John Pournaras

Treatment of tuberculous spondylitis with anterior stabilization and titanium cage

We retrospectively reviewed 12 patients with spinal tuberculosis of the thoracic and lumbar spine who had radical débridement, anterior decompression, interbody arthrodesis with an anterior interbody titanium cage, and autologous bone grafts, combined with a standardized perioperative antituberculous regimen. Their mean age was 55.1 years and they were observed for a mean of 65.3 months. Indications for surgery included epidural abscess, structural destruction with instability, progressive kyphosis, and/or neurologic deterioration. Kyphotic deformity was corrected from a mean of 24.6° (range, 15°-32°) to a mean of 10° (range, 4°-18°). Tuberculous infection was controlled and bony fusion was achieved in all patients. No recurrence of infection or construct failure was recorded. All patients were safely mobilized within the first postoperative week; back pain fully resolved in eight patients and improved in the remaining four. We conclude that radical débridement followed by anterior stabilization with a titanium cage and bone grafting is a reasonable alternative for tuberculous spondylitis requiring surgical treatment. It enables accurate and lasting deformity correction and provides adequate stability to allow early mobilization. The presence of a titanium cage in an area of mycobacterial infection did not preclude infection control or lead to recurrence.Level of Evidence: Therapeutic study. Level IV (case series). Please see Guidelines for Authors for a complete description of levels of evidence.

THE RESULTS OF SURGICAL REPAIR OF ACUTE TEARS OF THE POSTERIOR CRUCIATE LIGAMENT

In 20 patients, the torn posterior cruciate ligament (PCL) was repaired without reinforcement within two weeks after injury. Fourteen patients had a midsubstance tear, and in six the ligament was avulsed from the femur without bone. There were 11 isolated and nine combined injuries. The follow-up period ranged from two to 10.5 years. Postoperatively, all had posterior instability graded from 1+ to 2+. Nevertheless, the subjective results were good in 15 patients, fair in five, and poor in none. Posterior instability did not produce significant functional impairment of the knee for a considerable number of years. Suture alone cannot restore the PCL and is not strong enough to withstand the applied forces on the knee.

The Effectiveness of the Burch-Schneider Antiprotrusio Cage for Acetabular Bone Deficiency: Five to Twenty-one Years' Follow-up

From 1985 to 2001, the Burch-Schneider antiprotrusio cage (B-S APC) was implanted in 57 cases (55 patients) with massive acetabular deficiency. The B-S APC survived until the last review 5 to 21 years after operation in 89.5% of the cases, produced substantial pain relief, and increased range of hip motion and walking capacity. The 10.5% failure rate was due to aseptic loosening in 2 cases and mechanical failure in 4 cases. It appears that application of the B-S APC in extensive acetabular deficiency presents a durable solution provided that proper indications and technique are used.

Reduction of postoperative spinal infections based on an etiologic protocol.

Acute postoperative spinal infections are serious complications. We saw a sudden increase in the infection rate in our unit during a 6-month period. This led us to construct an assessment protocol combining risk factors into a mnemonic we named the “Nine Ps Protocol” (patient-related factors, personnel, place, preoperative length of stay, procedure, prosthetics, prophylaxis, packed red blood cells, and pus cultures). We reviewed 102 consecutive patients having spine surgery in three sequential 6 month periods: Group A included 34 patients before the outbreak of infection and Group B included 26 patients during the outbreak of infection. We prospectively applied the protocol in 26 patients (Group C) after the outbreak. After the implementation of the protocol the infection rate dropped from 16.7% (Group B) to 3.6% (Group C). Increased risk factors for postoperative infection included advanced age, posterior instrumented fusion, high allogenic blood transfusion rates, and suboptimal sheet and dressing changing conditions. We propose the Nine Ps Protocol as a useful clinical tool for the etiologic assessment and prevention of spinal infections.Level of Evidence: Prognostic study, Level II (Lesser quality prospective study [eg, patients enrolled at different points in their disease or < 80% followup]). Please see Guidelines for Authors for a complete description of levels of evidence.

Humeral head torsion in recurrent anterior dislocation of the shoulder

We measured torsion of the humeral head in 38 patients (40 shoulders) with recurrent anterior dislocation of the shoulder (RADS) and in 40 normal subjects. We found a reduced mean retroversion in the patients with RADS at 4.3 +/- 10.56 degrees (17 degrees anteversion to 32 degrees retroversion) as compared with 16.1 +/- 11.07 degrees in the control group (0 degrees to 49 degrees) (p = 0.0001). There was anteversion in 11 of the 40 shoulders in the RADS group (27.5%) and in none of the control group. The first dislocation had occurred after minimal force in 18 of 25 patients with less than 10 degrees retroversion, but in only three of 15 with over 10 degrees retroversion. We conclude that decreased retroversion of the humeral head is often associated with RADS and with first dislocation of the shoulder caused by minimal force.

Replacement of deficient acetabulum using Burch-Schneider cages. 22 patients followed for 2-10 years.

The absence of good bone stock with massive acetabular deficiency has been a major problem in both revision hip arthroplasty and in primary arthroplasty for congenital dislocation of the hip (CDH). 22 patients (24 hips; 21 revision and 3 primary replacements: mean age 58 years) with substantial bone loss underwent acetabular reinforcement with Burch-Schneider cages. Classification of acetabular deficiency was made according to the AAOS system. The surgical procedure involved preparation of acetabulum, filling the defect with bone autografts, placement of the cage with its flanges, fixation with screws on the lateral wall only and placement of a cement and plastic cup. Radiographic loosening with breakage of the screws was observed in only 1 patient. After a mean follow-up of 8 (2-10) years, good stability was achieved in all patients and no mechanical failure was observed. Satisfactory results were observed in all but one of the cases, indicating that effective support of the acetabulum can be achieved using Burch-Schneider cages.

Neglected trans-scaphoid trans-styloid volar dislocation of the lunate : Late result following open reduction and K-wire fixation

A rare case of radiocarpal dislocation is presented. The lunate and proximal pole of the scaphoid were displaced in a volar and proximal direction. The injury was missed initially and the patient was subsequently operated on six weeks later. Open reduction and internal fixation of the scaphoid was performed and this was followed by an uneventful postoperative period, with a satisfactory functional outcome at the eight-year follow-up, despite carpal instability non-dissociative-dorsal intercalated segmental instability configuration of the carpus. We believe that although open reduction in neglected cases carries the potential risks of avascular necrosis and nonunion of the affected carpal bones, an attempt should be made to restore the anatomy of the carpus.

Interposition arthroplasty of the first metatarsophalangeal joint with a fascia lata allograft.

A new technique for interposition arthroplasty of the first metatarsoplalangeal joint is described. It involves minimal resection of the base of the proximal phalanx and the use of a fascia lata allograft. The method is simple, safe, and easily reproducible. In selected cases it can offer restoration of pain-free motion in a nonsalvable joint.

Segmental spinal correction of idiopathic scoliosis : Luque rods and Hartshill rectangle in 30 patients followed for 2-6 years

30 patients with idiopathic scoliosis were treated by posterior spinal arthrodesis using the Luque (8 patients) and Hartshill (22 patients) rodding systems with sublaminar segmental wiring. Patients were followed for 2 to 6 years. In most cases, postoperative correction exceeded safety correction limits (lateral bending film plus 10 degrees). Final correction was 55%, while derotation was not significant (average 3 degrees). No neurological deficit was noted. Postoperative bracing was not applied and there was 1 patient with broken rods (Luque trolley system without fusion) and 1 patient with broken wires in 4 segments. Allogenic blood transfusion was avoided in 19 patients by preoperative donation of autologous blood, in combination with salvage of intraoperative shed blood. We found segmental spinal wiring with either rods or rectangles to be a safe method for correction of scoliosis in experienced hands. It offered satisfactory stability and fusion rate with no need for external support.

Percutaneous harlow wood needle biopsy of the spine : A retrospective analysis of 238 spine lesions

This retrospective study assessed the diagnostic accuracy and clinical usefulness of the Harlow Wood needle biopsy for spinal lesions. The medical records of 238 patients (138 men and 100 women) who underwent closed spine biopsy from 1987 through 1997 were reviewed. Patient age ranged from 21 to 83 years. Lesions involved the thoracic vertebrae in 127 patients, the lumbar vertebrae in 99 patients, and the sacrum in 12 patients. Cultures of the biopsy specimens were examined histopathologically and cytologically. One hundred twenty-four patients were diagnosed with a spinal infection, and 68 patients were diagnosed with a tumor. In the remaining 46 patients, the biopsy specimens were negative for infection or neoplasia in 20 patients and not diagnostic in 26 (10.9%) patients. There were no major complications. The Harlow Wood needle biopsy is a simple, repeatable procedure with satisfactory diagnostic accuracy (89.1%) and can be performed on an outpatient basis.