Sleiman Haddad

COMPOSITE VASCULARIZED FIBULAR EPIPHYSEO-OSTEO-PERIOSTEAL TRANSFER FOR HIP RECONSTRUCTION AFTER PROXIMAL FEMORAL TUMORAL RESECTION IN A 4-YEAR-OLD CHILD

Literature on the reconstruction of the proximal femur in skeletally immature patients with the use of an epiphyseal transplant is scarce and with variable results depending on the indication. We report successful outcomes using a modified vascularized fibular epiphyseal transplant in a 4‐year‐old boy with an oncologic lesion. We discuss the advantages of supplementing the standard graft with a vascularized fibular periosteal tissue.

Global Alignment and Proportion (GAP) Score: Development and Validation of a New Method of Analyzing Spinopelvic Alignment to Predict Mechanical Complications After Adult Spinal Deformity Surgery.

Background: The restoration of normal sagittal alignment is a critical goal in adult spinal deformity surgery to achieve favorable outcomes and prevent mechanical complications. Schwab sagittal modifiers have been accepted as targets for appropriate alignment, but addressing these targets does not always prevent high mechanical complication or revision rates. This may be because the linear absolute numerical parameters do not cover the whole pelvic incidence spectrum and the distribution of lordosis, pelvic anteversion, and negative malalignment are not considered as potential causes of failure. The aim of the present study was to develop and validate a score based on pelvic-incidence-based proportional parameters to better predict mechanical complications. Methods: Two hundred and twenty-two patients (168 women and 54 men) followed for ≥2 years after posterior fusion at ≥4 levels were included in the study. The mean age (and standard deviation) was 52.2 ± 19.3 years (range, 18 to 84 years), and the mean duration of follow-up was 28.8 ± 8.2 months (range, 24 to 62 months). The global alignment and proportion (GAP) score was developed and validated in groups of patients randomly assigned to derivation (n = 148, 66.7%) and validation (n = 74, 33.3%) cohorts. GAP score parameters were relative pelvic version (the measured minus the ideal sacral slope), relative lumbar lordosis (the measured minus the ideal lumbar lordosis), lordosis distribution index (the L4-S1 lordosis divided by the L1-S1 lordosis multiplied by 100), relative spinopelvic alignment (the measured minus the ideal global tilt), and an age factor. Proximal and distal junctional kyphosis and/or failure, rod breakage, and other implant-related complications were considered mechanical complications. The predictive accuracy of the GAP score was analyzed using receiver operating characteristic (ROC) analyses. Associations between GAP categories and mechanical complications and revisions were analyzed using Cochran-Armitage tests. Results: In the validation cohort, 32 patients (43%) experienced mechanical complications and 17 (23%) underwent mechanical revision. The area under curve for the GAP score predicting mechanical complications was 0.92 (standard error [SE] = 0.034, p < 0.001, 95% [confidence interval [CI] = 0.85 to 0.98). Postoperatively, patients with a proportioned spinopelvic state according to the GAP score had a mechanical complication rate of 6% while those with a moderately or severely disproportioned spinopelvic state had rates of 47% and 95%, respectively. Conclusions: The GAP score is a new pelvic-incidence-based proportional method of analyzing the sagittal plane that predicts mechanical complications in patients undergoing surgery for adult spinal deformity. Setting surgical goals according to the GAP score may decrease the prevalence of mechanical complications.

Mid-Term Outcomes and Complications with Cementless Distal Locking Hip Revision Stem with Hydroxyapatite Coating for Proximal Bone Defects and Fractures

We revised the first 100 revision total hip arthroplasties using a cementless distal locking revision stem conducted in our referral centre. Average follow-up was 9.2 years (range: 5.5-12 years). Harris Hip Score improved from 42.5 to 81.6, and none had thigh pain at last follow-up. No significant stress shielding, osteolysis, or radiologic loosening was found. All patients showed radiological evidence of secondary implant osseointegration. Overall survival was 97% with three patients being revised: two stem ruptures and one subsidence. We could trace these complications to technical errors. These findings suggest that a diaphyseal fixation of the revision stem with distal locking can provide the needed primary axial and rotational stability of the prosthesis. This would allow further bony ingrowth, enhanced by the hydroxyapatite coating.

Muscular and glenohumeral changes in the shoulder after brachial plexus birth palsy: an MRI study in a rat model

Background Shoulder abnormalities are the major cause of morbidity in upper brachial plexus birth palsy (BPBP). We developed a rat model of upper trunk BPBP and compared our findings to previously reported animal models and to clinical findings in humans. Methods Forty-three 5-day-old newborn rats underwent selective upper trunk neurectomy of the right brachial plexus and were studied 3 to 20 weeks after surgery. The passive shoulder external rotation was measured and the shoulder joint was assessed bilaterally by a 7.2T MRI bilaterally. Results We found a marked decrease in passive shoulder external rotation, associated with a severe subscapularis muscle atrophy and contracture. None however developed the typical pattern of glenohumeral dysplasia. Conclusions In contradiction with previous reports, our study shows that the rat model is not adequate for preclinical studies of shoulder dysplasia. However, it might serve as a useful model for studies analyzing shoulder contracture occurring after upper BPBP.

Diagnosis and neurologic status as predictors of surgical site infection in primary cervical spinal surgery.

BACKGROUND CONTEXT Surgical site infection (SSI) incidence after cervical spinal surgery ranges from 0.1% to 17%. Although the general risk factors for SSI have been discussed, the relationship of neurologic status and trauma to SSI has not been explicitly explored. PURPOSE This study aimed to study associated risk factors and to report the incidence of SSI in patients who have undergone cervical spinal surgery with the following four preoperative diagnoses: (1) degenerative disease with no myelopathy (MP), (2) degenerative disease with MP, (3) traumatic cervical injury without spinal cord injury (SCI), (4) traumatic cervical injury with SCI. We hypothesize that SSI incidence would increase from Group (1) to Group (4). STUDY DESIGN Retrospective database analysis was carried out. PATIENTS SAMPLE We used International Classification of Diseases codes to identify the four groups of patients in the U.S. Nationwide Inpatient Sample (NIS) from the years 2000 to 2011. We complemented this study with a similar search in our institutional database (ID) from the years 2000 to 2013. Patients with concomitant congenital deformity, infection, inflammatory disease, and neoplasia were excluded, as were revision surgeries. OUTCOME MEASURES The primary outcome studied was the occurrence of SSI. Statistical analyses included bivariate comparisons and chi-square distribution of demographic data and multivariable regression for demographic, surgical, and outcome variables. RESULTS A total of 1,247,281 and 5,540 patients met inclusion criteria in the NIS database and the ID, respectively. Overall SSI incidence was 0.73% (NIS) versus 1.75% (ID). Surgical site infection incidence increased steadily from 0.52% in Group (1) to 1.97% in Group (4) in the NIS data and from 0.88% to 5.54% in the ID. Differences between diagnostic groups and cohorts reached statistical significance. Surgical site infection was predicted significantly by status (odds ratio [OR] 1.69, p<.0001) and trauma (OR 1.30, p=.0003) in the NIS data. Other significant predictors included the following: approach, number of levels fused, female gender, black race, medium size hospital, rural hospital, large hospital, western US hospital and Medicare coverage. In the ID, only trauma (OR 2.11, p=.03) reached significance when accounting for comorbidities. CONCLUSIONS Both primary diagnosis (trauma vs. degenerative) and neurologic status (MP or SCI) were found to be strong and independent predictors of SSI in cervical spine surgery.

Case report: first report of a prosthetic joint infection caused by Facklamia hominis☆ , ☆☆ ,★

Facklamia spp. are gram-positive cocci first described in 1997. They are α-hemolytic, facultative anaerobes, catalase-negative cocci, resembling viridians streptococci on 5% sheep blood agar. Facklamia hominis is, by far, the most common species of the 6 so far described, and it is thought that its natural habitat is the female genital tract. Four previous human infections with Facklamia spp. have been documented. We report the first case of a chronic prosthetic joint infection caused by F. hominis and its successful treatment by a 2-stage exchange procedure to eradicate the infection. This is also the first osteoarticular infection reported. The clinical implications are discussed.

The role of subscapularis muscle denervation in the pathogenesis of shoulder internal rotation contracture after neonatal brachial plexus palsy: A study in a rat model

We assessed the role of subscapularis muscle denervation in the development of shoulder internal rotation contracture in neonatal brachial plexus injury. Seventeen newborn rats underwent selective denervation of the subscapular muscle. The rats were evaluated at weekly intervals to measure passive shoulder external rotation. After 4 weeks, the animals were euthanized. The subscapularis thickness was measured using 7.2T MRI axial images. The subscapularis muscle was then studied grossly, and its mass was registered. The fiber area and the area of fibrosis were measured using collagen‐I inmunostained muscle sections. Significant progressive decrease in passive shoulder external rotation was noted with a mean loss of 58° at four weeks. A significant decrease in thickness and mass of the subscapularis muscles in the involved shoulders was also found with a mean loss of 69%. Subscapularis muscle fiber size decreased significantly, while the area of fibrosis remained unchanged. Our study shows that subscapularis denervation, per se, could explain shoulder contracture after neonatal brachial plexus injury, though its relevance compared to other pathogenic factors needs further investigation.

Relative lumbar lordosis and lordosis distribution index: individualized pelvic incidence–based proportional parameters that quantify lumbar lordosis more precisely than the concept of pelvic incidence minus lumbar lordosis

OBJECTIVE The subtraction of lumbar lordosis (LL) from the pelvic incidence (PI) offers an estimate of the LL required for a given PI value. Relative LL (RLL) and the lordosis distribution index (LDI) are PI-based individualized measures. RLL quantifies the magnitude of lordosis relative to the ideal lordosis as defined by the magnitude of PI. LDI defines the magnitude of lower arc lordosis in proportion to total lordosis. The aim of this study was to compare RLL and PI - LL for their ability to predict postoperative complications and their correlations with health-related quality of life (HRQOL) scores. METHODS Inclusion criteria were ≥ 4 levels of fusion and ≥ 2 years of follow-up. Mechanical complications were proximal junctional kyphosis/proximal junctional failure, distal junctional kyphosis/distal junctional failure, rod breakage, and implant-related complications. Correlations between PI - LL, RLL, PI, and HRQOL were analyzed using the Pearson correlation coefficient. Mechanical complication rates in PI - LL, RLL, LDI, RLL, and LDI interpreted together, and RLL subgroups for each PI - LL category were compared using chi-square tests and the exact test. Predictive models for mechanical complications with RLL and PI - LL were analyzed using binomial logistic regressions. RESULTS Two hundred twenty-two patients (168 women, 54 men) were included. The mean age was 52.2 ± 19.3 years (range 18-84 years). The mean follow-up was 28.8 ± 8.2 months (range 24-62 months). There was a significant correlation between PI - LL and PI (r = 0.441, p < 0.001), threatening the use of PI - LL to quantify spinopelvic mismatch for different PI values. RLL was not correlated with PI (r = -0.093, p > 0.05); therefore, it was able to quantify divergence from ideal lordosis for all PI values. Compared with PI - LL, RLL had stronger correlations with HRQOL scores (p < 0.05). Discrimination performance was better for the model with RLL than for PI - LL. The agreement between RLL and PI - LL was high (κ = 0.943, p < 0.001), moderate (κ = 0.455, p < 0.001), and poor (κ = -0.154, p = 0.343), respectively, for large, average, and small PI sizes. When analyzed by RLL, each PI - LL category was further divided into distinct groups of patients who had different mechanical complication rates (p < 0.001). CONCLUSIONS Using the formula of PI - LL may be insufficient to quantify normolordosis for the whole spectrum of PI values when applied as an absolute numeric value in conjunction with previously reported population-based average thresholds of 10° and 20°. Schwab PI - LL groups were found to constitute an inhomogeneous group of patients. RLL offers an individualized quantification of LL for all PI sizes. Compared with PI - LL, RLL showed a greater association with both mechanical complications and HRQOL. The use of RLL and LDI together, instead of PI - LL, for surgical planning may result in lower mechanical complication rates and better long-term HRQOL.

Ischiofemoral Impingement Syndrome: Outcomes of Endoscopic Resection of the Lesser Trochanter

Ischiofemoral impingement syndrome is a rare clinical entity characterized by chronic groin, buttock or hip pain associated with radiographic evidence of narrowing of the space between the lesser femoral trochanter and the ischial tuberosity. Introduction of magnetic resonance imaging to the clinical practice as well as the establishment of the radiological definition of the abnormal ischiofemoral distance has led to an increasing interest in this condition. Ischiofemoral impingement syndrome is a poorly understood disorder of chronic pain, especially regarding its treatment. The authors present two cases of primary ischiofemoral impingement syndrome successfully treated with a minimally invasive surgical technique. With this endoscopic technique, it was possible to resect the lesser trochanter and restore the ischiofemoral space. Immediate clinical and functional improvement was reported by both patients.

Avulsion of the Femoral Attachment of the Medial Collateral Ligament of the Knee Associated to Complete Tear of the Posterior Cruciate Ligament: A Case Report

Medial collateral ligament (MCL) of the knee is one of the most commonly injured ligaments of the knee. Incidence of posterior cruciate ligament (PCL) injuries can vary widely. Conservative treatment has shown good clinical outcomes and relatively rapid return to play in both injuries alone. We present the case of a 38-year-old male who presented a combined MCL avulsion injury and PCL tear treated surgically. The PCL was reconstructed using the double-bundle Achilles allograft technique. Within the same surgery, a medial femoral incision was performed to reinsert the avulsion of the bone fragment rotated and distally retracted together with the MCL with bone anchors and Spike Washer. Two years after surgery, the patient enjoyed a 0/140-degree range of motion for flexion/extension. He had returned to sports and was pain-free. In conclusion, femoral avulsion of the MCL associated to PCL injury is a rare and nondescribed injury that, as opposed to most MCL isolated injuries, might benefit from early surgical reconstruction.