Publications by authors named "Alexander Aichmair"

45 Publications

Incidence of lateral femoral cutaneous nerve lesions after direct anterior approach primary total hip arthroplasty - a literature review.

Orthop Traumatol Surg Res 2021 May 4:102956. Epub 2021 May 4.

II. Orthopedic Department, Orthopedic Hospital Speising, Speisinger Str. 109, 1130 Vienna, Austria; Michael Ogon Laboratory for Orthopedic Research, Orthopedic Hospital Speising, Speisinger Str. 109, 1130 Vienna, Austria.

Introduction: Lesions of the lateral cutaneous femoral nerve are a reported complication of the direct anterior approach (DAA) for total hip arthroplasty (THA). Little is known about the incidence rates of this lesion. The goal of this study was to answer the following questions: (1) Is the true incidence rate of LFCN lesions after DAA THA known? (2) What are the reasons for the wide range of reported incidence rates in the literature? (3) Are surgeons increasingly aware of the significance of LFCN lesions?

Methods: A US Medical Library of Medicine database search was performed for DAA THA. In total, 1261 search results were screened for reported LFCN lesions.

Results: Forty-five studies were included reporting LFCN lesions rates of 0-83%. Subgroup analysis for studies with (group A, 6 studies, n=1113 cases) and without (group B, 39 studies n=16,741) primary focus on the LFCN lesions was performed. Incidence in group A ranged from 14.8-81% (mean 31%) and 0-83% (mean 3.8%) in group B. The difference between the groups was significant (p=0.005). No uniform and time sensitive definition of postoperative LFCN lesions was found in the literature. An analysis of the publication year and the discovered incidence rate showed an increase of incidence rates [r=0.521 (p<0.001, two-tailed)] over time.

Conclusion: Despite the absence of a uniform definition: LFCN lesions after DAA THA are a frequent and, in the past, often underestimated complication.

Level Of Evidence: IV; systematic review of level II to level IV studies.
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http://dx.doi.org/10.1016/j.otsr.2021.102956DOI Listing
May 2021

Reconstruction of Proximal Metaphyseal Femoral Defects Using Trabecular Metal Augments in Revision Total Hip Arthroplasty.

Arthroplast Today 2021 Apr 14;8:216-221. Epub 2021 Apr 14.

Michael Ogon Laboratory for Orthopaedic Research, Orthopaedic Hospital Vienna-Speising, Vienna, Austria.

Porous tantalum augments are widely used in revision total hip arthroplasty for the reconstruction of severe bone defects. Here, we present the first 3 cases who underwent femoral revision arthroplasty using standard distal femoral and proximal tibial porous tantalum cones to reconstruct severe bone loss in the proximal femur. Cones were inserted press fit, followed by implantation of a cemented revision stem in all cases. After a mean follow-up period of 15.8 months, all patients showed an improved Harris-Hip-Score and no radiological signs of subsidence or loosening. Porous tantalum cones may be an option in the reconstruction of severe femoral defects in revision total hip arthroplasty. The shape of the tantalum cones should be optimized for the use in the proximal femur.
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http://dx.doi.org/10.1016/j.artd.2021.03.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8079334PMC
April 2021

Impact of the 1st and 2nd Wave of the COVID-19 Pandemic on Primary or Revision Total Hip and Knee Arthroplasty-A Cross-Sectional Single Center Study.

J Clin Med 2021 Mar 18;10(6). Epub 2021 Mar 18.

Michael Ogon Laboratory for Orthopaedic Research, Orthopaedic Hospital Vienna-Speising, Speisinger Straße 109, 1130 Vienna, Austria.

The aim of this study was to evaluate the number of primary and revision total joint arthroplasties (TJA/rTJA) in 2020 compared to 2019. Specifically, the first and the second waves of the COVID-19 pandemic were evaluated as well as the pre-operative COVID-19 test. A cross-sectional single-center study of our prospectively maintained institutional arthroplasty registry was performed. The first COVID-19 wave and the second COVID-19 wave led to a socioeconomic lockdown in 2020. Performed surgeries, cause of revision, age, gender, and American Society of Anesthesiologists-level were analyzed. Preoperative COVID-19 testing was evaluated and nationwide COVID-19 data were compared to other countries. In 2020, there was a decrease by 16.2% in primary and revision TJAs of the hip and knee compared to 2019. We observed a reduction of 15.8% in primary TJAs and a reduction of 18.6% on rTJAs in 2020 compared to 2019. There is an incline in total hip arthroplasties (THAs) and a decline in total knee arthroplasties (TKAs) comparing 2019 to 2020. During the first wave, there was a reduction in performed primary TJAs of 86%. During the second wave, no changes were observed. This is the first study quantifying the impact of the COVID-19 pandemic on primary and revision TJAs regarding the first and second wave.
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http://dx.doi.org/10.3390/jcm10061260DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8003209PMC
March 2021

Analysis of Culture Positive First and Second Stage Procedures in Periprosthetic Knee and Hip Joint Infections.

J Arthroplasty 2021 Jun 2;36(6):2158-2164. Epub 2021 Feb 2.

Michael Ogon Laboratory for Orthopaedic Research, Orthopaedic Hospital Vienna-Speising, Vienna, Austria; 2nd Department, Orthopaedic Hospital Vienna-Speising, Vienna, Austria.

Background: A positive microbiological result at reimplantation may lead to a failed 2-stage revision arthroplasty in the treatment of periprosthetic joint infections. Little is known about changes in microbiological spectrum and resistance pattern between culture positive first and second stage procedures in revision knee and hip arthroplasty.

Methods: Between January 2011 and December 2019, we performed 327 two-stage revision arthroplasties on 312 patients. There were 37 of 312 (11.9%) patients (20 hips/17 knees) who had a positive microbiological culture during the first and second stage procedure. We analyzed the microbiological spectrum, antimicrobial resistance pattern, and clinical outcome of culture positive first and second stage procedures as well as subsequent re-revisions.

Results: Re-revision was necessary in 40.5% (15/37) of patients with culture positive first and second stage procedure at a median follow-up of 3.5 years. We found microbiological changes in 83.8% (31/37) of patients between the first and second stage and in 88.9% (8/9) between the second stage and subsequent culture positive re-revision. Polymicrobial infections were found in 21.6% (8/37) of first and in 16.2% (6/37) of second stage procedures. In 27% (10/37) of patients, microorganisms persisted between the first and second stage procedure. The antimicrobial resistance pattern changed in 60% of persistent microorganisms between the first and second stage procedure.

Conclusion: Changes in microbiological spectrum and resistance pattern are common between culture positive first and second stage procedures as well as subsequent re-revisions. This has to be considered in the antimicrobial treatment of periprosthetic joint infections.
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http://dx.doi.org/10.1016/j.arth.2021.01.074DOI Listing
June 2021

Biomechanical and Clinical Evaluation of the Optimal Arm Position After Rotator Cuff Surgery With an Adjustable Abduction Brace.

Orthopedics 2021 Jan 15;44(1):e1-e6. Epub 2020 Dec 15.

Abduction braces are used with the intention of relieving tension on the supraspinatus, thereby protecting an operative repair. It is not known, however, whether patients wearing a brace do deposit the weight of the arm on the brace effectively or actively stabilize the arm despite the brace. It is further unknown what position of the arm is most effective to relax the shoulder and is considered most comfortable. Twenty-two patients who had undergone an arthroscopic supraspinatus repair were postoperatively fitted with a standard abduction brace equipped with a torque sensor to measure the weight of the arm on the brace on the first and second postoperative days. The most comfortable arm position, tear size, and degenerative muscular changes on magnetic resonance imaging were assessed. Most patients (15 vs 5) preferred a low angle of abduction with the brace in the scapular rather than the true frontal plane irrespective of tear location or size. While loads applied to the brace were slightly higher at high abduction angles (70° and 90°) under regional anesthesia (day 1), they were significantly higher at low abduction angles (30° and 50°) with the arm fully awake (day 2). The most comfortable brace position-which is at low angles of abduction (30° to 50°) in the scapular plane-is associated with the highest load transfer to the brace in the unanesthetized arm. The authors therefore conclude that if an abduction brace is used, it should be fitted in the scapular plane with an abduction angle between 30° and 50°. [Orthopedics. 2021;44(1):e1-e6.].
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http://dx.doi.org/10.3928/01477447-20201210-01DOI Listing
January 2021

Accuracy of 3D-planned patient specific instrumentation in high tibial open wedge valgisation osteotomy.

J Exp Orthop 2020 Feb 27;7(1). Epub 2020 Feb 27.

Computer Assisted Research and Development Group (CARD), Balgrist University Hospital, University of Zurich, Zurich, Switzerland.

Purpose: High tibial osteotomy (HTO) is an effective treatment option in early osteoarthritis. However, preoperative planning and surgical execution can be challenging. Computer assisted three-dimensional (3D) planning and patient-specific instruments (PSI) might be helpful tools in achieving successful outcomes. Goal of this study was to assess the accuracy of HTO using PSI.

Methods: All medial open wedge PSI-HTO between 2014 and 2016 were reviewed. Using pre- and postoperative radiographs, hip-knee-ankle angle (HKA) and posterior tibial slope (PTS) were determined two-dimensionally (2D) to calculate 2D accuracy. Using postoperative CT-data, 3D surface models of the tibias were reconstructed and superimposed with the planning to calculate 3D accuracy.

Results: Twenty-three patients could be included. A mean correction of HKA of 9.7° ± 2.6° was planned. Postoperative assessment of HKA correction showed a mean correction of 8.9° ± 3.2°, resulting in a 2D accuracy for HKA correction of 0.8° ± 1.5°. The postoperative PTS changed by 1.7° ± 2.2°. 3D accuracy showed average 3D rotational differences of - 0.1° ± 2.3° in coronal plane, - 0.2° ± 2.3° in transversal plane, and 1.3° ± 2.1° in sagittal plane, whereby 3D translational differences were calculated as 0.1 mm ± 1.3 mm in coronal plane, - 0.1 ± 0.6 mm in transversal plane, and - 0.1 ± 0.6 mm in sagittal plane.

Conclusion: The use of PSI in HTO results in accurate correction of mechanical leg axis. In contrast to the known problem of unintended PTS changes in conventional HTO, just slight changes of PTS could be observed using PSI. The use of PSI in HTO might be preferable to obtain desired correction of HKA and to maintain PTS.
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http://dx.doi.org/10.1186/s40634-020-00224-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7046844PMC
February 2020

Applicability of augmented reality in orthopedic surgery - A systematic review.

BMC Musculoskelet Disord 2020 Feb 15;21(1):103. Epub 2020 Feb 15.

Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zürich, Switzerland.

Background: Computer-assisted solutions are changing surgical practice continuously. One of the most disruptive technologies among the computer-integrated surgical techniques is Augmented Reality (AR). While Augmented Reality is increasingly used in several medical specialties, its potential benefit in orthopedic surgery is not yet clear. The purpose of this article is to provide a systematic review of the current state of knowledge and the applicability of AR in orthopedic surgery.

Methods: A systematic review of the current literature was performed to find the state of knowledge and applicability of AR in Orthopedic surgery. A systematic search of the following three databases was performed: "PubMed", "Cochrane Library" and "Web of Science". The systematic review followed the Preferred Reporting Items on Systematic Reviews and Meta-analysis (PRISMA) guidelines and it has been published and registered in the international prospective register of systematic reviews (PROSPERO).

Results: 31 studies and reports are included and classified into the following categories: Instrument / Implant Placement, Osteotomies, Tumor Surgery, Trauma, and Surgical Training and Education. Quality assessment could be performed in 18 studies. Among the clinical studies, there were six case series with an average score of 90% and one case report, which scored 81% according to the Joanna Briggs Institute Critical Appraisal Checklist (JBI CAC). The 11 cadaveric studies scored 81% according to the QUACS scale (Quality Appraisal for Cadaveric Studies).

Conclusion: This manuscript provides 1) a summary of the current state of knowledge and research of Augmented Reality in orthopedic surgery presented in the literature, and 2) a discussion by the authors presenting the key remarks required for seamless integration of Augmented Reality in the future surgical practice.

Trial Registration: PROSPERO registration number: CRD42019128569.
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http://dx.doi.org/10.1186/s12891-020-3110-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7023780PMC
February 2020

Classification of perioperative complications in spine surgery.

Spine J 2020 05 23;20(5):730-736. Epub 2019 Dec 23.

Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, Zurich 8008, Switzerland.

Background Context: Perioperative complications affect surgical outcomes. Classification systems of perioperative complications are well established and widely applied in many surgical fields other than spine surgery.

Purpose: The aim of this study was to construct and validate a comprehensive classification system for perioperative complications in spine surgery.

Study Design: Retrospective case series.

Methods: A comprehensive classification system was constructed to stratify complications in spinal surgery and consequently applied to 934 patients who consecutively underwent spine surgery in a university hospital setting. A complication was defined as any kind of deviation from the normal perioperative course, ranging from a postoperative anemia to death. The comprehensive classifications system stratifies complications according to (1) complexity of index procedure (2) immediate cause of complication (surgical vs. medical) (3) the required treatment, and (4) potentially associated long-term functional deficits resulting from neural injury. Subsequently, the proposed classification system was validated by applying the duration of cumulative hospital stay as the primary outcome.

Results: Perioperative complications were recorded in 135 (14.3%) out of 934 cases. There was a significant difference in the hospital stay between complications stratified according to therapeutic consequences, grade A: 5.6±1.6 (range: 3-8) days, grade B: 7.9±3.8 (range: 3-21) days, grade C: 13.1±8.1 (range: 4-59) days, and grade D: 55.2±56.6 (range: 14-198) days, respectively (p≤.001). Also, there was a significant difference in hospital stay between groups of increasing point difference of neurologic deficit, 0 versus -1 and -1 versus -2, respectively.

Conclusion: A comprehensive classification system for perioperative complications in spine surgery (considering four categories) is presented and validated. The categories therapeutic consequence (A-E) and decrease in neurological function correlate strongly with hospital stay.
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http://dx.doi.org/10.1016/j.spinee.2019.12.013DOI Listing
May 2020

Acromial Fractures Following Reverse Total Shoulder Arthroplasty: A Cohort Controlled Analysis.

Orthopedics 2020 Jan 8;43(1):15-22. Epub 2019 Nov 8.

Fractures of the acromion can develop after reverse total shoulder arthroplasty (RTSA). This study sought to identify risk factors for acromial fractures in patients with RTSA. A total of 1146 RTSAs were performed at the authors' institution between 1999 and 2016. In 21 patients (1.8%), the authors identified an acromial fracture during the postoperative course. These patients were compared with a matched cohort of 84 patients who had not developed an acromial fracture postoperatively. As an indicator of changes in pre- to postoperative deltoid loading, the authors created an angle called the "delta angle." There was an elevated risk for acromial fractures with lower lateralization of the humerus from pre- to postoperatively (4.1±7.1 mm vs 8.4±6.1 mm; P=.006), lower preoperative anteroposterior acromial slope (117.3°±11.2° vs 121.7°±17.0°; P=.044), and higher glenoid inclination (beta angle, 72.0°±5.5° vs 76.5°±6.8°; P=.005). Pre- to postoperative changes in the beta angle (9.2°±8.0° vs 4.4°±9.4°; P=.022) and the delta angle (29.4°±8.1° vs 19.5°±9.7°; P<.001) were larger in the fracture group. In addition, diagnosed and treated osteoporosis appeared to be a risk factor for acromial fractures (33% vs 13%; P=.047). The delta angle after RTSA seems to correlate with the risk of developing an acromial fracture. Patients with a high glenoid inclination and/or osteoporosis should be informed that they are at risk. Further, surgeons should be aware that lower distalization together with greater medialization of the center of rotation was associated with more acromial fractures in this study. [Orthopedics. 2020; 43(1):15-22.].
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http://dx.doi.org/10.3928/01477447-20191031-03DOI Listing
January 2020

No benefit of early versus late ambulation after incidental durotomy in lumbar spine surgery: a randomized controlled trial.

Eur Spine J 2020 01 24;29(1):141-146. Epub 2019 Sep 24.

University Spine Center Zurich, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland.

Purpose: Incidental durotomy (ID) is a complication occurring in 4-17% of decompressive spinal surgeries. Persisting CSF leakage can occur even after ID repair and requires revision surgery. Prolonged flat bed rest (BR) to reduce the incidence of persisting CSF leakage is frequently applied but highly debated. A randomized controlled trial comparing prolonged BR versus early ambulation after ID repair is lacking. The aim of this study was to investigate the incidence of revision surgery as a result of persistent cerebro-spinal fluid (CSF) leakage and medical complications after immediate or late post-operative ambulation following ID during decompressive spinal surgery.

Methods: Ninety-four of 1429 consecutive cases undergoing lumbar spine surgery (6.58%) were complicated by an ID. Sixty patients (mean age of 64 ± 13.28 years) were randomized to either early post-operative ambulation (EA, n = 30) or flat BR for 48 h (BR, n = 30). The incidence of CSF leakage resulting in revision surgery, medical complications and duration of hospitalization were compared between groups.

Results: Two patients in the BR group and two patients in the EA group underwent revision surgery as a result of persisting CSF leakage. Four patients in the BR group experienced medical complications associated with prolonged immobilization. The duration of hospitalization was 7.25 ± 3.0 days in the BR group versus 6.56 ± 2.64 days in the EA group, p = 0.413.

Conclusion: The results of this study indicate no benefit of prolonged BR after an adequately repaired ID in lumbar spine surgery.

Level Of Evidence: Level 1b (individual randomized controlled trial). These slides can be retrieved under Electronic Supplementary Material.
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http://dx.doi.org/10.1007/s00586-019-06144-5DOI Listing
January 2020

Validation of a Virtual Reality-Based Hip Arthroscopy Simulator.

Arthroscopy 2019 03 4;35(3):789-795. Epub 2019 Feb 4.

Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.

Purpose: To assess construct and face validity of a novel virtual reality-based hip arthroscopy simulator using the previously validated Arthroscopic Surgery Skills Evaluation Tool (ASSET), metric parameters, and a questionnaire.

Methods: Metric parameters including task completion time, camera path, and grasper path were recorded, and the ASSET score was used to assess construct validity. Face validity was evaluated using a questionnaire.

Results: Nine hip arthroscopy experts, of whom the majority performed more than 200 procedures (age, 48 ± 7.3; range, 38-61 years; 8 men, 1 woman), and 33 nonexperts (age, 33 ± 7.9; range, 26-62 years; 25 men, 8 women) performed 3 individual tasks on a virtual reality-based arthroscopy simulator of a left hip. The ASSET global rating scale showed a statistically significant difference between the hip arthroscopy expert and the nonexpert group, indicating strong construct validity (25.0 in the expert group, range, 17-34, versus 15.30 in the nonexpert group, range, 8-30 [P < .001], respectively). This also applied to most metric parameters recorded by the simulator. The simulator also demonstrated high face validity. The overall impression in terms of realism was graded "completely realistic" by 17% and "close to realistic" by 62% of participants.

Conclusions: The tested simulator demonstrated high construct and face validity.

Clinical Relevance: This study demonstrates the construct and face validity of a novel hip arthroscopy simulator. The device proved to be an adequate model for the simulation of some arthroscopic procedures of the hip.
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http://dx.doi.org/10.1016/j.arthro.2018.10.131DOI Listing
March 2019

Risk factors for perioperative morbidity in spine surgeries of different complexities: a multivariate analysis of 1,009 consecutive patients.

Spine J 2018 09 13;18(9):1625-1631. Epub 2018 Feb 13.

Spine Division, Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland. Electronic address:

Background Context: There is a broad spectrum of complications during or after surgical procedures, with differing incidences reported in the published literature. Heterogeneity can be explained by the lack of an established evidence-based classification system for documentation and classification of complications in a standardized manner.

Purpose: The objective of this study was to identify predictive risk factors for perioperative and early postoperative morbidities in spine surgeries of different complexities in a large cohort of consecutive patients.

Study Design: This study is a retrospective case series.

Outcome Measures: The outcome measures are the occurrence of perioperative and early postoperative morbidities.

Methods: A classification of surgical complexity (Grades I-III) was created and applied to 1,009 patients who consecutively underwent spine surgery at a single university hospital. The incidence and the type of perioperative and early postoperative morbidities were documented. Multivariate binary logistic regression analyzed risk factors for (1) hospital stay of ≥10 days, (2) intermediate care unit (IMC) stay of ≥24 hours, (3) blood loss of >500 mL, and occurrence of a (4) surgical or (5) medical morbidity.

Results: A deviation from the regular postoperative course (defined as "morbidity") included surgical reasons, such as relapse of symptoms of any kind (3.3%), wound healing problems (2.4%), implant-associated complications (1.6%), postoperative neurologic deficits (1.5%), infection (1.5%), fracture (0.8%), and dural tear in need of revision (0.6%). Medical reasons included anemia (1.8%), symptomatic electrolyte derailment (1.0%), and cardiac complications (0.7%), among others. An independent risk factor associated with a surgical reason for an irregular postoperative course was male gender. Risk factors associated with a medical reason for an irregular postoperative course were identified as preoperatively high creatinine levels, higher blood loss, and systemic steroid use. Independent risk factors for a prolonged hospitalization were preoperatively high C-reactive protein level, prolonged postoperative IMC stay, and revision surgery. Spinal stabilization or fusion surgery, particularly if involving the lumbosacral spine, age, and length of surgery were associated with blood loss of >500 mL. Higher surgical complexity, involvement of the pelvis in instrumentation, American Society of Anesthesiologists Grade ≥III, and preoperatively higher creatinine levels were associated with a postoperative IMC stay of >24 hours.

Conclusions: The present study confirms several modifiable and non-modifiable risk factors for perioperative and early postoperative morbidities in spine surgery, among which surgical factors (such as complexity, revision surgery, and instrumentation, including the pelvis) play a crucial role. A classification of surgical complexity is proposed and validated.
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http://dx.doi.org/10.1016/j.spinee.2018.02.003DOI Listing
September 2018

Early clinical and radiological results of unilateral posterior pedicle instrumentation through a Wiltse approach with lateral lumbar interbody fusion.

J Spine Surg 2017 Sep;3(3):338-348

Department of Orthopedic Surgery, Spine and Scoliosis Service, Hospital for Special Surgery, Weill Cornell Medical College, New York City, NY, USA.

Background: To assess the clinical outcomes of 44 patients who underwent single-level lateral lumbar interbody fusion (LLIF) with unilateral pedicle screw instrumentation through a paramedian Wiltse approach.

Methods: Demographic, comorbidity, clinical assessment, peri-operative, and complication data were assessed. Visual analog scale (VAS), Oswestry disability index (ODI), and short form-12 (SF-12) were used to assess clinical outcomes. Post-operative plain radiographs were assessed for subsidence, cage migration, and fusion.

Results: Average age of patients at surgery was 60.8±10.6 years (range, 32-79 years), with 15 males and 29 females. Recombinant human bone morphogenic protein-2 (rhBMP-2) was used in 32 cases (73%) and 13 posterolateral fusions (30%). Average duration of surgery was 195.2±36.9 minutes (range: 111-295 minutes), with an estimated blood loss of 159.3±90.8 cc (range, 50-500 cc). There were no intra-operative complications. Average length of hospital stay was 4.2±2.5 days (range, 2-13 days). Four patients (9%) experienced neurological deficit, 2 of which resolved by 3-month follow-up and 2 of which improved but did not resolve by final follow-up at 11 and 16 months. There was significant improvement in VAS (P<0.001), ODI (P<0.001), and SF-12 physical component (P<0.001), but not for SF-12 mental component (P=0.053). Patients with minimum 6 months radiographic follow-up demonstrated successful fusion in 90% of cases (35/39), with 2 cases of grade 1 (5%) subsidence of the adjacent cranial vertebra, and no cases higher than grade 0 subsidence of the adjacent caudal vertebra.

Conclusions: Unilateral pedicle screw instrumentation following LLIF was associated with significant improvement in clinical outcomes and favorable radiographic outcomes.
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http://dx.doi.org/10.21037/jss.2017.06.16DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5637208PMC
September 2017

Lateral lumbar interbody fusion with unilateral pedicle screw fixation for the treatment of adjacent segment disease: a preliminary report.

J Spine Surg 2017 Sep;3(3):330-337

Department of Orthopedic Surgery, Spine and Scoliosis Service, Hospital for Special Surgery, Weill Cornell Medical College, New York City, NY, USA.

Background: To assess the clinical outcomes of 20 patients who underwent single level unilateral pedicle screw fixation following lateral lumbar interbody fusion (LLIF) for treatment of lumbar adjacent segment disease (ASD).

Methods: Demographic, comorbidity, clinical assessment, peri-operative, and complication data were assessed. Visual analog scale (VAS), Oswestry disability index (ODI), and short form-12 (SF-12) were used to assess clinical outcomes. Post-operative radiographs were assessed for subsidence, cage migration, and fusion.

Results: Average age of patients was 63.2±13.7 years (range, 41-86 years), with 8 males and 12 females. Recombinant human bone morphogenic protein-2 (rhBMP-2) was utilized in 18 LLIF cages (90%) and 12 posterolateral fusions (60%). Mean operation time was 214.1±47.2 minutes (range, 146-342 minutes), mean estimated blood loss of 187.5±90.1 cc (range, 50-400 cc). No patients received a blood transfusion. There were no intra-operative complications. Mean hospital length of stay was 4.4±1.7 days (range, 2-9 days). At final follow-up (mean: 13.0±12.7 months after surgery), there was significant improvement in post-op VAS (P=0.006) score compared to pre-op, but not ODI (P=0.181), SF-12 PC (P=0.480), and SF-12 MC (P=0.937). Patients with >6 months of post-operative imaging (14/20, 70%) demonstrated successful fusion in 13 out of 14 cases (93%). There was grade 0 subsidence of adjacent cranial vertebra in all cases (100%). There was grade 0 subsidence of the adjacent caudal vertebra in 13 cases (93%) and grade 1 subsidence in 1 case (7%). There was evidence of cage migration in 3 cases (21%). There were 4 patients (20%) who experienced transient neurological deficits that eventually resolved. Two patients required surgery for further ASD.

Conclusions: In conclusion, this pilot study suggests that patients who undergo LLIF with unilateral pedicle screw fixation for treatment of ASD may have significantly reduced pain and favorable radiographic results. Further investigation in techniques for treatment of ASD is warranted.
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http://dx.doi.org/10.21037/jss.2017.06.17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5637191PMC
September 2017

Total knee arthroplasty in patients with a history of illicit intravenous drug abuse.

Int Orthop 2018 01 14;42(1):101-107. Epub 2017 Oct 14.

Department of Orthopaedics, Balgrist University Hospital, University of Zurich, 8008, Zurich, Switzerland.

Purpose: Injection drug users are at high risk for both infection with blood-borne pathogens, namely, human immune deficiency virus (HIV), hepatitis-B, -C virus, various bacterial infections, as well as early primary and secondary joint degeneration. When total knee arthroplasty (TKA) is anticipated the risk of septic complications is a major concern. The purpose of this study was to assess the clinical and radiographic outcome of patients with a history of intravenous drug use after total knee arthroplasty. The primary outcome was revision rate. Secondary outcomes were the Western Ontario and McMaster Universities Arthritis Index (WOMAC), Knee Society Score (KSS) and radiographic loosening.

Methods: We retrospectively reviewed the records of 1,692 TKA performed or revised in our institution. Data of 18 TKA in 12 patients (11 male, 1 female; average age 42, range 23-62 years) with a history of intravenous opioid abuse were available for final analysis.

Results: The mean follow up was 125 (range 25-238) months. Seven patients required revision surgery due to periprosthetic joint infection after 62 months (range 5-159): one two staged revision, three arthrodesis and three amputations. The median prosthesis survival was 101 (95%-CI 48-154) months.

Conclusion: Total knee arthroplasty in patients with a history of intravenous drug abuse is associated with major complications, including above-the-knee amputation. If permanent abstinence from intravenous drug abuse is doubtful, other therapeutic options including primary arthrodesis should be considered.
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http://dx.doi.org/10.1007/s00264-017-3655-3DOI Listing
January 2018

Conventional Versus Computer-Assisted Corrective Osteotomy of the Forearm: a Retrospective Analysis of 56 Consecutive Cases.

J Hand Surg Am 2017 Jun 20;42(6):447-455. Epub 2017 Apr 20.

Computer Assisted Research and Development Team, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.

Purpose: Accuracy and feasibility of corrective osteotomies using 3-dimensional planning tools and patient-specific instrumentation has been reported by multiple authors with promising results. However, studies describing clinical outcomes following these procedures are rare. Therefore, the purpose of this study was to compare the results of computer-assisted corrective osteotomies of the diaphyseal and distal radius with a conventional non-computer-assisted technique regarding duration of surgery, consolidation of the osteotomy, and complications. Also, subjective and objective clinical outcome parameters were assessed.

Methods: We retrospectively compared the results of 31 patients who underwent a corrective osteotomy performed conventionally with 25 patients treated with a computer-assisted method (CA) using patient-specific instrumentation. Baseline data were similar among both groups. The duration of surgery, bony consolidation, complications, gain in range of motion, and subjective outcome were recorded.

Results: The mean operating time was significantly shorter in the CA group compared with the conventional group. After 12 weeks, significantly more osteotomies were considered healed in the CA group compared with the conventional group. Two patients in the CA group required revision surgery to treat nonunion of the osteotomy. Otherwise clinical results were similar among both groups.

Conclusions: The results demonstrate that the computer-assisted method facilitates shorter operation times while providing similar clinical results.

Type Of Study/level Of Evidence: Therapeutic IV.
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http://dx.doi.org/10.1016/j.jhsa.2017.03.024DOI Listing
June 2017

Single-Level Lateral Lumbar Interbody Fusion for the Treatment of Adjacent Segment Disease: A Retrospective Two-Center Study.

Spine (Phila Pa 1976) 2017 May;42(9):E515-E522

Department of Orthopaedic Surgery, Spine and Scoliosis Service, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY.

Study Design: A retrospective case series.

Objective: The aim of this study was to assess the postoperative outcome after single-level lateral lumbar interbody fusion (LLIF) for adjacent segment disease (ASD).

Summary Of Background Data: Although there is a plethora of literature on ASD following traditional arthrodesis techniques, literature on ASD following LLIF is limited. Vice versa, the surgical outcome after LLIF for the treatment of ASD remains to be elucidated.

Methods: Patients who underwent single-level LLIF for ASD at two institutions (March 2006-April 2012) were included, and the medical records, operative reports, radiographic imaging studies, and office records reviewed.

Results: Out of 523 LLIF patients, 52 met the inclusion criteria, and were postoperatively followed for 16.1 ± 9.8 months (range: 5-44). When comparing the pre-operative data with both the first and most recent follow-up postoperatively, LLIF resulted in a reduction in back pain (P < 0.001, and P < 0.001, respectively) and leg pain (P < 0.001, and P < 0.001, respectively), increase in segmental lordosis (P = 0.003, and P = 0.014, respectively), decrease in segmental coronal angulation (P < 0.001, and P = 0.003, respectively), and increase in intervertebral height (P < 0.001, and P < 0.001, respectively) at the surgical level. The reoperation rate related to the LLIF procedure was 21.2% (11/52), which was performed after an average of 14.6 ± 10.1 months (range: 3.3-31.0). Eight out of 11 patients (72.7%) in the reoperation subgroup underwent standalone LLIF, whereas only 23 out of 41 patients (56.1%) without a reoperation underwent standalone LLIF (P = 0.491). There was a trend toward a higher fusion rate in patients who underwent circumferential fusion than the standalone subgroup (87.5% vs. 53.8%; P = 0.173).

Conclusion: LLIF may be an effective surgical treatment option for ASD with regard to both the clinical and radiographic outcome in a large proportion of cases. Although standalone LLIF is associated with a narrower spectrum of adverse effects than circumferential fusion, posterior instrumentation may be necessary to increase segmental stability.

Level Of Evidence: 4.
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http://dx.doi.org/10.1097/BRS.0000000000001871DOI Listing
May 2017

Incidence of vascular complications during lateral lumbar interbody fusion: an examination of the mini-open access technique.

Eur Spine J 2015 Apr 10;24(4):800-9. Epub 2015 Feb 10.

Spine and Scoliosis Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA,

Purpose: This article examines the incidence and management of vascular injury during Lateral Lumbar Interbody Fusion (LLIF). The details of the mini-open access technique are presented.

Methods: A total of 900 patients who underwent a LLIF at an average 1.94 levels (range: 1-5 levels) by one of six fellowship trained surgeons on 1,754 levels from 2006 to 2013 were identified. The incidence of intraoperative vascular injury was retrospectively determined from the Operative Records. The management of vascular injury was evaluated. The mini-open access adapted by our institution for LLIF is described.

Results: The incidence of major vascular complication in our series was 1/900. The incidence of minor vascular injury was 4/900. The overall incidence of vascular injury was calculated to be 0.056 % per case and 0.029 % per level. All minor vascular injuries were identified to be segmental vessel lacerations, which were readily ligated under direct visualization without further extension of the incision with no clinical sequelae. The laceration of the abdominal aorta, the major vascular complication of this series, was emergently repaired through an exploratory laparotomy. None of the patients suffered long-term sequelae from their intraoperative vascular injuries.

Conclusions: The mini-open lateral access technique for LLIF provides for minimal risk of vascular injury to the lumbar spine. In the rare event of minor vascular injury, the mini-open access approach allows for immediate visualization, confirmation and repair of the vessel with no long-term sequelae.
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http://dx.doi.org/10.1007/s00586-015-3796-2DOI Listing
April 2015

Biomechanical analysis of screw constructs for atlantoaxial fixation in cadavers: a systematic review and meta-analysis.

J Neurosurg Spine 2015 Feb 5;22(2):151-61. Epub 2014 Dec 5.

Spine and Scoliosis Surgery, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York.

Object: The unique and complex biomechanics of the atlantoaxial junction make the treatment of C1-2 instability a challenge. Several screw-based constructs have been developed for atlantoaxial fixation. The biomechanical properties of these constructs have been assessed in numerous cadaver studies. The purpose of this study was to systematically review the literature on the biomechanical stability achieved using various C1-2 screw constructs and to perform a meta-analysis of the available data.

Methods: A systematic search of PubMed through July 1, 2013, was conducted using the following key words and Boolean operators: "atlanto [all fields]" AND "axial [all fields]" OR "C1-C2" AND "biomechanic." Cadaveric studies on atlantoaxial fixation using screw constructs were included. Data were collected on instability models, fixation techniques, and range of motion (ROM). Forest plots were constructed to summarize the data and compare the biomechanical stability achieved.

Results: Fifteen articles met the inclusion criteria. An average (±SD) of 7.4±1.8 cadaveric specimens were used in each study (range 5-12). The most common injury models were odontoidectomy (53.3%) and cervical ligament transection (26.7%). The most common spinal motion segments potted for motion analysis were occiput-C4 (46.7%) and occiput-C3 (33.3%). Four screw constructs (C1 lateral mass-C2 pedicle screw [C1LM-C2PS], C1-2 transarticular screw [C1-C2TA], C1 lateral mass-C2 translaminar screw [C1LM-C2TL], and C1 lateral mass-C2 pars screw [C1LM-C2 pars]) were assessed for biomechanical stability in axial rotation, flexion/extension, and lateral bending, for a total of 12 analyses. The C1LM-C2TL construct did not achieve significant lateral bending stabilization (p=0.70). All the other analyses showed significant stabilization (p<0.001 for each analysis). Significant heterogeneity was found among the reported stabilities achieved in the analyses (p<0.001; I2>80% for all significant analyses). The C1LM-C2 pars construct achieved significantly less axial rotation stability (average ROM 36.27° [95% CI 34.22°-38.33°]) than the 3 other constructs (p<0.001; C1LM-C2PS average ROM 49.26° [95% CI 47.66°-50.87°], C1-C2TA average ROM 47.63° [95% CI 45.22°-50.04°], and C1LM-C2TL average ROM 53.26° [95% CI 49.91°-56.61°]) and significantly more flexion/extension stability (average ROM 13.45° [95% CI 10.53°-16.37°]) than the 3 other constructs (p<0.001; C1LM-C2PS average ROM 9.02° [95% CI 8.25°-9.80°], C1-C2TA average ROM 7.39° [95% CI 5.60°-9.17°], and C1LM-C2TL average ROM 7.81° [95% CI 6.93°-8.69°]). The C1-C2TA (average ROM 5.49° [95% CI 3.89°-7.09°]) and C1LM-C2 pars (average ROM 4.21° [95% CI 2.19°-6.24°]) constructs achieved significantly more lateral bending stability than the other constructs (p<0.001; C1LM-C2PS average ROM 1.51° [95% CI 1.23°-1.78°]; C1LM-C2TL average ROM -0.07° [95% CI -0.44° to 0.29°]).

Conclusions: Meta-analysis of the existing literature showed that all constructs provided significant stabilization in all axes of rotation, except for the C1LM-C2TL construct in lateral bending. There were significant differences in stabilization achieved in each axis of motion by the various screw constructs. These results underline the various strengths and weaknesses in biomechanical stabilization of different screw constructs. There was significant heterogeneity in the data reported across the studies. Standardized spinal motion segment configuration and injury models may provide more consistent and reliable results.
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http://dx.doi.org/10.3171/2014.10.SPINE13805DOI Listing
February 2015

Spinal subdural hematoma following lumbar decompressive surgery: a report of two cases.

Wien Klin Wochenschr 2015 Jan 15;127(1-2):71-4. Epub 2014 Nov 15.

Department of Orthopedic Surgery, Spine and Scoliosis Service, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th Street, 10021, New York, NY, USA,

Spinal subdural hematoma (SSDH) following spine surgery is an extremely rare condition, with only three cases being reported in the literature. Unintended durotomy has been associated with SSDH due to alterations of pressures in the dural compartments. The objective of the present report was to report two rare cases of acute SSDH developed after lumbar decompressive surgery. In one of the patients, the diagnosis of SSDH was followed by urgent hematoma evacuation via durotomy due to the patient's worsening neurological symptoms. In the second patient, the SSDH was treated conservatively due to the absence of severe or progressive motor or sensory deficits. In conclusion, emergency evacuation via durotomy is the treatment of choice for patients with SSDH and neurologic impairment. Conservative management may be indicated in selected cases with absent motor and sensory deficits.
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http://dx.doi.org/10.1007/s00508-014-0632-3DOI Listing
January 2015

Microdiscectomy for the treatment of lumbar disc herniation: an evaluation of reoperations and long-term outcomes.

Evid Based Spine Care J 2014 Oct;5(2):77-86

Department of Orthopaedic Surgery, Spine and Scoliosis Service, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York, United States.

Design Retrospective case series. Objective The objective of this study was to assess the reoperation rate after microdiscectomy for the treatment of lumbar disc herniation (LDH) in patients with ≥ 5-year follow-up and identify demographic, perioperative, and outcome-related differences between patients with and without a reoperation. Methods The medical records, operative reports, and office notes of patients who had undergone microdiscectomy at a single institution between March 1994 and December 2007 were reviewed and long-term follow-up was assessed via a telephone questionnaire. Results Forty patients (M:24, F:16) with an average age at surgery of 39.9 ± 12.5 years (range: 18-80) underwent microdiscectomy at the levels L5-S1 (n = 28, 70%), L4-L5 (n = 9, 22.5%), L3-L4 (n = 2, 5.0%), and L1-L2 (n = 1, 2.5%). After an average of 40.4 ± 40.1 months (range: 1-128), 25% of patients (10/40) required further spine surgery related to the initial microdiscectomy. At an average postoperative follow-up of 11.1 ± 4.0 years (range: 5-19), additional symptoms apart from back and leg pain were reported more frequently by patients who underwent a reoperation (p = 0.005). Patient satisfaction was significantly higher in patients who did not undergo a reoperation (p = 0.041). For the Oswestry disability index, pain intensity (p = 0.036), and pain-related sleep disturbances (p = 0.006) were reported to be more severe in the reoperation group. Conclusions Microdiscectomy for the treatment of LDH results in a favorable long-term outcome in the majority of cases. The reoperation rate was higher in our series than reported in previous investigations with shorter follow-up. Although there were no statistically significant pre-/perioperative differences between patients with and without reoperation, our findings suggest a difference in self-reported long-term outcome measures.
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http://dx.doi.org/10.1055/s-0034-1386750DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4174230PMC
October 2014

Merits of different anatomical landmarks for correct numbering of the lumbar vertebrae in lumbosacral transitional anomalies.

Eur Spine J 2015 Mar 16;24(3):600-8. Epub 2014 Sep 16.

MRI Radiology Department, Hospital for Special Surgery, New York, USA.

Purpose: Anatomical landmarks and their relation to the lumbar vertebrae are well described in subjects with normal spine anatomy, but not for subjects with lumbosacral transitional vertebra (LSTV), in whom correct numbering of the vertebrae is challenging and can lead to wrong-level treatment. The aim of this study was to quantify the value of different anatomical landmarks for correct identification of the lumbar vertebra level in subjects with LSTV.

Methods: After IRB approval, 71 subjects (57 ± 17 years) with and 62 without LSTV (57 ± 17 years), all with imaging studies that allowed correct numbering of the lumbar vertebrae by counting down from C2 (n = 118) or T1 (n = 15) were included. Commonly used anatomical landmarks (ribs, aortic bifurcation (AB), right renal artery (RRA) and iliac crest height) were documented to determine the ability to correctly number the lumbar vertebrae. Further, a tangent to the top of the iliac crests was drawn on coronal MRI images by two blinded, independent readers and named the 'iliac crest tangent sign'. The sensitivity, specificity and the interreader agreement were calculated.

Results: While the level of the AB and the RRA were found to be unreliable in correct numbering of the lumbar vertebrae in LSTV subjects, the iliac crest tangent sign had a sensitivity and specificity of 81 % and 64-88 %, respectively, with an interreader agreement of k = 0.75.

Conclusion: While anatomical landmarks are not always reliable, the 'iliac crest tangent sign' can be used without advanced knowledge in MRI to most accurately number the vertebrae in subjects with LSTV, if only a lumbar spine MRI is available.
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http://dx.doi.org/10.1007/s00586-014-3573-7DOI Listing
March 2015

Incidental durotomy during spinal surgery: a multivariate analysis for risk factors.

Spine (Phila Pa 1976) 2014 Oct;39(22):E1339-45

From the Spine and Scoliosis Service, Hospital for Special Surgery, Weill Cornell Medical College, New York City, NY.

Study Design: Multivariate analysis.

Objective: The purpose of this study was to investigate risk factors for incidental durotomy (ID) in modern spine surgery techniques.

Summary Of Background Data: ID, a relatively common complication of spine surgery, has been associated with postoperative complications such as durocutaneous fistulas, pseudomeningoceles, and arachnoiditis. Revision surgery may be necessary if the dural tear is not recognized and repaired during the initial procedure.

Methods: ID was prospectively documented in patients who underwent spine surgery at a single institution during a 2-year period (n=4822). Patients with ID (n=182) from lumbar or thoracolumbar cases were matched 1:1 to a control cohort without ID. Demographic, diagnostic, and surgical procedure data were retrospectively collected and analyzed.

Results: Multivariate analysis identified revision spine surgery (adjusted odds ratio [aOR]: 4.78, 95% confidence interval [CI]: 2.84-8.06, P<0.01), laminectomy (aOR: 3.82, 95% CI: 2.02-7.22, P<0.01), and older age (aOR: 1.03, 95% CI: 1.01-1.04, P<0.01) as independent risk factors for ID. Fusion (aOR: 0.59, 95% CI: 0.35-0.99, P=0.04), foraminectomy, (aOR: 0.42, 95% CI: 0.25-0.69, P<0.01), and lateral approach (aOR: 0.29, 95% CI: 0.14-0.61, P<0.01) were independent protective factors.

Conclusion: Prior spine surgery, laminectomy, and older age were significant independent risk factors for ID. The recently developed lateral approach to interbody fusion was identified as a significant protective factor for ID, along with fusion and foraminectomy. These findings may help guide future surgical decisions regarding ID and aid in the patient informed-consent process.

Level Of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000000559DOI Listing
October 2014

Determinants of evolution of endplate and disc degeneration in the lumbar spine: a multifactorial perspective.

Eur Spine J 2014 Sep 5;23(9):1863-8. Epub 2014 Jun 5.

MRI, Radiology Department, Hospital for Special Surgery, New York, NY, USA.

Purpose: Evolution and progression of disc and endplate bone marrow degeneration of the lumbar spine are thought to be multifactorial, yet, their influence and interactions are not understood. The aim of this study was to find association of potential predictors of evolution of degeneration of the lumbar spine.

Methods: Patients (n = 90) who underwent two lumbar magnetic resonance imaging (MRI) exams with an interval of at least 4 years and without any spinal surgery were included into the longitudinal cohort study with nested case-control analysis. Disc degeneration (DD) was scored according to the Pfirrmann classification and endplate bone marrow changes (EC) according to Modic in 450 levels on both MRIs. Potential variables for degeneration such as age, gender, BMI, scoliosis and sagittal parameters were compared between patients with and without evolution or progression of degenerative changes in their lumbar spine. A multivariate analysis aimed to identify the most important variables for progression of disc and endplate degeneration, respectively.

Results: While neither age, gender, BMI, sacral slope or the presence of scoliosis could be identified as progression factor for DD, a higher lordosis was observed in subjects with no progression (49° ± 11° vs 43° ± 12°; p = 0.017). Progression or evolution of EC was only associated with a slightly higher degree of scoliosis (10° ± 10° vs 6° ± 9°; p = 0.04) and not to any of the other variables.

Conclusion: While a coronal deformity of the lumbar spine seems associated with evolution or progression of EC, a higher lumbar lordosis is protective for radiographic progression of DD. This implies that scoliotic deformity and lesser lumbar lordosis are associated with higher overall degeneration of the lumbar spine.
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http://dx.doi.org/10.1007/s00586-014-3382-zDOI Listing
September 2014

Paresis of the L5 nerve root after reduction of low-grade lumbosacral dysplastic spondylolisthesis: a case report.

J Pediatr Orthop B 2014 Sep;23(5):461-6

Departments of aOrthopedic Surgery, Spine and Scoliosis Service bOrthopedic Surgery, Pediatric Orthopedics Service, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York, USA.

We present a unique case of a 16-year-old patient who underwent lumbar decompression surgery (L4-S1), low-grade spondylolisthesis reduction surgery at L5-S1, and posterior instrumented fusion from L4 to the pelvis. Neurologic monitoring did not show any sustained changes throughout the operation. The patient was awoken from endotracheal anesthesia with grade 0 muscle function of the left extensor hallucis longus and tibialis anterior muscles resulting in left-sided foot drop. At the last follow-up 12 months after surgery, the patient had partial recovery, with grade 4 muscle function of the left extensor hallucis longus and tibialis anterior muscles. We suggest that early identification with direct nerve root stimulation and wake-up test immediately after reduction of spondylolisthesis will allow prompt release of the reduction and further foramen exploration, and increase the possibility of good postoperative nerve root recovery.
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http://dx.doi.org/10.1097/BPB.0000000000000071DOI Listing
September 2014

Cervical stenosis in a patient with arthrogryposis: case report.

Evid Based Spine Care J 2014 Apr;5(1):57-62

Weill Cornell Medical College, New York, New York, United States ; Department of Spine and Scoliosis Surgery, Hospital for Special Surgery, New York, New York, United States.

Study Design Case report. Objective Amyoplasia-type arthrogryposis is a rare congenital disease that presents as multiple contractures involving various areas of the body. To the authors' knowledge, there have been no reports of adults with amyoplasia in the current literature. We report a case of an adult patient with cervical stenosis in the setting of amyoplasia. Patients and Methods A 48-year-old patient with amyoplasia and over 30 previous orthopedic reconstructive surgeries presented with neck pain radiating down his left shoulder and into the fingers, dysesthesia in his fingertips, and left-sided periauricular headache. A diagnosis of central spinal canal stenosis and bilateral foraminal stenosis at C3-C7 with radiculopathy was made based on computed tomography scans. Because of a prior right-side sternocleidomastoid muscle transfer, a left-side C3-C4, C5-C7 anterior cervical discectomy and fusion procedure was performed. Results The patient experienced significant improvement in symptoms that was transient. Symptoms returned to preoperative values after 1 year, despite significant and persistent improvement in stenosis. Conclusions Both amyoplasia and cervical stenosis can manifest in neurologic symptoms. Distinguishing the causing pathology can be challenging. The radiographic improvement of cervical stenosis in a patient with amyoplasia is not always associated with long-standing pain relief.
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http://dx.doi.org/10.1055/s-0034-1368669DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3969424PMC
April 2014

Is an annular tear a predictor for accelerated disc degeneration?

Eur Spine J 2014 Sep 13;23(9):1825-9. Epub 2014 Mar 13.

MRI, Radiology Department, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA,

Purpose: It is questionable whether an annular tear (AT) is a predictor for accelerated degeneration of the intervertebral discs. The aim of the present study was to answer this question via a matched case-control study design that reliably eliminates potential confounders.

Materials: Presence or absence of AT, defined as a hyperintense lesion within the annular fibrosus on T2-weighted non-contrast MRI images, was documented in 450 intervertebral lumbar discs of 90 patients who could be followed up for at least 4 years with MRI. Discs with an AT (n = 36) were matched 1:1 to control discs according to the level, degree of initial disc degeneration on MRI (both Pfirrmann grade median 4, range 3-4), age (59.5 ± 15.0 versus 59.3 ± 14.6 years), BMI (26.7 ± 4.4 versus 26.9 ± 4.4 kg/m(2)) and interval to the follow-up MRI (4.8 ± 0.9 versus 5.1 ± 0.8 years). The degree of disc degeneration after a minimum of 4 years was graded on the follow-up MRI in both groups according to the Pfirrmann classification.

Results: One-fourth (25%) of the 36 discs with an AT on the initial MRI exam progressed in degeneration. This was similar to the rate of the matched control discs with no AT, in which also around one-fourth (22%) showed a progression of degeneration (p = 1.00), also without any difference in the degree of degeneration.

Conclusion: Discs with a Pfirrmann grade >2 with an AT, defined by a hyperintense signal intensity on MRI, are not prone to accelerated degeneration if compared to discs without an AT. Therefore, the presence of an AT per se does not predict accelerated disc degeneration.
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http://dx.doi.org/10.1007/s00586-014-3260-8DOI Listing
September 2014

Vertebral body Hounsfield units as a predictor of incidental durotomy in primary lumbar spinal surgery.

Spine (Phila Pa 1976) 2014 Apr;39(9):E593-8

From the Department of Orthopedic Surgery, Spine and Scoliosis Service, Hospital for Special Surgery, Weill Cornell Medical College, New York City, NY.

Study Design: Retrospective cohort study.

Objective: To assess the association between vertebral body Hounsfield unit (HU) measurements on quantitative computed tomography and the risk for incidental durotomy (ID).

Summary Of Background Data: ID during spine surgery has been associated with adverse postoperative sequelae that may require prolonged hospital stay and reoperation. Previously identified independent risk factors include age, revision surgery, and lumbar surgery.

Methods: ID was prospectively documented in spine surgery patients at a single institution during a 2-year period (incidence: 4%, 191/4,822). Patients with ID were matched 1:1 to a control cohort without ID based on age and sex. Inclusion criteria for both cohorts were primary lumbar surgery and quantitative computed tomographic scans within 1 year of date of surgery. Demographic, radiographical, and intraoperative data, along with dual x-ray absorptiometry t scores, were collected and analyzed.

Results: A total of 71 patients with ID met the inclusion criteria (38 male, 33 female). Average age of patients with ID was 63.8 ± 12.9 years (range: 34-85 yr). Computed tomographic scans were acquired 1.5 ± 2.2 months away from date of surgery (range: 0-12 mo). Inter-rater reliability for HU measurements between a fellowship-trained spine surgeon and a research fellow was strong (r = 0.901, P < 0.001). HU values were significantly lower in patients with ID than controls (149.2 ± 60.7 [range: 44.5-301.5] versus 177.0 ± 81.4, [range: 62.0-524.0], respectively; P = 0.023). The area under the receiver operating characteristic curve was 0.603 (P = 0.034). A threshold of 169 HU optimized sensitivity (0.718) and specificity (0.451), and patients with HU value 169 or less were found to be at increased risk for ID (odds ratio: 2.092, 95% confidence interval: 1.042-4.201, P = 0.037).

Conclusion: Lower HU value is an accessible clinical marker for increased risk of ID. A threshold value of HU was defined (≤169) that may be used clinically to identify patients at elevated risk for ID, which may improve the informed decision making process prior to spinal surgery.

Level Of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000000255DOI Listing
April 2014

Recovery after cervical decompression surgery for the treatment of crowned dens syndrome causing progressive neurological decline: a case report.

HSS J 2014 Feb 24;10(1):83-7. Epub 2013 Sep 24.

Hospital for Special Surgery, Department of Orthopedic Surgery, Spine and Scoliosis Service, 535 East 70th Street, New York, NY 10021 USA.

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http://dx.doi.org/10.1007/s11420-013-9364-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3903944PMC
February 2014