Is the Femoral Neck Geometry Adequate for Placement of the Proximal Femoral Nail in the Malaysian Population? A Review of 100 Cases

SUMMARY Issues that had been encountered during proximal femoral fracture fixation using proximal femoral nail include i) the adequacy of the femoral neck width in the local population and ii) the potential difficulty encountered during fixation in certain prefixed angles as determined by the implant. This was a retrospective, descriptive study evaluating the anterior-posterior pelvic radiographs of 100 consecutive patients, from January to August 2007, managed at University Malaya Medical Centre, Kuala Lumpur. The femoral neck width in the population studied was adequate for placement of femoral neck screw and anti-rotation pin or hip pin using the proximal femoral nail implant. (mean = 34.0±3.7mm, min = 24.6mm). There was no significant difference between the working area using an implant angled at 130º or 135º (P=0.91). Both femoral neck width and neck shaft angle of the Malaysian population studied were not a factor influencing the placement of femoral neck lag screws and anti-rotation pin

Cervical Supine Side-Bending versus Cervical Supine Traction Radiographs: Which Is Better in Predicting Proximal Thoracic Flexibility for Lenke 1 and 2 Adolescent Idiopathic Scoliosis?

Study Design Prospective cohort study. Purpose This study compared cervical supine side-bending (CSSB) and cervical supine traction (CST) radiographs to assess the flexibility and predict the correctability of the proximal thoracic (PT) curve for patients with adolescent idiopathic scoliosis (AIS) classified as Lenke 1 and 2. Overview of Literature Knowledge of the flexibility of the PT curve is crucial in the management of patients with AIS. There are no reports comparing CSSB and CST radiographs to assess this parameter. Methods Thirty patients with Lenke 1 and 2 AIS scheduled for posterior spinal fusion surgery were recruited. A standing whole spine radiography and physician-supervised CSSB and CST radiographies were performed. Patient demographic and radiological parameters were recorded, including age, gender, weight, height, body mass index, PT angle, main thoracic angle, CSSB PT angle, CST PT angle, and postoperative PT angle. From the data collected, the curve flexibility and curve correction index were calculated and compared. Results CSSB had a significantly (p <0.05) smaller PT angle (16.6°±10.4°) in comparison to CST (23.7°±10.7°). CSSB had significantly (p <0.05) greater flexibility (44.2%±19.7%) in comparison to CST (19.5%±18.1%). The CSSB correction index (1.2±0.9) was significantly closer to 1 in comparison to the CST correction index (4.4±5.3). There was no difference (p =0.72) between the CSSB PT angle (16.6°±10.4°) and the postoperative PT angle (16.1°±7.5°). However, the CST PT angle (23.7°±10.7°) was significantly (p <0.05) larger than the postoperative PT angle (16.1°±7.5°). Conclusions CSSB radiographs were better for demonstrating PT flexibility and more accurately predicted correctability in comparison to the CST radiographs

Neurological Recovery in Two Patients with Cauda Equina Syndrome Secondary to L5 Lumbar Spine Giant Cell Tumour after Treatment with Denosumab without Surgery

We report two patients with cauda equina syndrome (CES) secondary to L5 giant cell tumour (GCT) who achieved good neurological recovery after treatment with denosumab without surgery. The first patient was a 26-year-old man with L5 GCT causing CES who regained bowel and urinary control, muscle power improvement from grade 2 to grade 4 and Oswestry disability index (ODI) improvement from 48 to 23 after denosumab treatment. The second patient was a 25-year-old woman with L5 GCT causing CES who regained bowel and urinary control, muscle power improvement from grade 0 to grade 4 and ODI improvement from 42 to 20 after denosumab treatment. The usage of denosumab in the treatment of patients with CES due to GCT allows potential neurological recovery without any surgical intervention. If surgery is not contraindicated, more time is obtained to prepare the patient preoperatively to attain safer surgery and to achieve complete tumour clearance

Chronic recurrent multifocal osteomyelitis of the first metatarsal bone: a case report.

We report a case of chronic recurrent multifocal osteomyelitis in a 9-year-old girl. She presented with a 9-month history of gradually worsening pain and swelling in her left foot. Non-steroidal anti-inflammatory drugs were prescribed but the symptoms persisted. She underwent curettage through a small oval corticotomy window on the first metatarsal bone. The pain and swelling improved promptly and she was able to walk without pain 2 weeks later. Curettage enabled rapid symptomatic relief and induced remission, with little risk of complications

The use of a trifurcation of the lateral antebrachial cutaneous nerve for digital nerve grafting

A 17-year-old male was stabbed. The digital nerves to his thumb and radial aspect of the index finger were divided completely and repaired with the FPL tendon and both tendons to the index finger. At 3-months postoperatively there was no recovery of sensibility and the repair was explored. The digital nerve repairs had ruptured at the branching of a large single cutaneous branch of the median nerve into three smaller digital nerves supplying the thumb and the radial aspect of the index finger. The neuroma was excised leaving a gap of 2 cm

Single vs two attending senior surgeons: assessment of intra-operative blood loss at different surgical stages of posterior spinal fusion surgery in Lenke 1 and 2 adolescent idiopathic scoliosis

Purpose: To assess the pattern of intra-operative blood loss at various surgical stages comparing between single and two surgeons. Methods: Lenke 1 and 2 adolescent idiopathic scoliosis (AIS) patients who underwent instrumented posterior spinal fusion (PSF) surgery from two centres between June 2014 and December 2015 were prospectively recruited into this study. The patients were grouped into Group 1 (single surgeon) and Group 2 (two surgeons). One to one matching using ‘prospective propensity score-matched cohort patient sampling method’ was done. The surgery was divided into six stages: stage 1—exposure, stage 2—screw insertion, stage 3—release, stage 4—correction, stage 5—corticotomies and bone grafting and stage 6—closure. Results: A total of 116 patients were recruited. Of 86 patients who were operated by the two surgeons, 30 patients were matched with 30 patients that were operated by a single surgeon. Operation duration was significantly longer in Group 1 (257.3 ± 51.4 min) compared to Group 2 (164.0 ± 25.7 min). The total blood loss was significantly higher in Group 1 (1254.7 ± 521.5 mL) compared to Group 2 (893.7 ± 518.4 mL). Total blood loss/level fused was significantly higher in Group 1 (117.5 ± 42.8 mL/level) compared to Group 2 (82.6 ± 39.4 mL/level). Group 1 had significantly higher blood loss and blood loss/level fused for stages 1, 2 and 3. Group 2 had lower incidence of allogenic blood transfusion. Conclusions: In PSF surgery for AIS patients, two-surgeon strategy was associated with shorter operation duration, lesser blood loss and lower incidence of allogenic blood transfusion

Quantitative analysis of local bone graft harvested from the posterior elements during posterior spinal fusion in Adolescent Idiopathic Scoliosis patients

Objective: This study analyses the quantity of local bone graft obtained from different anatomical parts of the posterior elements during corrective surgery for Adolescent Idiopathic Scoliosis patients. Summary of background data: Locally harvested autogenous bone graft eliminates possible donor site morbidity and has all the important basic bone graft properties such as osteoinductivity, osteogenicity and osteoconductivity. Its usage was reported to be adequate to achieve fusion but none had quantifies the amount of local bone graft harvested. Methods: Total of 40 AIS patients were recruited in the study. All posterior spinal fusion surgeries were performed by the same dual surgeons and same anesthetist with a single observer collecting and measuring bone grafts harvested. The bone grafts harvested from each respective posterior element (spinous processes, laminas, facets and transverses processes) and measured accordingly. Results: There were 36 females and 4 males. Amongst cases recruited, there were 32% Lenke 1, 28% Lenke 2, 8%Lenke 3, 22%Lenke 5 and 10% Lenke 6. Total thoracic levels involved were 333, whereas lumbar levels were 81. The mean total weight of bone graft obtained per case was 36.5 ± 13.7 g. The total weight of lumbar bone graft to the number of lumbar fusion levels (4.5 ± 1.2 g/fusion level) was significantly higher than the total weight of thoracic bone graft to the number of thoracic fusion levels (3.2 ± 1.2 g/fusion level). The amount of bone graft was obtained was highest from lumbar spinous process (42%), followed by thoracic spinous process (32%), lumbar lamina (29%), lumbar facet (28%), thoracic lamina (25%), thoracic facet (22%), and thoracic transverse process (21%). Conclusions: Lumbar vertebra provided more bone graft than thoracic vertebra. Spinous processes contributed the highest amount of local bone graft in the thoracic and lumbar spine

APSS-ASJ Best Clinical Research Award: Is There a Difference between Patients’ and Parents’ Perception of Physical Appearance in Adolescent Idiopathic Scoliosis?

Study Design Prospective study. Purpose To compare patients’ and parents’ perceptions of physical attributes (PAs) of adolescent idiopathic scoliosis (AIS) patients and to report any correlations between their perceptions and Scoliosis Research Society-22r (SRS-22r) scores. Overview of Literature Few studies have looked into the differences between patients’ and parents’ perceptions of their appearance. Methods AIS patient–parent pairs (n=170) were recruited. The patients’ and parents’ perceptions of six PAs were evaluated: waist asymmetry (WA), rib hump (RH), shoulder asymmetry (SA), neck tilt, breast asymmetry (BrA), and chest prominence. These PAs were ranked, and an aggregate PA (Agg-PA) score was derived from a score assigned to the attribute (6 for the most important PA and 1 for the least important). The patients also completed the SRS-22r questionnaire. Results Ninety-nine patients (58.2%) and 71 patients (41.8%) had thoracic and lumbar major curves, respectively. WA was ranked first by 54 patients (31.8%) and 50 parents (29.4%), whereas RH was ranked first by 50 patients (29.4%) and 38 parents (22.4%). The overall Agg-PA scores were similar for patients and parents (p>0.05). However, for thoracic major curves (TMCs) >40°, a significant difference was noted between the Agg-PA scores of patients and parents for SA (3.5±1.6 vs. 4.2±1.6, p=0.041) and BrA (3.0±1.6 vs. 2.2±1.3, p=0.006). For TMCs 40°, there were significant differences in the Agg-PA for SA and BrA. Pa¬tients were more concerned about BrA and parents were more concerned about SA. Patients’ perception of the six PAs had weak correlation with SRS-22r scores

Do the dynamic stress mobility radiographs predict the postoperative vertebral height restoration, kyphosis correction, and cement volume injected after vertebroplasty for osteoporotic thoracolumbar vertebral fractures with intravertebral cleft?

Background: This prospective clinical–radiological study was conducted to determine whether the dynamic mobility stress radiographs can predict the postoperative vertebral height restoration, kyphosis correction, and cement volume injected after vertebroplasty. Methods: Patients included had the diagnosis of significant back pain caused by osteoporotic vertebral compression fracture secondary to trivial injury. All the patients underwent routine preoperative sitting lateral spine radiograph, supine stress lateral spine radiograph, and supine anteroposterior spine radiograph. The radiological parameters recorded were anterior vertebral height (AVH), middle vertebral height (MVH), posterior vertebral height (PVH), MVH level below, wedge endplate angle (WEPA), and regional kyphotic angle (RKA). The supine stress versus sitting difference (SSD) for all the above parameters were calculated. Results: A total of 28 patients (4 males; 24 females) with the mean age of 75.6 ± 7.7 years were recruited into this study. The mean cement volume injected was 5.5 ± 1.8 ml. There was no difference between supine stress and postoperative radiographs for AVH (p = 0.507), PVH (p = 0.913) and WEPA (p = 0.379). The MVH (p = 0.026) and RKA (p = 0.005) were significantly less in the supine stress radiographs compared to postoperative radiographs. There was significant correlation (p 0.05). Only the SSD-MVH had significant correlation with cement volume, but the correlation was weak (r = 0.39, p = 0.04). Conclusions: Dynamic mobility stress radiographs can predict the postoperative vertebral height restoration and kyphosis correction after vertebroplasty for thoracolumbar osteoporotic fracture with intravertebral clefts. However, it did not reliably predict the amount of cement volume injected as it was affected by other factors

Posterior Spinal Fusion in a Scoliotic Patient With Congenital Heart Block Treated With Pacemaker: An Intraoperative Technical Difficulty

STUDY DESIGN: Case report. OBJECTIVE: To describe the technical difficulties on performing posterior spinal fusion (PSF) on a pacemaker-dependent patient with complete congenital heart block and right thoracic scoliosis. SUMMARY OF BACKGROUND DATA: Congenital complete heart block requires pacemaker implantation at birth through thoracotomy, which can result in scoliosis. Corrective surgery in this patient was challenging. Height gain after corrective surgery may potentially cause lead dislodgement. The usage of monopolar electrocautery may interfere with the function of the implanted cardiac device. METHODS: A 17-year-old boy was referred to our institution for the treatment of right thoracic scoliosis of 70°. He had underlying complete congenital heart block secondary to maternal systemic lupus erythematosus. Pacemaker was implanted through thoracotomy since birth and later changed for four times. PSF was performed by two attending surgeons with a temporary pacing inserted before the surgery. The monopolar electrocautery device was used throughout the surgery. RESULTS: The PSF was successfully performed without any technical issues and complications. Postoperatively, his permanent pacemaker was functioning normally. Three days later, he was recovering well and was discharged home from hospital. CONCLUSION: This case indicates that PSF can be performed successfully with thoughtful anticipation of technical difficulties on a pacemaker-dependent patient with underlying congenital heart block.5