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Ankylosing spondylitis is a genetic condition [1] that frequently results in spinal sagittal plane deformity of thoracolumbar or cervicothoracic junction. Generally, a combination of osteotomy and spinal fixation is used to treat severe cases of ankylosing spondylitis to restore spinal balance and horizontal gaze [2]. This study investigates the biomechanics of opening wedge osteotomy at the cervicothoracic junction. Although surgical techniques for traumatic injury across the cervicothoracic junction have been well characterized in the clinical and biomechanical literature, the specific model of instrumented opening wedge ostetomy in autofused ankylosing spondylitis has not been studied biomechanically.

Failure of the posterior rods in long thoracolumbar deformity correction cases often requires revision surgery to treat the pseudoarthrosis and prevent loss of correction. While the entire rod can be replaced, this involves opening the entire incision which can lead to increased morbidity. Other clinically advantageous options include minimally invasive surgical approaches such as percutaneous insertion of connectors and additional rods.Copyright © 2010 by ASME

Both expandable and non-expandable interbody cage designs are available to surgeons for cases involving spinal reconstruction and stabilization following single level lumbar corpectomy [1]. Different expandable cage designs are on the market [2], but all involve a manual mechanism to intraoperatively adjust the compressive load applied by the cage against the vertebral body endplates. Non-expandable cages do not have such a mechanism, and surgeons rely on cutting the cage to the appropriate length to achieve a “press-fit.” The clinical reasoning behind the expandable cage design is that the adjustability of the device will allow the surgeon to achieve the maximum contact area between the cage and the vertebral endplate without “overstuffing” the interbody space and thus causing a sagittal-plane deformity.Copyright © 2010 by ASME

Study design Retrospective matched cohort. Objective To investigate the factors that may affect the decision-making process of adult deformity patients. Summary of background data Adult deformity is a significant cause of morbidity in the elderly population. Despite high complication rates a significant number of patients still prefer operative treatment. Analysis of the factors that drive these patients to operative treatment would help surgeons to better evaluate these patients. Methods Adult deformity patients who are evaluated in a single institute were reviewed. The inclusion criteria were being >18 years old, having a coronal curve magnitude of >30 degrees , having no previous surgery or associated neuromuscular or inflammatory condition, having completed SF-12, SRS-30, and Oswestry Disability Index questionnaires in the initial visit, and having a complete set of radiographs. The demographic data as well as back and leg pain incidences and magnitudes were collected. The eligible patients were compared first as age-gender-curve type matched cohorts. Results Functional domain scores particularly walking in Oswestry Disability Index and vitality in the SRS-30 were significantly worse in the operative treatment group, whereas the pain scores were similar in both groups in all outcomes assessment questionnaires. Besides, there was no difference among 2 groups with respect to either the incidence or the magnitude of back or leg pain. Conclusion These results suggest that functional limitations are more important than pain for adult deformity patients when deciding for operative or nonoperative treatment.

Femoral head-neck junction osteochondroplasty is commonly used to treat femoroacetabular impingement, yet remodeling of the osteochondroplasty site is not well described. We therefore describe bony remodeling at the osteochondroplasty site and analyze clinical outcomes and complications associated with femoral osteochondroplasty. We retrospectively reviewed 135 patients (150 hips) who underwent femoral head-neck osteochondroplasty combined with hip arthroscopy, surgical hip dislocation, periacetabular osteotomy, or proximal femoral osteotomy. The minimum clinical followup was 10 months (mean, 22.3 months; range, 10–65 months). We assessed the femoral-head neck offset, head-neck offset ratio, alpha angle, and cortical remodeling. We used the Harris hip score to determine hip function. We observed an increase in the head-neck offset, offset ratio, and decrease in the alpha angle postoperatively and at latest followup. Ninety-eight of 113 (87%) hips had partial or complete recorticalization at the osteochondroplasty site. The mean Harris hip score improved from 64 to 85. We excised heterotopic bone in one hip. There were no femoral neck fractures. The deformity correction achieved with femoral head-neck osteochondroplasty is maintained and recorticalization occurs in the majority of cases during the first two years. Level of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

STUDY DESIGN: This is a prospective observational study of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) in a cohort of patients undergoing spinal surgery. OBJECTIVE: We sought to characterize the normal kinetics of ESR and CRP after spinal surgery and compare their usefulness as predictors of infectious complications in the early postoperative period. SUMMARY OF BACKGROUND DATA: ESR and CRP are nonspecific markers of inflammation used to evaluate postoperative infection. CRP is a quantitative test that exhibits predictable kinetics consisting of a postoperative rise and a peak followed by a decrease toward the normal value. Deviation from normal kinetics may be an indicator of infection. METHODS: ESR and CRP were collected before surgery and daily after surgery in consecutive patients. All infectious complications were recorded. RESULTS: One hundred forty-nine patients met inclusion criteria. Infectious complications occurred in 20 patients. A postoperative peak, which is necessary to apply the test, was observed in 78% of patients for CRP and 48% for ESR. Multiple linear regression analysis revealed preoperative CRP, number of levels, and lumbar region as significant predictors of greater CRP peak value (r = 0.435, P = 0.001). After the peak, CRP showed an exponential decrease with a half-life of 2.6 days (r = 0.701, P < 0.001). No trend could be determined for ESR. A second rise or failure to decrease as expected had a sensitivity, specificity, positive predictive value, and negative predictive value of 82%, 48%, 41%, and 86% for infectious complications, respectively. Of 8 cases of deep wound infection, 7 exhibited substantial deviations from expected CRP values. CONCLUSION: CRP is more applicable, predictable, and responsive in the early postoperative period compared with ESR. The postoperative kinetics of CRP derived in this study seems to be conserved regardless of operation, magnitude, or region. Knowledge of the kinetics allows assessment of the degree of difference between actual and expected values. Using a second rise or failure to decrease as expected for CRP is sensitive for infection. A negative test is reassuring that infection is unlikely.

A descriptive clinical study in healthy adolescents was done to evaluate the clinical shoulder balance and analyze the correlation between clinical and radiological parameters which are currently used to evaluate shoulder balance. In addition to trunk shift and rib hump, shoulder balance is one of the criteria that are used to evaluate the outcomes in spinal deformity surgery. Several methods have been proposed to evaluate the shoulder balance in scoliotic patients; however, there is no uniformity to these methods in the current literature. Patients who applied to pediatric clinic without musculoskeletal pathology formed the patient population. Volunteers were asked to fill out a questionnaire assessing shoulder balance perception and had their clinical photograph taken simultaneously with a P-A chest X-ray. The clinical shoulder balance was evaluated through analysis of the clinical photograph. The X-rays were used to evaluate the radiological shoulder balance. The evaluated parameters included coracoid height difference (CHD), clavicular angle (CA), the clavicle-rib cage intersection difference (CRID), clavicular tilt angle difference (CTAD), and T1-tilt. The study group was composed of 48 male and 43 female patients with an average age of 13.6 +/- 2.1 (10-18) years. In the questionnaire, all patients stated that their shoulders were level. The digital photographs revealed that only 17(18.7%) adolescents had absolutely level shoulders. The average height difference between shoulders was 7.5 +/- 5.8 mm. The average CHD was 6.9 +/- 5.8 mm, average CA was 2.2 +/- 1.7 degrees , average CRID was 4.8 +/- 3.6 mm, average CTAD was 4 +/- 3.2 degrees , and average T1-tilt was 1.3 +/- 1.4 degrees . CHD, CA, and CRID demonstrated high correlation with clinical pictures, whereas CTAD demonstrated moderate and T1-tilt demonstrated only mild correlation. The radiological parameters used to evaluate the shoulder balance correlate with the clinical appearance. Contrary to popular belief, shoulder balance in healthy adolescents often does not exist.

Pelvic osteotomies are an integral part of treatment in developmental dysplasia of the hip after 18 months. This article focuses on the innominate osteotomy which was introduced by Richard Salter in 1961. Salter innominate osteotomy is a complete pelvic osteotomy that hinges on the symphysis pubis and results in anterolateral displacement of the acetabulum. The derotated acetabulum is held in place with a bone graft and fixed with Kirschner wires. Salter osteotomy has been performed over four decades and excellent short- and long-term results have been reported from different centers all over the world. Its success is closely related to appropriate patient selection and meticulous surgical technique with strict adherence to prerequisites.

Cobb method has been shown to be the most reliable technique with a reasonable measurement error to determine the kyphosis in fresh fractures of young patients. However, measurement errors may be higher for elderly patients as it may be difficult to determine the landmarks due to osteopenia and the degenerative changes. The aim of this study is to investigate the intrinsic error for different techniques used in evaluation of local sagittal plane deformity caused by OVCF. Lateral X-rays of OVCF patients were randomly selected. Patient group was composed of 28 females and 7 males and the mean age was 62.7 (55-75) years. The kyphosis angle and the vertebral body height were analyzed to reveal the severity of sagittal plane deformity. Kyphotic deformity was measured by using four different techniques; and the vertebral body heights (VBH) were measured at three different points. The mean intra-observer agreement interval for kyphosis angle measurement techniques ranged from +/-7.1 to +/-9.3 degrees while it ranged from +/-4.5 to +/-6.5 mm for VBH measurement techniques. The mean interobserver agreement interval for kyphosis angle ranged from +/-8.2 to +/-11.1 degrees , while it was between +/-4.5 to +/-6.5 mm for vertebral body height measurement techniques. This study revealed that although the intra and interobserver agreement were similar for all techniques, they are still higher than expected. These high intervals for measurement errors should be taken into account when interpreting the results of correction in local sagittal plane deformities of OVCF patients after surgical procedures such as vertebral augmentation techniques.

A suprapatellar plica is a persistent remnant of the embryologic synovial membrane between the suprapatellar pouch and the knee joint. Pathologic synovial plica is not a common entity, however, when present, it can mimic a variety of clinical situations. We describe here a case of pathologic suprapatellar plica that has a check-valve mechanism, which results in a clinical presentation as knee joint swelling.

RESULTS: The response rate was 83%. 66% of participants had an official C-spine clearance protocol. American College of Surgeons’ accredited centers had a higher rate of protocols (75%) when compared non-accredited centers (54%). The majority of the centers had 24-hour access to CT (93%) and MRI (87.5%). The majority of the centers (89%) use NEXUS (National Emergency X-Radiography Utilization Study) criteria with/without painless range of motion to clear asymptomatic patients. A CT scan was the most commonly (52%) utilized first line of imaging. In symptomatic patients with a negative CT scan flexion-extension plain radiographs (51%) and MRI (13%) were the most common next steps of imaging. In obtunded patients, CT scans followed by MRI was the most common method (34%) to clear C-spine, but 6% of the centers were still using dynamic flexion-extension views that are now contraindicated.

Introduction Minimally invasive lateral retroperitoneal transpsoas interbody fusion (LIF) is a surgical approach that is gaining popularity both as a standalone and in conjunction with other surgical techniques to treat adult degenerative scoliosis. It has been shown to minimize tissue destruction, blood loss and length of hospital stay. The technique and degree of correction accomplished by this approach has not been described. Results Two hundred and one patients underwent LIF and 26 patients matched the inclusion criteria. The mean age for the 26 patients was 64 years (range 37-80 years). The mean preoperative curve magnitude was 47.7°, which improved to 28.0° (mean correction of 42.8%) post-LIF and to 13.1° (mean correction of 31.2%), after the second stage. The final mean curve magnitude was 13.1°, for a total mean correction of 34.6° and 73.8%. The preoperative mean L1-L5 lordosis was 32.4° and post LIF it was 49.1°, with a mean increase of 16.6 °. Nineteen of the twenty-six patients had worsening coronal balance after LIF and prior to posterior instrumented fusion. The coronal balance consistently shifted to the side of the convexity in all patients with a 1cm or greater shift in balance. Eight patients had severe decompensation ranging from 3cm to 6.4cm. Fifteen of the nineteen patients with post LIF decompensation of their coronal balance had a partial correction after the second stage of surgery. Mean back pain VAS improved from 7.4 to 2.9 with a mean improvement of 4.5.

Sagittal imbalance of the cervicothoracic spine often causes severe pain and loss of horizontal gaze. Traditionally, C7 opening wedge osteotomy has been classically performed for patients with ankylosing spondylitis. For patients without ankylosing spondylitis closing wedge osteotomy may be considered for more controlled closure. Biomechanical characteristics of the two osteotomy alternatives have not yet been analyzed. The goal of this study is to characterize the structural stability of the two types of cervicothoracic junction osteotomies and the independent effect of rod diameter.Copyright © 2010 by ASME

Degenerative joint disease is not uncommon in patients with lower extremity amputations. These patients are candidates for joint arthroplasty procedures; however, certain modifications may be necessary during the procedure to overcome the challenges presented by the amputation. The authors describe a total hip arthroplasty in a 51-year-old patient 45 years after an ipsilateral through-knee amputation. The patient was informed that the data concerning his case would be submitted for publication, and he consented.