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ABSTRACT: Spinal cord injury can occur following surgical procedures for correction of scoliosis and kyphosis, as these procedures produce lengthening of the vertebral column. The objective of this study was to cause spinal cord injury by vertebral column distraction and evaluate the histological changes in the spinal cord in relationship to the pattern of recovery from the spinal cord injury.
Global osteotomy of all three spinal columns was performed on the ninth thoracic vertebra of sixteen pigs. The osteotomized vertebra was distracted until transcranial electrical stimulation-motor evoked potential (TES-MEP) signals disappeared or decreased by >80% compared with the baseline amplitude; this was defined as spinal cord injury. The distraction distance at which spinal cord injury occurred was measured, the distraction was released, and the TES-MEP recovery pattern was observed. A wake-up test was performed, two days of observations were made, and histological changes were evaluated in relationship to the recovery pattern.
Spinal cord injury developed at a distraction distance of 20.2 ± 4.7 mm, equivalent to 3.6% of the thoracolumbar spinal length, and the distraction distance was correlated with the thoracolumbar spinal length (r = 0.632, p = 0.009). No animals exhibited complete recovery according to TES-MEP testing, eleven exhibited incomplete recovery, and five exhibited no recovery. During the two days of observation, all eleven animals with incomplete recovery showed positive responses to sensory and motor tests, whereas none of the five animals with no recovery had positive responses. On histological evaluation, three animals that exhibited no recovery all showed complete severance of nerve fibers (axotomy), whereas six animals that exhibited incomplete recovery all showed partial white-matter injury.
Parallel distraction of approximately 3.6% of the thoracolumbar length after global osteotomy resulted in spinal cord injury and histological evidence of spinal cord damage. The pattern of recovery from the spinal cord injury after release of the distraction was consistent with the degree of axonal damage. Axotomy was observed in animals that exhibited no recovery on TES-MEP, and only hemorrhagic changes in the white matter were observed in animals that exhibited incomplete recovery.
The information on TES-MEP changes and histological responses associated with distraction in an animal model may be useful in corrective surgery for spinal deformity in humans.
The Journal of Bone and Joint Surgery 05/2013; 95(9):835-42. · 3.27 Impact Factor
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ABSTRACT: The aim of this study was to introduce a simple and reliable intraoperative reference guide to reproduce the normal femoral anteversion during total hip arthroplasty (THA). We hypothesized that the posterior lesser trochanter line (PLTL) could be a useful guide for estimating femoral anteversion during THA. We conducted a study of 56 men (112 hips) to evaluate the relationship between the PLTL and the femoral anteversion using computed tomography scans. The mean femoral anteversion was 9.0°±8.1° (range, -16.2° to 32.9°). The PLTL angle correlated (r(2)=0.12, P<0.05) with the femoral anteversion. We found a constant relationship between the PLTL and femoral anteversion, and the PLTL may be used as a guide for estimating the femoral stem anteversion during femoral stem fixation.
The Journal of arthroplasty 03/2013; · 1.79 Impact Factor
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ABSTRACT: PURPOSE: To report a complication of airway obstruction during spinal deformity correction surgery in Duchenne muscular dystrophy (DMD) patient, due to lordoscoliosis, airway malacia, and prone surgical positioning, which was rectified by changing the position of the patient and surgery was successfully completed. CASE DESCRIPTION: A 15-year-old boy was diagnosed with DMD and admitted for surgical treatment of thoracolumbar scoliosis. The patient's preoperative Cobb's angle was 79° and the kyphotic angle was -19°. During the initial period of surgery, while in the prone position, peak inspiratory pressure (PIP) suddenly increased from 20-21 to 38-41 cmH2O, wheezing sounds were heard on auscultation of both lungs, and his blood pressure began to fall. Under suspicion of airway problem, intraoperative fiberoptic bronchoscopy was performed which confirmed airway obstruction. Attributing patient's prone position as the cause of airway obstruction, the surgical position of the patient was changed from prone to semi-lateral. After this change, the PIP stabilized to within normal limits (20-23 cmH2O). The surgical correction was successfully completed with a posterior-only pedicle screw by the free-hand technique, with the patient in the semi-lateral position for the rest of surgery. CONCLUSIONS: Lordoscoliosis and airway malacia in a patient with DMD can lead to occlusion of the tracheobronchial lumen when the patient is in the prone position. Changing the patient's position from prone to semi-lateral can be of help to reverse this airway obstruction and complete the surgery. Pedicular screw insertion can be safely and effectively carried out in this position using free-hand technique.
European Spine Journal 03/2013; · 1.97 Impact Factor
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ABSTRACT: PURPOSE: To identify factors that can affect postoperative shoulder balance in AIS. METHOD: 89 adolescent idiopathic scoliosis patients with six types of curvatures who underwent surgery were included in this study. Whole spine antero-posterior and lateral radiographs were obtained pre- and postoperatively. In radiograms, shape and changes in curvatures were analyzed. In addition, four shoulder parameters and coronal balance were analyzed in an effort to identify factors significantly related to postoperative shoulder balance. RESULT: In general, all the four shoulder parameters (CHD, CA, CRID, RSH) were slightly increased at final follow up (t test, P < 0.05), although there was a decrease in Lenke type II and IV curvatures. However, pre- and postoperative shoulder parameters were not significantly different between each curvature types (ANOVA, P > 0.05). Moreover, no significant differences of pre- and postoperative shoulder level between different level of proximal fusion groups (ANOVA, P > 0.05) existed. In the analysis of coronal curvature changes, no difference was observed in every individual coronal curvatures between improved shoulder balance and aggravated groups (P > 0.05). However, the middle to distal curve change ratio was significantly lower in patients with aggravated shoulder balance (P < 0.05). In addition, patients with smaller preoperative shoulder imbalance showed the higher chance of aggravation after surgery with similar postoperative changes (P < 0.05). CONCLUSIONS: Significant relations were found between correction rate of middle, and distal curvature, and postoperative shoulder balance. In addition, preoperative shoulder level difference can be a determinant of postoperative shoulder balance.
European Spine Journal 03/2013; · 1.97 Impact Factor
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ABSTRACT: We report a case of polyethylene insert breakage in a 45-year-old man after 3.5years of cruciate retaining type mobile bearing total knee arthroplasty (TKA). Interstingly, both condyles of the polyethylene insert have fractured. The visual assessment done by stereoscopic microscope in the investigation report suggested that the fracture propagation was a result of cyclic loading and that the fracture was from the articular surface as a result of tibio-femoral and anteroposterior shear loading. The initial flexion-extension gap mismatch and/or specific Asian habits like kneeling or deep knee bending could have been the possible factors for over-stress for the insert causing this complication. After replacement of the broken insert and modification for daily activity preventing deep knee flexion, the patient obtained complete relief of previous symptoms. It remains unclear whether insert breakage was secondary to polyethylene insufficient design or to the polyethylene material fracture propagation.
The Knee 01/2013; · 1.74 Impact Factor
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ABSTRACT: Late presentation of congenital patellar dislocation with advanced osteoarthritis is rare. This article presents a case of a 59-year-old man with underlying pseudoachondroplastic dwarfism. Advanced osteoarthritis due to bilateral neglected congenital patellar dislocation was treated with total knee arthroplasty without patella relocation surgery. Two years later, the patient had an improvement in Knee Society scores, painless function, and stability.
The Knee 11/2012; · 1.74 Impact Factor
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ABSTRACT: Total hip arthroplasty (THA) is one of the most commonly performed orthopedic surgery worldwide. Current research and development had improved the designs of modern total hip prosthesis. Although long femoral stems are widely used, short stems are thought to preserve more native host bone and optimize proximal load transfer utilized with the advent of less invasive surgery. Modular short femoral stems in THA may have versatile applicability by virtue of their unique geometry, mechanism of fixation, and modularity. In this report, we present two unique case scenarios where the use of short stems has given successful results.
European Journal of Orthopaedic Surgery & Traumatology 11/2012; · 0.10 Impact Factor
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ABSTRACT: PURPOSE: This study was designed to examine the effect of biplane medial opening wedge high tibial osteotomy (MOWHTO) on patellofemoral indices and posterior tibial slope. MATERIALS AND METHODS: Sixty-two knees (61 patients) underwent biplane MOWHTO for unicompartmental osteoarthritis of the knee. Patellar indices were measured by radiographic assessment postoperatively. The Merchant's views were used for patellar tilt and shift while standing lateral view radiographs were used for the patellar height analysis using the modified Blackburne-peel ratio (mBP). The patients were divided into two groups according to the change between the pre- and postoperative mechanical axis. Group A constituted the correction angle of equal more than 10°, and group B of less than 10°. RESULTS: Group A demonstrated a significant change of mechanical axis and the tibial slope. Patellar indices including the patellar tilt, shift, and mBP did not show significant difference. Group B demonstrated the statistical significant difference in only the mechanical axis deviation. Patellar indices including the patellar tilt, shift, and mBP as well as the tibia slope did not show significant difference. When evaluated as a whole group, the mean shift in weight bearing line, patellar height (mBP), and tibial slope from preoperative to postoperative value was statistically significant. However, the patellar tilt and shift were not changed significantly. CONCLUSIONS: After biplane MOWHTO, patellar tilt and shift do not significantly change when measured on static mode supine X-ray. However, patella was lowered and tibia slope increased after MOWHTO. LEVEL OF EVIDENCE: II.
The Knee 11/2012; · 1.74 Impact Factor
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ABSTRACT: Study Design. Prospective case series studyObjective. To study effect of percutaneous thoracoplasty only procedure on curve pattern in mature adolescent idiopathic scoliosis (AIS).Summary of Background Data. The rib hump prominence on convex side is major cosmetic concern among patients in AIS. Thoracoplasty combined with spinal fusion is commonly used procedure in scoliosis. However, there are no studies regarding the effect of isolated thoracoplasty procedure on curve pattern in mature AIS.Methods. The study involved seven skeletally matured female AIS patients. The convex rib hump deformity was measured pre-operatively using hump height and hump angle. We performed thoracoplasty without spinal fusion in patients with Cobb's angle under 40 degrees, but with prominent hump deformity. Thoracoplasty was performed percutaneously using one or two transverse incisions along the rib hump and apex portions of the deformed ribs were resected. Cobb's angle was measured before surgery, immediately post-surgery and at final follow-up visit. In all cases, clinical satisfaction was assessed using SRS-22 questionnaires and trunk appearance perception scale (TAPS) before surgery and at final follow-up visit.Results. The mean patient age was 20.24 years and an average of four ribs was resected. The mean pre-operative hump height and hump angle of 38.14 mm and 14.14 degrees improved to 11.70 mm and 11.42 degrees respectively post-surgery (P = 0.018 and 0.042). Pre-operative and final follow-up mean Cobb's angle was 35.43 and 45.00 degrees, respectively (P = 0.028). On an average, the mean thoracic curve progressed by 9.57 degrees. Pre-operative SRS-22 questionnaires and TAPS scores of 4.09 and 2.57 respectively improved to and 4.26 and 3.66 post-surgery (P = 0.126 and 0.014).Conclusion. Percutaneous thoracoplasty only procedure gives significant rib humps correction and satisfactory clinical outcome. However, progression of curve was observed post surgery. This suggests function of convex ribs as buttress for curve progression.
Spine 10/2012; · 2.08 Impact Factor
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ABSTRACT: The authors hypothesized that an image-free navigation system would be more accurate than postoperative 3-dimensional (3-D) reconstructed computed tomography (CT) for acetabular cup inclination and anteversion during total hip arthroplasty (THA) in an Asian population. Eighty-one THAs were performed in 72 patients using the OrthoPilot image-free navigation system (B. Braun Aesculap, Tuttlingen, Germany). Cup placement position was measured by postoperative 3-D CT and compared with intraoperative navigation data. The discrepancies between the navigation data and the 3-D CT data were analyzed, as well as the correlation factors that affected the discrepancies. The discrepancies between the navigation data and the 3-D CT data were -1.5°±7.1° (P=.04) for anteversion and -1.1°±7.6° (P=.02) for inclination. The accuracy and precision of the anteversion discrepancies were 5.6°±4.4° and 3.2°, respectively. The accuracy and precision of the inclination discrepancies were 4.5°±4.4° and 2.8°, respectively. Five (6%) outliers existed in terms of the safe zones of anteversion and inclination. The main correlated factor among the pelvic geometry was tilt rather than rotation and obliquity of the bony anterior pelvic plane.In an Asian population, the calculated accuracy and precision of acetabular cup inclination and anteversion during THA were more reliable and the outliers were reduced using the OrthoPilot navigation system. However, discrepancies existed between intraoperative navigation data and postoperative 3-D CT data. The pelvic geometry of biometrical factors influenced the discrepancies in the navigation data.
Orthopedics 10/2012; 35(10):13-7. · 2.66 Impact Factor
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ABSTRACT: Estrogens act on estrogen receptors distributed in articular cartilages, synovial membrane, and ligaments, which are thought to be related with degenerative changes. Meanwhile, progesterone is known to have a weak anabolic action on bone formation This study evaluates the effects of estrogen and progesterone hormone on bone/cartilage turnover in ovariectomized (OVX) rats.
Thirty-five 7-month-old female Sprague-Dawley rats were randomly divided into 5 groups and then ovariectomized bilaterally except the sham control group. The first and the second group acting as controls did not receive hormonal therapy, the third group received estrogen, the fourth group received progesterone, and the fifth group received combination of both hormones 10 weeks after surgery. Evaluations were done using the serum levels of cartilage oligomeric matrix protein (COMP) for cartilage turnover, collagen type I C-telopeptide (CTX-1) and osteocalcin (OC) for bone turnover at 11, 15, 19 weeks after OVX and histology using the Osteoarthritis Research Society International (OARSI) osteoarthritis (OA) cartilage histopathology assessment system.
Significantly less cartilage degradation (decreased levels of COMP) was found in the combined hormone treated group in comparison with OVX group. Similarly, both hormonal treatment resulted in increased bone formation and decreased bone resorption i.e., a low overall bone turnover status (decrease in the serum OC and CTX-1 levels).
Combined estrogen and progesterone therapy was found to be convincing in terms of reducing the severity of OA in this experimental model.
Clinics in orthopedic surgery 09/2012; 4(3):234-41.
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ABSTRACT: Although controversy continues over the choice of graft tissue, including autografts, allografts, and synthetic ligaments, for posterior cruciate ligament (PCL) reconstruction, the use of a mixed graft consisting of a hamstring (semitendinosus and gracilis) autograft plus tibialis anterior allograft tendon has not been studied in detail.
Outcomes of PCL reconstructions performed with a mixed graft would be superior to those using solely an Achilles tendon allograft in terms of functional knee scores, posterior stability, and the graft appearance.
Cohort study; Level of evidence, 2.
Fifty-eight patients who underwent isolated single-bundle PCL reconstruction using an arthroscopic trans-septal portal with remnant preservation technique were evaluated. They were divided into group A (mixed tendon; n = 30) and group B (Achilles tendon; n = 28). Knee function was evaluated using the Lysholm knee score, Tegner activity score, and the International Knee Documentation Committee (IKDC) grading scale. Anteroposterior stability was measured using the Telos stress view. Twenty patients (66.7%) from group A and 21 patients (75.0%) from group B underwent hardware removal and a second-look arthroscopic examination.
The Lysholm knee scores in groups A and B increased from a respective average of 43 and 50 preoperatively to 90 and 88 at follow-up. The IKDC grade and Tegner activity scores were also significantly improved in both groups. Stability was improved in both groups, with an average posterior laxity of 3.0 mm (group A) and 3.3 mm (group B) at follow-up (P > .05). However, there were 4 intraoperative complications in group B: 2 bone fractures and 2 graft pullouts during precyclic tensioning. Second-look arthroscopy revealed a partial tear in 8 cases (40%) from group A and 15 cases (71.4%) from group B (P = .03). All of the partial tears were located in the femoral aperture area. Complete synovial coverage was demonstrated in 10 patients (50%) from group A and 5 patients (23.8%) from group B (P = .04). However, clinical outcomes and stability were not affected by the arthroscopic graft appearance.
Satisfactory results were obtained for groups A and B in patients who underwent reconstruction for isolated PCL injury. However, 4 intraoperative complications (14.3%) were encountered with use of the Achilles tendon allograft (group B), with a relative higher rate of partial tear and less synovialization in the femoral aperture area.
The American journal of sports medicine 08/2012; 40(9):2052-60. · 3.61 Impact Factor
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Journal of Orthopaedic Science 07/2012; · 0.84 Impact Factor
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ABSTRACT: STUDY DESIGN.: Observational study with 3 examiners. OBJECTIVE.: The aim of this study was to enhance the reproducibility and reliability of coronal curvature measurements in early-onset scoliosis. SUMMARY OF BACKGROUND DATA.: Previous reports show high variability of the Cobb method, especially on the measurement of the immature spine. METHODS.: A total of 115 whole-spine posteroanterior radiographs were collected to compare the reliability of the Cobb, lateral tangent, pedicle, and centroid methods in early-onset scoliosis. Radiographs were measured twice by each of the 3 examiners using the 4 measurement methods. Statistical analysis was performed to determine the inter- and intraobserver reliability. RESULTS.: In this study, total inter- and intraobserver inter- and intraclass correlation coefficients (ICCs) in 115 radiographs were excellent in all methods (ICCs >0.961). However, mean absolute differences (MADs) in the lateral tangent method were less than 3.78°, which was higher than other methods (MADs <2.95°). In analysis of different severity groups (<15°, 15°-30°, and >30°), total inter- and intraobserver ICCs gradually increased with increasing the severity of the deformity, whereas MADs of each severity group were similar despite their increased measurement scale. Particularly, interobserver ICCs and MADs of lateral tangent method were more than 0.474 and less than 3.76° with poor reliability, which showed high variability in the less deformed spine group (<15°). However, intraobserver ICCs and MADs of pedicle method were more than 0.853 and less than 2.61°, interobserver ICCs and MADs were more than 0.729 and less than 2.86° with excellent reliability, which showed constantly high reliability regardless of coronal curvature severity. CONCLUSION.: In this study, the pedicle method showed constantly higher ICCs and lower MAD values in the early-onset scoliosis regardless of severity. However, the other 3 methods showed lower ICCs and higher MAD values, which showed lowest reliability in the lateral tangent method. For improved treatment of early-onset scoliosis, we recommend the pedicle method for measuring curvature regardless of severity.
Spine 06/2012; 37(20):E1273-81. · 2.08 Impact Factor
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ABSTRACT: The purpose of this study was to assess the intra-articular patterns in the rotational deformities of bucket handle meniscal tears (BHMTs) based on arthroscopic findings and their clinical relevance.
From 2004 to 2009, 42 patients with a BHMT diagnosed by magnetic resonance imaging underwent arthroscopic surgery. The arthroscopic data (all procedures were recorded) were evaluated retrospectively, and BHMTs were classified according to the rotational directions of centrally displaced fragments. To assess the reliability of the agreement in this classification, 2 orthopedic surgeons re-classified BHMTs, 1 week after first trial. Intra- and interobserver reliabilities were assessed using kappa statistics. In addition, we address specific tear patterns, associated anterior cruciate ligament injury, medio-lateral difference, reducibility, chronicity, and reparability.
Most of the tears could be categorized into one of 3 morphologic patterns. Of the tears, 4.8% could not be categorized. BHMTs were classified, based on the rotational directions of centrally displaced fragments, as follows; the upward rotation group (type 1), the downward rotation group (type 2) and the reverse group (type 3). The most common intra-articular pattern was type 1 (29 patients, 69%). The occurrence of the other patterns was: type 2 in 7 patients (16.7%), type 3 in 4 patients (9.5%); we were not able to make a classification of type in 2 patients (4.8%). Intra-observer reliability was 0.86 in terms of kappa statistics, which implies almost perfect agreement. Mean interobserver reliability (0.73) showed substantial agreement. Type 1 and 2 tears were easily reduced, whereas all type 3 tears (4/4) needed additional procedures to achieve reduction.
Based on arthroscopic findings, we describe a comprehensive BHMT classification scheme that encompasses 95.2% of all tears. Tear type was correlated with reducibility.
Clinics in orthopedic surgery 06/2012; 4(2):129-33.
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ABSTRACT: Popliteofascicular injury had been proposed as a possible cause of unstable lateral meniscus. Meniscal repair at popliteal hiatus area during lateral meniscal allograft transplantion (MAT) had not been described in literature previously. In this report, a case of unstable lateral meniscus after MAT has been described. Arthroscopic repair for the unstable meniscus at popliteal hiatus resolved the mechanical symptom.
The Knee 05/2012; · 1.74 Impact Factor
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ABSTRACT: Chemical burn under pneumatic tourniquet is an iatrogenic preventable injury and is rarely reported in the literature. The two important mechanisms are maceration (friction) and wetness underneath the tourniquent. In this report, our experience with two illustrative patients who presented with iatrogenic tourniquet associated burn is described.
Indian Journal of Orthopaedics 05/2012; 46(3):356-9. · 0.50 Impact Factor
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ABSTRACT: We hypothesized that the lesser trochanter could be a useful guide for estimating femoral component version during total hip arthroplasty. We conducted a study of 88 patients to evaluate the relationship between the posterior lesser trochanter line (PLTL) and the femoral neck axis (FNA) using computed tomographic scans. The mean angle between the PLTL and the FNA was 17.4° ± 7.1° (range, -1.6° to 36.5°). The PLTL angle correlated (r(2) = 0.67-0.72) with the FNA angle. Intraclass correlation coefficient values showed a high level of intraobserver and interobserver agreement in the angles between the PLTL and the FNA. We found a constant relationship between the lesser trochanter and the FNA, and femoral neck version can be estimated, using the PLTL, with reasonable reliability.
The Journal of arthroplasty 04/2012; · 1.79 Impact Factor
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ABSTRACT: In the present study, we investigated whether there is a difference between visual depth (VD) and radiological image depth (RD) of cages (i.e., structural interbody support devices) placed in disc spaces during posterior lumbar interbody fusion and whether soft tissues covering the posterior border of the vertebral body and associated disc space are the cause of any observed differences. Using digital calipers, cages were inserted at a depth of 5 mm from the soft tissues covering the posterior border of the vertebral body and disc space under direct vision; this depth was defined as VD. After insertion, RD was measured in triplicate. The reliability of RD measurements was evaluated using an intraclass coefficient test. To identify the cause of differences between VD and RD, the thicknesses of soft tissues were measured microscopically. A total of 40 lumbar intervertebral disc spaces with cages were evaluated. The mean RD of cages was 3.12 mm, while the mean difference between the VD and RD of cages (DVRD) was 1.91 mm. On histological examination, the mean thickness of the soft tissue was 2.02 mm. Comparative analysis between histological values and DVRD showed no statistical difference (P = 1.14, 1.55, 0.06). There was a significant difference between VD and RD during cage placement, and soft tissue structure appeared to be responsible for the DVRD of inserted cages. Therefore, cages should be inserted deeper to account for differences between visual and radiological image depths. Clin. Anat. 2012. © 2012 Wiley Periodicals, Inc.
Clinical Anatomy 04/2012; · 1.29 Impact Factor
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ABSTRACT: The purpose of this study was to evaluate the reliability of the PowerPoint (PP) (2007 Version; Microsoft, Redmond, Wash) method for measuring polyethylene liner wear after total hip arthroplasty. Seventeen retrieved polyethylene liners were included in this study. Wear volumes were calculated using the PP, the Dorr and Wan, and 3-dimensional (3D) laser scanning methods. Spearman correlation coefficients for wear volume results indicated strong correlations between the PP and 3D laser scanning methods (range, 0.89-0.93). On the other hand, Spearman correlation analysis revealed only moderate correlations between the Dorr and Wan and 3D laser scanning methods (range, 0.67-0.77). The PP method can be used to monitor linear wear after total hip arthroplasty and could serve as an alternative method when computerized methods are not available.
The Journal of arthroplasty 04/2012; 27(8):1530-7. · 1.79 Impact Factor
