomy. Anterior column structural support is required in non-deformity situations and may be accomplished with the use of polymethyl methacrylate (PMMA) cement, osseous strut grafts (i.e. allografts/autograft), or titanium cages (static vs. expandable). The newest generation of cages have wide, rectangular footprints that span the apophyseal ring and provide a sound biomechanical environment and minimize the risk of cage subsidence compared to those with circular footprints. Neural decompression and placement of structural support can be accomplished by a variety of surgical approaches. While a traditional anterior approach is the gold-standard for lumbar vertebrectomies, minimally invasive lateral approaches and a posterior-only approach are viable management strategies. Supplemental fixation is also required and may be achieved with anterior-only instrumentation, posterior-only instrumentation, and circumferential instrumentation. In the review to follow, an evidence-based approach will be used to outline appropriate indications, surgical technique, and concomitant reconstructive and stabilization options for lumbar corpectomies. The discussion to follow ideally will help optimize outcomes for patients treated with vertebral resection and lumbar corpectomies in the lumbar spine.     

Use of structural allografts in acetabular revision surgery

Bone loss is a challenging problem with complex acetabular revisions. With an adequate biologic and mechanical environment, uncemented hemispheric component reconstructions have provided long-term durable results for acetabular revisions. Decisions about reconstructive options can be made with the aid of a classification system that addresses the location and severity of bone loss as it relates to achieving the prerequisites for biologic fixation with a hemispheric component. Structural allograft may be used to provide a mechanical environment that supports host bone ingrowth into an acetabular component. Alternatively, structural allograft may allow restoration of joint mechanics in situations where host bone loss precluded biologic fixation. We describe the indications and technique for the use of structural allograft in revision acetabular surgery.     

Mesh cages for spinal deformity in adults.

Correction of deformity including restoration of sagittal plane malalignment in patients with spinal disorders is facilitated by placement of structural allografts and cages into the anterior column. The effectiveness of these implants will be reviewed with a focus on anterior column implantation of titanium mesh cages. In a consecutive study of adult patients who had spinal fusions for sagittal plane deformities using structural titanium mesh cages, cage status, fusion status, and outcome were assessed. Followup ranged from 24 to 62 months (average, 33 months). No cage failure of extrusion was observed. The average segmental improvement in lordosis with cage implantation was 11 degrees with a loss of correction of less than 1 degree at latest followup. No radiographic gold standard for fusion assessment with metallic implants in the anterior column could be found in the literature. The use of radiographic techniques for fusion assessment and functional outcome data for patients with implanted titanium mesh cages will be discussed.     

Use of the Ilizarov method to correct lower limb deformities in children and adolescents

The introduction to the West in the early 1980s of the Ilizarov circular external fixator and method resulted in rapid advances in limb lengthening, deformity correction, and segmental long-bone defect reconstruction. The mechanical features of and biologic response to using distraction osteogenesis with the circular external fixator are the unique aspects of Ilizarov's contribution. The most common indications for children and adolescents are limb lengthening and angular deformity correction. Surgical application and postoperative management of the device require diligent attention to detail by both patient and surgeon. Also required of the surgeon is a thorough appreciation of the basic principles of the apparatus, mechanical axial realignment, potential complications, and biologic response to stretching.     

Single-stage Anterior and Posterior Fusion Surgery for Correction of Cervical Kyphotic Deformity Using Intervertebral Cages and Cervical Lateral Mass Screws: Postoperative Changes in Total Spine Sagittal Alignment in Three Cases with a Minimum Follow-up of Five Years

The surgical treatment of cervical kyphotic deformity remains challenging. As a surgical method that is safer and avoids major complications, the authors present a procedure of single-stage anterior and posterior fusion to correct cervical kyphosis using anterior interbody fusion cages without plating, as illustrated by three consecutive cases. Case 1 was a 78-year-old woman who presented with a dropped head caused by degeneration of her cervical spine. Case 2 was a 54-year-old woman with athetoid cerebral palsy. She presented with cervical myelopathy and cervical kyphosis. Case 3 was a 71-year-old woman with cervical kyphotic deformity following a laminectomy. All three patients underwent anterior release and interbody fusion with cages and posterior fusion with cervical lateral mass screw (LMS) fixation. Postoperative radiographs showed that correction of kyphosis was 39° in case 1, 43° in case 2, and 39° in case 3. In all three cases, improvement of symptoms was established without major perioperative complications, solid fusion was achieved, and no loss of correction was observed at a minimum follow-up of 61 months. We also report that preoperative total spine sagittal malalignment was improved after corrective surgery for cervical kyphosis and was maintained at the latest follow-up in all three cases. The combination of anterior fusion cages and LMS is considered a safe and effective procedure in cases of severe cervical kyphotic deformity. Preoperative total spine sagittal malalignment improved, accompanied by correction of cervical kyphosis, and was maintained at last follow-up in all three cases.     

Relapsed clubfoot correction with soft-tissue release and selective application of Ilizarov technique

The Ilizarov technique is an alternative for the treatment of complex foot deformities in children. The authors retrospectively reviewed children with relapsed clubfoot deformity, treated with soft tissue procedures and additional correction with an Ilizarov frame. Twelve consecutive patients (13 feet) with relapsed clubfoot deformity after previous surgical correction were reviewed. Treatment included open releases. An Ilizarov frame was applied as an adjunct in seven patients (mean age of 7.8 years) with severe deformity where complete intraoperative correction was not achieved. Clinical and radiographic assessment was undertaken. The mean Laaveg–Ponseti score, for the 7 feet treated with the Ilizarov frame, was 85.1 after minimum 4 years follow-up. One recurrence of forefoot deformity required metatarsal osteotomies. Postoperative radiographic measurements revealed values that can be considered as normal. Complications included pin tract infections (12% of inserted wires). Flat-topped talus was observed in 3 feet. Deformity correction was possible when soft tissue procedures were combined with the use of Ilizarov technique, in order to support and gradually improve surgical correction.     

The totem pole rib graft reconstruction of the nose

The totem pole rib bone graft for nasal reconstruction is presented as an effective way to prepare the donor bone for the correction of saddle-nose deformity. The article's title emanates from the fact that when the sculpturing of the rib is completed it has the appearance of a totem pole before the separate parts are disarticulated for insertion into the nose. The use of this technique permits an accurate, detailed sculpturing of the component parts of the subsequent reconstruction, permitting correction of each feature of the saddle-nose deformity. If these bony segments were dissected or sculptured separately, the smallness of each part would make it very difficult to carve the precise definition needed for a reconstruction that would give structural support and at the same time afford an aesthetically pleasing result. The rationale of the technique and representative cases are presented.     

The treatment of the hip cotructure with intertrochanteric osteotomy of the femur in children with Arthrogryposis multiplex congenita]

BACKGROUND: The flexion contractures of the hips affect mobility in patients with Arthrogryposis Multiplex Congenita (AMC). There are only a few reports concerning correction of those deformities with femoral intertrochanteric osteotomy. AIM: The results' analysis of fixed hip flexion deformity correction with femoral intertrochanteric osteotomy in AMC patients. MATERIAL: 16 femoral intertrochanteric osteotomies were performed for hip contracture between 1992 and 2002 in 7 AMC patients. Mean follow up period was 6.5 years postoperatively. The hip contractures between 20 and 110 degrees making mobility impossible or difficult fulfilled the criteria for surgery. In 7 cases knee flexion deformity correction was performed simultaneously with the hip procedure. At the final check up, the hip ROM, the rate of deformity recurrence and patients' mobility were assessed. RESULTS: The mobility was affected in all children preoperatively. The range of deformity correction during the procedure was average 53 degrees. In 10 cases the improvement of mobility status was estimated postoperatively. The deformity recurrence occurred in 13 cases, in 4 of them required procedure to be repeated. The age in the recurrence group was lower and the contractures measured preoperatively more severe in comparison to the non recurrence group. CONCLUSIONS: Femoral intertrochanteric osteotomy tends to be efficient method of treatment of hip flexion contracture in children with AMC. Deformity correction has been achieved in all patients. The mobility status improvement is noted in majority of the patients, despite high rate of deformity recurrence postoperatively.     

Tuberculosis of the cervicodorsal junction

Sixteen patients had paraplegia due to tuberculosis of the cervicodorsal junction. Spinal decompression was performed through an extended lower cervical approach, and a humeral allograft was used to reconstruct the anterior column. All patients improved neurologically with satisfactory correction of the deformity and successful incorporation of the allograft.     

Oblique distraction external pelvic fixation

Simple anterior pelvic external fixation is a safe and effective strategy for reduction of pelvic ring deformity as well as the provisional or definitive stabilization of selected patterns of pelvic ring disruption. A two-pin oblique anterior pelvic deformity correction frame is a unique frame configuration designed to reduce and stabilize lateral compression pelvic ring disruptions associated with flexion/internal rotation hemipelvic deformities. In a small case series, we demonstrate that the oblique distraction external fixation frame alone or in combination with internal fixation is a simple and safe strategy for reduction and stabilization of unstable multiplanar hemipelvic deformities associated with partial posterior ring stability.     

A novel surgical technique for the management of massive osseous defects in the hindfoot with bulk allograft

The use of a spherical femoral head allograft in conjunction with spherical reaming provides a safe and effective technique for the management of a massive osseous defect in the hindfoot. This technique presents specific advantages over the standard technique of trapezoidal block allograft and joint preparation by way of flat osteotomies, including increased flexibility and freedom in deformity correction and joint alignment.     

Accuracy of complex lower-limb deformity correction with external fixation: a comparison of the Taylor Spatial Frame with the Ilizarov ring fixator

Purpose Circular external fixators have several advantages over other surgical options in the treatment of limb length discrepancy and axial deformity. The innovative Taylor Spatial Frame (TSF) combines a rigid hexapod fixation system with the support of a web-based software program, and thus offers the possibility of simultaneous corrections of multidirectional deformities. Whilst there is still some scepticism of many Ilizarov device users about the advantages of the TSF, the purpose of the study was to perform a comparison between the TSF and the Ilizarov ring fixator (IRF) with regard to the accuracy of deformity correction in the lower limb. Methods Two hundred and eight consecutive deformity corrections in 155 patients were retrospectively evaluated. There were 79 cases treated with the IRF and 129 cases treated with the TSF. The mean age of the patients at the time of surgery was 13.2 years (range; 2–49 years). Standing anteroposterior and lateral radiographs were evaluated preoperatively and immediately after removal of the frames. The final result was compared to the preoperatively defined aim of the deformity correction. According to the treated count of dimensions, we differentiated four types of deformity corrections. The results were graded into four groups based on the persisting axial deviation after removal of the frame. Results The aim of the deformity correction was achieved in a total of 90.7% in the TSF group, compared to 55.7% in the IRF group. On the basis of the count of dimensions, the TSF achieved obviously higher percentages of excellent results (one dimension: TSF 100%; IRF 79.3%; two dimensions: TSF 91.8%; IRF 48.6%; three dimensions: TSF 91.1%; IRF 28.6%; four dimensions: TSF 66.7%; IRF 0%). In addition, the degree of the persisting deformity increased with the number of planes of the deformity correction. Conclusions The TSF allowed for much higher precision in deformity correction compared to the IRF. In two-, three- and four-dimensional deformity corrections in particular, the TSF showed clear advantages. This may derive from the TSF-specific combination of a hexapod fixator with the support of an Internet-based software program, enabling precise simultaneous multiplanar deformity corrections.     

Anterior cortical allograft in thoracolumbar fractures.

A prospective cohort study of consecutive patients with thoracolumbar fractures from two centers was conducted to evaluate the use of cortical allograft for anterior spine reconstruction. The purpose was to determine whether allograft bone had deleterious effects on fusion rates and maintenance of correction. Thirty-six patients were followed for a minimum of 2 years. A radiologic fusion rate of 81% was found, and there was a loss of postoperative correction in eight patients. The addition of posterior instrumentation was not significantly different from anterior surgery alone with respect to union rates but did provide a more reliable maintenance of correction of deformity. There were no cases of disease transmission. The authors conclude that cortical allograft for anterior spine reconstruction in trauma is safe and despite having a fusion rate lower than autogenous iliac crest, little clinical significance is attributable to the radiologic appearance of nonunion at the host-allograft junctions.     

Posterior lumbar interbody fusion

Posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF) create intervertebral fusion by means of a posterior approach. Both techniques are useful in managing degenerative disk disease, severe instability, spondylolisthesis, deformity, and pseudarthrosis. Successful results have been reported with allograft, various cages (for interbody support), autograft, and recombinant human bone morphogenetic protein-2. Interbody fusion techniques may facilitate reduction and enhance fusion. The rationale for PLIF and TLIF is biomechanically sound. However, clinical outcomes of different anterior and posterior spinal fusion techniques tend to be similar. PLIF has a high complication rate (dural tear, 5.4% to 10%; neurologic injury, 9% to 16%). These findings, coupled with the versatility of TLIF throughout the entire lumbar spine, may make TLIF the ideal choice for an all-posterior interbody fusion.