Surgical treatment of symptomatic degenerative lumbar spondylolisthesis by decompression and instrumented fusion

Degenerative spondylolisthesis is characterized by the slippage of one vertebral body over the one below, with association of intervertebral disc degeneration and degenerative arthritis of the facet joints, which cause spinal stenosis. The aim of this study was to evaluate the clinical and radiographic results of 22 patients with symptomatic degenerative spondylolisthesis, operated on by decompressive laminectomy and instrumented posterolateral fusion associated with interbody fusion (PLIF). Mean age at surgery was 64 years (range, 57\u201372). Clinical results were evaluated on a questionnaire at the last follow-up visit concerning postoperative low back and leg pain, restriction of daily life activities, and resumption of sports activity. Lumbar spine radiographs were used to evaluate the status of fixation devices, the reduction of the spondylolisthesis, the lumbar sagittal balance and the presence of spinal fusion. No intraoperative or postoperative complications were encountered. There were no superficial or deep infections, fixation device loosening, or hardware removal. Mean follow-up time was 4 years (range, 3\u20136 years). Clinical outcome was excellent or good in 19 patients and fair in 3 patients. Preoperatively, mean forward vertebral slipping on neutral lateral radiographs was 5 mm, while postoperatively it decreased to 3 mm. Preoperatively, mean sagittal motion was 3 mm and angular motion was 8\ub0, while postoperatively these values decreased to 1 mm and 1\ub0, respectively. This study demonstrated that spinal decompression followed by transpedicular instrumentation associated with PLIF technique is a valid surgical option for the treatment of degenerative spondylolisthesis with symptomatic spinal stenosis. Clinical outcome, intended as relief of pain and resumption of activity, was improved significantly and fusion rate was high

Sagittal segmental alignment as predictor of adjacent-level degeneration after a cloward procedure.

BACKGROUND: The Cloward anterior interbody fusion is commonly performed for cervical disc herniation or spondylosis. In followup studies, various authors have noted clinically relevant adjacent-level degeneration. However, factors associated with adjacent-level degeneration are not well known. QUESTIONS/PURPOSES: We asked whether the postoperative sagittal segmental alignment of the fused vertebrae could be used as a predictor of adjacent-level degeneration. METHODS: We retrospectively studied 107 patients, aged 35 to 55 years, with one-level cervical disc disease between C4 and C7 operated on from 1985 to 1995 by discectomy and one-level anterior cervical fusion according to the Cloward procedure. In standard radiographs of the cervical spine in lateral view, the alignment of the involved intervertebral space (sagittal segmental alignment) and the sagittal alignment of the cervical spine were measured and the adjacent-level degeneration was assessed using the Kellgren and Lawrence criteria. The minimum followup was 10 years (mean, 16 years; range, 10-23 years). RESULTS: Preoperatively, mean sagittal segmental alignment was 0.6\ub0\ub12.0\ub0 and sagittal alignment of the cervical spine was 17.0\ub0\ub14.9\ub0. At last followup, the mean sagittal segmental alignment was 1.8\ub0\ub14.1\ub0 and mean sagittal alignment of the cervical spine was 19.7\ub0\ub16.6\ub0. Adjacent-level degeneration was present in 60% of cases with postoperative sagittal segmental alignment of 0\ub0 or less and in 27% of cases with postoperative sagittal segmental alignment of more than 0\ub0. CONCLUSIONS: To prevent adjacent-level degeneration, we recommend proper lordotic sagittal segmental alignment when anterior interbody fusion of the cervical spine is indicated. LEVEL OF EVIDENCE: Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence

Guidelines for surgical treatment of hallux rigidus.

Hallux rigidus is a limitation of dorsiflexion of the first metatarsophalangeal joint associated with pain, and its treatment remains a debated topic in orthopaedic surgery. Most authors have recommended resection arthroplasty of the first metatarsophalangeal joint in the past, but others, more recently have presented good results with cheilectomy, various types of osteotomies and arthrodeses or bioreabsorbable implants. The aim of this video is to present guidelines for surgical treatment of hallux rigidus, recently published by the authors showing step by step clinical and X-ray evaluation, classification, algorithm of treatment and different surgical techniques, based on the reviewing 111 consecutive feet operated. Labelling factors of each case were considered for classification. In cases of hallux rigidus without arthritis, surgical treatment consisted in plantar release. In cases with a grade 1 hallux rigidus, surgical treatment consisted in distal decompressive osteotomies. In cases with a grade 2 hallux rigidus, surgical treatment consisted in cheilectomy. In cases with a grade 3 hallux rigidus, surgical treatment consisted in arthrodesis or resection arthroplasty using bioreabsorbable implant. Immediate weight-bearing was allowed with talus shoes for 4 weeks. Results are presented of patients clinically and radiographically checked at an average follow-up of 6 years. The mean clinical pre-operative AOFAS score was 42+14, while at follow-up it was 81+9. The mean pre-operative metatarsophalangeal range of motion was 27+17\ub0, while at follow-up it was 75+8\ub0. Surgical treatment of hallux rigidus depends on its pathoanatomy, and the precise evaluation of labelling factors is the key point to obtain optimal results

Use of homologous bone graft in the treatment of aseptic forearm nonunion

The dyaphyseal nonunion of forearm bones is a complication that changes the normal interaction between radius and ulna, which may lead to forearm malfunction. We reviewed 14 patients treated by surgical technique included a homologous bone graft in combination with a plate. The mean age was 31 years (range, 18-45 years) at the time of surgery. Minimum follow-up was 2 years (mean, 5 years; range, 2-13 years). There were no intraoperative or postoperative complications. At last follow-up, all forearm bones had remodelled. The mean visual analogue pain scale was 1 (range, 0-4). There was a high success rate regarding forearm alignment and functional results; all patients recovered daily and working activities quickly. This surgical technique in treatment of aseptic forearm nonunion by combining homologous bone graft with a plate led to bone healing, improved forearm function, and a durable outcome with long-term follow-up

Pseudoartrosi asettiche di avambraccio trattate mediante placca e innesto osseo contrapposto ed intercalare da perone autologo

Objective Forearm nonunion frequently changes the relationship between the radius end ulna and may lead to impairment of forearm function. We propose a new surgical technique for aseptic forearm nonunionscombining a fibular cortical autograft atrut with a metal plate and a fibukar intercalary autograft in cases with a segmental bone defect. Material and Methods We retrospectively reviewed 20 patients with a mean age of 31 years (range, 17-48 years) at the time of surgery, presenting in 2 cases an isolated nonunion of the radius, in 14 cases an isolated nonunione of the ulna and in 4 cases the nonunion of both bones. Nonunions were atrophic in 18 cases and ipertrophic in 6 cases. Minimum follow-up was 12 years (mean, 14 years; range, 12-21 years). Results There were non intraoperative or postoperative complications. At last follow-up, all forearm bones had remolled. The mean visual analog pain scale was 1 (range, 0-3). Forearm function improved; there were no radiographic signs of ankle arthritis at follow-up. Conlusions Surgical treatment of aseptic forearm nonunions by combining a massive fibular cortical autogrft strut with a plate anmd associating a fibular intercalary autograft in caseof a segmental bone defect led to bone healing, improved forearmfunction, and a durable outcome with long-term follow-up

How to perform a lumbar discectomy?

Herniated disc syndrome in the lumbar spine is the consequence of the conflict between a spinal root or cauda equina and a fragment of nucleous polpous migrated trough the annulus fibrosus. The rapid compression of one or more spinal roots produces severe pain and or sensitive or motor deficits. Lumbar discectomy is usually indicate after 6-12 weeks of conservative treatment if pain remains intractable or in case of severe sensitive or motor deficits. The aim of this video is to show the lumbar discectomy of a 36 Y/O patients suffering from 12 weeks intractable low-back pain associated with right S1 root radiculopathy. 3 cm median skin incision is made from L5 to S1. Paravertebral muscles were detached from the right lamina of L5 and S1. A little laminectomy of right L5 lamina was peformed sparing the lateral articular process and the pars interarticularis. The ligamentum flavum is removed in the interlaminal space, to expose the dural sac and the S1 exiting root. The herniated fragment is identified and carefully removed; attention should be paid to extract the disc fragments in continuity to decreasing the risk of disc herniation fragmenting and leaving residual fragments inaccessible. The herniated disc syndrome in the lumbar spine can successfully treated by discectomy; the articular facet remains intact and the bone removal is little

Kinematics of the three components of a total ankle replacement: in vivo fluoroscopic analysis.

BACKGROUND: Careful kinematic analysis of ankle joints with newly developed prostheses should be carried out to assess the actual performance in vivo. This study analyzed the pattern of motion of the three components of a ligament-compatible ankle replacement, developed to replicate normal joint kinematics. Materials and METHODS: Twelve patients treated with this design were analyzed at 6, 12, and 24 months followup. A series of images were acquired by videofluoroscopy at extremes of the range of motion, and during flexion/extension against gravity and stair-climbing/descending. Three-dimensional positions and orientations of the tibial and talar metal components and of the polyethylene mobile-bearing were obtained from the images by a standard shape-matching procedure. Motion between the three components was calculated and descriptively analyzed. RESULTS: Large tibiotalar joint mobility of the replaced ankle was observed in all three anatomical planes, particularly in the sagittal. In flexion/extension against gravity, the mean range of flexion was 17.6, 17.7, and 16.2 degrees, respectively, over the three followups. The inclination angle of the mean axis of joint rotation was 3.7 degrees down and lateral in the frontal plane and 4.7 degrees posterior and lateral in the transverse plane, similar to those in the normal ankle. The corresponding antero-posterior translation of the meniscal-bearing with respect to the tibia was 3.3, 3.3, and 3.2 mm, with statistically significant correlation with joint flexion. CONCLUSION: Physiological motion can be achieved in ligament-compatible ankle joint replacements. The considerable antero-posterior bearing-to-tibial motion and its coupling with flexion support the main original claims of this design

Trattamenti ortopedici nella distrofia muscolare

Le distrofie muscolari rappresentano un gruppo eterogeneo di patologie ereditarie che colpiscono la muscolatura, caratterizzate dalla progressiva compromissione dell\u2019integrit\ue0 e della funzione muscolare. L\u2019indicazione al trattamento chirurgico ortopedico nei pazienti affetti da distrofia muscolare prevede necessariamente una diagnosi precisa ed una altrettanto accurata valutazione clinica e strumentale, indirizzata in particolar modo ad identificare le risorse funzionali residue del paziente, in modo da poter prevedere un reale beneficio derivante dall\u2019intervento chirurgico, a fronte dell\u2019aumentato rischio operatorio che presentano questi pazienti. Vengono descritti alcuni dei principali trattamenti chirurgici ortopedici pi\uf9 frequentemente utilizzati in pazienti affetti da distrofia muscolare, riportati secondo un criterio di finalit\ue0 legato al beneficio per il paziente che attraverso tali metodiche si intende ottenere, a seconda delle diverse tipologie di paziente e dei diversi quadri clinici e anatomo-patologici della malattia. Tali tecniche, pur senza modificare il decorso della malattia, si sono dimostrate efficaci nel migliorare la qualit\ue0 di vita dei pazienti, consentendo loro di ottimizzare le residue risorse funzionali. Tuttavia, nei pazienti affetti da forme gravi di distrofia muscolare, il trattamento ortopedico spesso non \ue8 in grado di ottenere un beneficio significativo, pertanto \ue8 opportuno riconsiderare la strategia chirurgica a favore del trattamento medico o fisioterapico