Matias Petracchi

Displacement of a cemented polished tapered stem during closed reduction of a dislocated total hip arthroplasty--a case report.

A 96-year-old woman was admitted with a right dislocated femoral neck fracture. She underwent total hip arthroplasty with a cemented Exeter stem (Howmedica International, Staines, United Kingdom) through a posterolateral approach. The stem was cemented with Simplex bone cement (Howmedica, Rutherford, NJ, USA). No distal plug was implanted to prevent escape of procoagulants to the peripheral venous system (Maltry et al. 1995). The short external rotators and the joint capsule were repaired, using Pellicci et al.’s method (1998). Immediate postoperative radiographs showed a stem in a neutral position, with a homogeneous cement mantle. The polyethylene acetabular cup had 42° of inclination and 29o of planar anteversion (Ackland et al. 1986). The postoperative course was uneventful and the patient was discharged after 6 days, mobilized with a walker. 14 days after surgery, while standing up from the high toilet seat, her hip dislocated. Radiographs showed a postero-superior dislocation with a normal cement-stem interface (Figure 1). We tried to perform a closed reduction without sedation. A click was heard, and the leg-length equalized; however, passive hip motion was still limited and painful. Additional radiographs showed that the joint remained dislocated and that the stem had separated from the cement mantle, and migrated 12 mm proximally (Figure 2). We therefore performed an open reduction. At surgery, failure of the posterior soft tissue repair was seen with the tagging sutures pulled-out from the tendons and capsule. We removed the femoral component. The femoral head, cement mantle, and polyethylene cup were macroscopically intact. The same stem was reimplanted using the cement-within-cement technique (Lieberman et al. 1993) and leaving the stem 5 mm higher to exert more tension on the soft Displacement of a cemented polished tapered stem during closed reduction of a dislocated total hip arthroplasty—a case report

Use of CT-guided periradicular injection for the treatment of foraminal and extraforaminal disc herniations

Study design: Retrospective case series. Evidence level IV. Objectives: To evaluate surgical candidates with foraminal or extraforaminal lumbar disc herniation treated with CT-guided periradicular injection (CTGPI) as a valid treatment option for avoiding surgery. Methods: We carried out a retrospective evaluation of 46 consecutive patients with foraminal or extraforaminal disc herniation treated with CTGPI. CTGPI was performed only when radicular pain could not be controlled, or in patients who continued requiring pain medication following an acute episode and whose radicular pain precluded them from resuming their daily activities. Forty-six patients with a minimum 2-year follow-up met the inclusion criteria. There were 21 women and 25 men, with a mean age of 47 years. Results: At 1 month after injection, 41 (89%) patients experienced a decrease in radicular pain; 3 experienced no change; and 2 had received surgical treatment. At the final follow-up visit (mean, 74 months) 6 additional patients underwent surgery while 38 (83%) did not require surgery. Pain level comparison between pre-injection and last examination showed that low back pain had decreased a mean of 5 points and radicular pain diminished a mean of 7 points. Twenty-two (58%) of the 38 nonoperated patients had no pain at all and 35 patients had resumed their normal daily activities. No complications were recorded. Conclusion: Based on these results, we consider that the use of CTGPI is a reliable alternative before surgery for patients with foraminal or extraforaminal disc herniation without severe motor deficit but with intractable radicular pain. Final Class of evidence (CoE)-treatment Yes Study design: RCT Cohort Case control Case series • Methods Concealed allocation (RCT) Intention to treat (RCT) Blinded/independent evaluation of primary outcome F/U ≥85% • Adequate sample size • Control for confounding Overall class of evidence IV The definiton of the different classes of evidence is available on page 59.

Percutaneous cement discoplasty for the treatment of advanced degenerative disk disease in elderly patients

PurposeThe authors describe a percutaneous technique to treat advanced degenerative disk disease in elderly patients.MethodA step-by-step technical description based on our experience in selected cases.ResultPostoperative imaging results are presented as well as indications and recommendations.ConclusionPercutaneous discoplasty can result as an alternative minimal invasive strategy for the treatment of advanced degenerative disk disease.

The influence of anatomy (normal versus scoliosis) on the free-hand placement of pedicle screws: Is misplacement more frequent in patients with anatomical deformity?

Study design: Retrospective prognostic study. Objective: To evaluate whether patients with anatomical deformity due to scoliosis have a higher frequency of inaccurate pedicle screw insertion and related complications using the free-hand technique compared with those whose normal anatomy had been impacted by trauma. Methods: Consecutively treated trauma patients with otherwise normal anatomy (48 patients instrumented with 291 screws, group A) and scoliosis patients (24 patients instrumented with 287 screws, group B) were evaluated. Screw position on CT was evaluated using the classification by Gertzbein and Robbins with modification by Karagoz Guzey. (See web appendix at www.aospine.org/ebsj for complete classification description.) Images were examined by two fellows and one junior staff member none of whom participated in patient management. Screw position was determined by consensus. Results: In group A, five (1.7%) out of 289 screws were severely misplaced and 26 (9%) screws caused either medial (3.8%) or lateral (5.2%) cortical breeches. The other 258 (89.3%) screws were fully contained within the cortical boundaries of the pedicle. In group B, seven (2.8%) out of 256 screws were severely misplaced. Thirty-three (13%) screws caused cortical breeches, either medial (9%), lateral (2%), or anterior (2%), and 216 (84.3%) screws were fully contained within the cortical boundaries of the pedicle and the vertebra. Neurological complications were reported in one patient with scoliosis. No vascular complications were reported in either group. Conclusions: The percentage of incorrectly placed screws was similar in both groups, trauma and deformity patients. The presence of vertebral anatomical changes related to adult scoliosis was not associated with an increase in the screw-related neurological or vascular complications. Methods evaluation and class of evidence (CoE) Methodological principle: Study design: Prospective cohort Retrospective cohort • Case control Case series Methods Patients at similar point in course of treatment Follow-up ≥85% • Similarity of treatment protocols for patient groups • Patients followed for long enough for outcomes to occur • Control for extraneous risk factors Evidence class: III The definiton of the different classes of evidence is available on page 73.

Short-term complication rate following orthopedic surgery in a tertiary care center in Argentina

Introduction: Registration of adverse events following orthopedic surgery has a critical role in patient safety and has received increasing attention. The purpose of this study was to determine the prevalence and severity of postoperative complications in the department of orthopedic unit in a tertiary hospital. Methods: A retrospective review from the postoperative complication registry of a cohort of consecutive patients operated in the department of orthopedic surgery from May 2015 to June 2016 was performed. Short-term complications (3 months after surgery), age gender, types of surgery (elective, scheduled urgency, non-scheduled urgency, and emergency), operative time, surgical start time (morning, afternoon or evening), American Society of Anesthesiologists score and surgeons experience were assessed. Complications were classified based on their severity according to Dindo-Clavien system: Grade I complications do not require alterations in the postoperative course or additional treatment; Grade II complications require pharmacological treatment; Grade III require surgical, endoscopic, or radiological interventions without (IIIa) or with (IIIb) general anesthesia; Grade IV are life-threatening with single (IVa) or multi-organ (IVb) dysfunction(s), and require ICU management; and Grade V result in death of the patient. Complications were further classified in minor (Dindo I, II, IIIa) and major (Dindo IIIb, IVa, IVb and V), according to clinical severity. Results: 1960 surgeries were performed. The overall 90-day complication rate was 12.7% (249/1960). Twenty-three complications (9.2 %) were type I, 159 (63.8%) type II, 9 (3.6%) type IIIa, 42 (16.8%) type IIIb, 7 (2.8%) type IVa and 9 (3.6%) were grade V according to Dindo-Clavien classification (DCC). The most frequent complication was anemia that required blood transfusion (27%) followed by wound infection (15.6%) and urinary tract infection (6%). Discussion: The overall complication rate after orthopedic surgery in our department was 12.7%. The implementation of the DCC following orthopedic surgery was an important tool to measure the standard of care.

Factores asociados a recidiva de hernia de disco lumbar luego de una microdiscectomía

INTRODUCTION Lumbar disc hernias are a common cause of spinal surgery. Hernia recurrence is a prevalent complication. OBJECTIVE To analyse the risk factors associated with hernia recurrence in patients undergoing surgery in our institution. MATERIALS AND METHODS Lumbar microdiscectomies between 2010 and 2014 were analysed, patients with previous surgeries, extraforaminales and foraminal hernias were excluded. Patients with recurrent hernia were the case group and those who showed no recurrence were the control group. RESULTS 177 patients with lumbar microdiscectomy, of whom 30 experienced recurrence (16%), and of these 27 were reoperated. Among the risk factors associated with recurrence, we observed a higher rate of disc height, higher percentage of spinal canal occupied by the hernia and presence of degenerative facet joint changes; we observed no differences in sex, body mass index or age. DISCUSSION Previous studies show increased disc height and young patients as possible factors associated with recurrence. CONCLUSION In our series we found that the higher rate of disc height, the percentage of spinal canal occupied by the hernia and degenerative facet joint changes were associated with hernia recurrence.

Osteosintesis directa en espondilolistesis traumática del axis. Reporte de un caso y revision bibliografica.

La espondilolistesis traumatica del axis representa un 5% de las fracturas cervicales y es definida por una fractura de la pars interarticularis de la segunda vertebral cervical. El mecanismo de esta fractura usualmente implica fuerzas de hiperextension. Los aspectos mas importantes realcionados al pronostico y tratamiento son el compromiso discal C2-C3, el compromiso neurologico y la presencia de luxacion facetaria. En relacion al tratamiento conservador o quirurgicos en patrones no desplazados, el tratamiento quirurgico podria resultar en una recuperacion precoz. Por otro lado se han descrito buenos resultados con el uso de Halo chaleco. A continuacion se presenta un caso de espondilolistesis traumatica del axis tratado con osteosintesis directa a traves de un abordaje posterior en un paciente que rechazo el tratamiento conservador.

Diagnosis and Treatment Options for Cervical Spondylodiscitis

Introduction Cervical spondylodiscitis can present through a variety of unspecific signs and symptoms usually associated with a delay diagnosis. The close anatomic relation of the infection process with the spinal cord at this mobile area leads to a serious medical situation. Its low incidence and the lack of papers with high level of evidence in the literature explain why there are no well-established treatment protocols. Our objective was to evaluate retrospectively the treatment of a consecutive series of 19 adult patients treated for cervical spondylodiscitis. Material and Methods 19 patients were evaluated with an average of 4 years of follow up. Eleven patients with a diagnosis of mechanical instability, neurologic compromise, or abscess formation were treated surgically; the remaining 8 were managed conservatively with external immobilization while all received intravenous antibiotics. Staphylococcus aureus, identified in 9 patients, was the most frequent etiologic agent. Results At final follow up all patients presented resolution of signs and symptoms of infection; a solid fusion was obtained in every case. In 5 patients with incomplete spinal cord compromise the remission was complete. Only 1 of the 5 patients with radicular compromise remains with paresthesias. Conclusion According to our selection guidelines, the combination of parenteral antibiotic treatment and external immobilization or surgery proved to be an adequate treatment in our small series of patients with cervical spondilodiscitis.