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Journal of Plastic, Reconstructive &... Jun 2024Congenital pseudarthrosis of the forearm bones (CPFBs) is rare, with only 106 reported cases, and is frequently associated with neurofibromatosis (NF). Approximately 5%...
Congenital pseudarthrosis of the forearm bones (CPFBs) is rare, with only 106 reported cases, and is frequently associated with neurofibromatosis (NF). Approximately 5% of patients with NF develop pseudarthrosis, and 50% of patients with pseudarthrosis have NF. Achieving bone union is difficult in congenital pseudarthrosis. Many methods have been attempted, including casting, internal fixation with or without grafting, and electrical stimulation, but failure is frequent. Free vascularized fibular flaps (FVFs) have been used to bridge long bone defects since 1975 and in tibial pseudarthrosis since 1979. In CPFB, FVF is more successful than other methods in achieving union and is the current treatment of choice. Here, we presented three cases of forearm pseudarthrosis treated with FVF, reviewed the literature on CPFB, and discussed some technical aspects of FVF treatment. Three cases of congenital pseudoarthrosis were treated with free fibula flaps, diagnosed at ages of 7 years (ulna), 15 months (radius), and 9 years (radius and ulna). Two flaps were stabilized with intramedullary wires and latterly, one with compression plates. One persistent nonunion received revision nonvascularized bone grafting and plating. All patients achieved union by 11 months after index surgery. Reconstruction with vascularized fibula is the treatment of choice because it offers the highest published union rates and good functional results. Complete resection of the affected bone and stable fixation, latterly with compression plates are critical to success. Surgery is technically demanding, and complications are common. Secondary surgery may be required, but outcomes are favorable. LEVEL OF EVIDENCE: IV.
PubMed: 38924895
DOI: 10.1016/j.bjps.2024.06.015 -
Science Translational Medicine Jun 2024Congenital pseudarthrosis of the tibia (CPT) is a severe pathology marked by spontaneous bone fractures that fail to heal, leading to fibrous nonunion. Half of patients...
Congenital pseudarthrosis of the tibia (CPT) is a severe pathology marked by spontaneous bone fractures that fail to heal, leading to fibrous nonunion. Half of patients with CPT are affected by the multisystemic genetic disorder neurofibromatosis type 1 (NF1) caused by mutations in the tumor suppressor gene, a negative regulator of RAS-mitogen-activated protein kinase (MAPK) signaling pathway. Here, we analyzed patients with CPT and knockout mice to elucidate the pathogenic mechanisms of CPT-related fibrous nonunion and explored a pharmacological approach to treat CPT. We identified -deficient Schwann cells and skeletal stem/progenitor cells (SSPCs) in pathological periosteum as affected cell types driving fibrosis. Whereas -deficient SSPCs adopted a fibrotic fate, -deficient Schwann cells produced critical paracrine factors including transforming growth factor-β and induced fibrotic differentiation of wild-type SSPCs. To counteract the elevated RAS-MAPK signaling in both -deficient Schwann cells and SSPCs, we used MAPK kinase (MEK) and Src homology 2 containing protein tyrosine phosphatase 2 (SHP2) inhibitors. Combined MEK-SHP2 inhibition in vivo prevented fibrous nonunion in the knockout mouse model, providing a promising therapeutic strategy for the treatment of fibrous nonunion in CPT.
Topics: Animals; Schwann Cells; Pseudarthrosis; Neurofibromin 1; Humans; Protein Tyrosine Phosphatase, Non-Receptor Type 11; Mice, Knockout; Stem Cells; Tibia; Mice; Cell Differentiation; Male; Neurofibromatosis 1; Fibrosis; Female; Mitogen-Activated Protein Kinase Kinases
PubMed: 38924432
DOI: 10.1126/scitranslmed.adj1597 -
European Spine Journal : Official... Jun 2024Revision lumbar fusion is most commonly due to nonunion, adjacent segment disease (ASD), or recurrent stenosis, but it is unclear if diagnosis affects patient outcomes....
INTRODUCTION
Revision lumbar fusion is most commonly due to nonunion, adjacent segment disease (ASD), or recurrent stenosis, but it is unclear if diagnosis affects patient outcomes. The primary aim of this study was to assess whether patients achieved the patient acceptable symptom state (PASS) or minimal clinically important difference (MCID) after revision lumbar fusion and assess whether this was influenced by the indication for revision.
METHODS
We retrospectively identified all 1-3 level revision lumbar fusions at a single institution. Oswestry Disability Index (ODI) was collected at preoperative, three-month postoperative, and one-year postoperative time points. The MCID was calculated using a distribution-based method at each postoperative time point. PASS was set at the threshold of ≤ 22.
RESULTS
We identified 197 patients: 56% with ASD, 28% with recurrent stenosis, and 15% with pseudarthrosis. The MCID for ODI was 10.05 and 10.23 at three months and one year, respectively. In total, 61% of patients with ASD, 52% of patients with nonunion, and 65% of patients with recurrent stenosis achieved our cohort-specific MCID at one year postoperatively with ASD (p = 0.78). At one year postoperatively, 33.8% of ASD patients, 47.8% of nonunion patients, and 37% of patients with recurrent stenosis achieved PASS without any difference between indication (p = 0.47).
CONCLUSIONS
The majority of patients undergoing revision spine fusion experience significant postoperative improvements regardless of the indication for revision. However, a large proportion of these patients do not achieve the patient acceptable symptom state. While revision spine surgery may offer substantial benefits, these results underscore the need to manage patient expectations.
PubMed: 38913182
DOI: 10.1007/s00586-024-08358-8 -
Revista Brasileira de Ortopedia Jun 2024Wrist and hand arthroscopy, despite being an old tool, has gained popularity and advanced in assisting in the treatment of various injuries and conditions in the region...
Wrist and hand arthroscopy, despite being an old tool, has gained popularity and advanced in assisting in the treatment of various injuries and conditions in the region in recent years. Dorsal, volar, ulnar, and radial accessory portals are used to reach all points of the carpal and hand joints. The minimal tissue damage, lesser injury to the capsule and its mechanoreceptors, the assessment of injuries associated with the reason for surgery, and aesthetically more favorable scars have attracted many doctors and their patients. As a result, there has been an increase in publications and diversifications of arthroscopic techniques. The aim of this update article is to present the advances and the evidence available in the literature to assist readers in their decision on which technique to use in the treatment of wrist and hand conditions.
PubMed: 38911879
DOI: 10.1055/s-0044-1779336 -
Neurosurgery Jun 2024Disruption of the spine's sagittal balance is associated with significant negative impacts on quality of life. Compared with other spinal osteotomies, pedicle...
BACKGROUND AND OBJECTIVES
Disruption of the spine's sagittal balance is associated with significant negative impacts on quality of life. Compared with other spinal osteotomies, pedicle subtraction osteotomy (PSO), which can potentially offer greater correction, is considered technically challenging and performed at lower rates. The aim of this study was to review the use of PSO to correct fixed sagittal imbalance and assess its efficacy and associated perioperative complications.
METHODS
In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the PubMed, EBSCO host, MEDLINE, and Google Scholar databases were queried for full-text English manuscripts published from 1961 to 2022, exploring PSO for the management of fixed sagittal imbalance. Studies were included if they reported preoperative and postoperative radiographic measurements. The mean Methodological Index for Nonrandomized Studies (MINORS) for included articles was 9.6 ± 1.1. The outcomes of interest included etiology, operative time, blood loss, complications, radiographic outcomes, and patient-reported outcomes. Statistical analysis was performed using a random-effects, inverse variance-weighted meta-analysis of observational data. Pre and postoperative radiographic and clinical outcomes were compared using a Student t-test.
RESULTS
Fourteen studies with 595 patients were included. Meta-analysis showed that the mean operative time was 7.2 ± 2.0 hours, and the average blood loss was 2033 ± 629 mL. After PSO, there was a significant improvement in sagittal vertebral axis (12.41-3.92 cm, P = .0003), LL (13.35°-42.60°, P = .000002), PSO angle (5.11° to -26.91°, P = .0001), and Oswestry Disability Index (55.36-27.35, P = .02). Common complications include pseudarthrosis (8.1%), neurological deficits (7.8%), and proximal junctional failure (6.0%).
CONCLUSION
PSO offers significant correction of sagittal vertebral axis, lumbar lordosis, PSO angle, and Oswestry Disability Index scores despite its reduced utilization in recent years. Blood loss and high complication rates must be considered when evaluating the efficacy of this procedure; however, surgeon experience and operative techniques can be used to reduce morbidity.
PubMed: 38904379
DOI: 10.1227/neu.0000000000003008 -
Cureus May 2024Spondylolysis with pseudarthrosis may be treated surgically by repairing the spondylolysis using the smiley face rod (SFR) technique. The SFR technique can avoid...
Spondylolysis with pseudarthrosis may be treated surgically by repairing the spondylolysis using the smiley face rod (SFR) technique. The SFR technique can avoid adjacent segmental disease caused by transforaminal lumbar interbody fusion (TLIF), which is one of the main surgical techniques to treat isthmic lumbar spondylolisthesis. A 59-year-old woman had been playing softball since she was 12 years old and was a member of a prefectural representative team. She sought treatment because of numbness in her left lower limb and difficulty playing softball. Despite conservative treatment for a year, her symptoms did not improve. Physical examination revealed decreased patellar tendon reflexes and numbness and pain from the front of the thigh to the lower leg without muscle weakness. Imaging showed L4 isthmic spondylolisthesis with Meyerding classification grade 2 anterior slip and L5 spondylolysis with pseudarthrosis. We diagnosed L4 radiculopathy caused by L4/5 foraminal stenosis and L4 isthmic spondylolisthesis with L5 spondylolysis. She underwent surgery combining the TLIF of L4/5 and the SFR technique of L5 using dual-headed pedicle screws that can fix two types of rods with L5 pedicle screws. Three months after surgery, fusion between L4/5 and fusion of the L5 pars cleft were confirmed. She resumed sports, and one year postoperatively, she was able to participate in softball games. Two years postoperatively, she could bat, run, and play defense without adjacent segmental disease. Two-segment TLIF increases adjacent segmental disease more than single-segment TLIF. Because the L5 spondylolysis had not slipped, we chose the SFR technique to preserve mobility at L5/S1. The dual-headed pedicle screw fastens two-type rods at the head of the pedicle screw, making it a suitable design for this procedure.
PubMed: 38903306
DOI: 10.7759/cureus.60756 -
Orthopaedic Surgery Jun 2024The unclear clinical outcomes of two different zero-profile implants with different number of screws in hybrid surgery restricts the choice of patient-specific implants....
OBJECTIVE
The unclear clinical outcomes of two different zero-profile implants with different number of screws in hybrid surgery restricts the choice of patient-specific implants. This study aims to compare two different implants on its postoperative subsidence, motion stabilization and clinical outcomes. It also provides references to the most reasonable implant choice in fusion surgery.
METHODS
This was a retrospective study. From February 2014 to March 2022, 173 patients who underwent hybrid surgery were included. Among them, 122 received surgery with a four screw implant, while 51 received a two screw implant. We analyzed the significance of patient-specific factors, radiographic factors and clinical outcomes. The Wilcoxon rank sum test, t tests/analysis of variance (ANOVA) test and stepwise multivariate logistic regression were adopted for statistical analysis.
RESULTS
No statistically significant difference was observed between the two screw and four screw groups in terms of immediate, middle, and long-term stability and fusion rate (p > 0.05). However, the two screws group had higher FSU height subsidence at 3, 6, and 12 months postoperatively and higher rates of significant subsidence at three and 6 months postoperatively (p < 0.05). Both groups showed significant clinical improvements at the final follow-up.
CONCLUSION
Two screw and four screw implants provide comparable stability, fusion rates and clinical outcomes. However, the two screw implant was inferior to the four screw implant in subsidence prevention. Therefore, the two-screw implant is non-inferior to the four-screw implant in most patients. It can be used as the priority choice in the fusion segment by its easy manageability. However, the patients with a high risk of subsidence such as multilevel surgery, the elderly, lower BMD, bad cervical alignment should receive a four screw implant rather than a two screw implant.
PubMed: 38898377
DOI: 10.1111/os.14139 -
Journal of Plastic, Reconstructive &... Jun 2024Children's bone loss of limbs represents a significant challenge for surgeons, especially given that children are growing individuals. In the pediatric population, we...
BACKGROUND
Children's bone loss of limbs represents a significant challenge for surgeons, especially given that children are growing individuals. In the pediatric population, we compared bone reconstruction using vascularized fibula flaps with the induced membrane technique. The primary purpose of this study was to evaluate the delay and quality of consolidation.
METHODS
Data from patients who underwent limb reconstruction using either the fibula flap or the induced membrane were retrospectively collected from files across two centers. Perioperative and long-term complications were documented, along with functional and aesthetic outcome.
RESULTS
Between 2004 and 2020, 31 children underwent limb reconstruction using a fibula flap, and 13 patients were treated using the induced membrane technique. The etiologies included 76% tumors, 20% congenital pseudarthroses, and 3.7% infections. The median size of the bone resection was 12.5 cm (range: 1.8 to 31 cm). The median time to consolidation after free fibula flap transfer was 10 months (range: 2 to 55 months) versus 7.5 months (range: 1 to 64 months) for the Masquelet technique (p = 0.54). Limb length inequality occurred in 52% of fibula cases and 39% of the induced membrane cases (p = 0.55).
CONCLUSIONS
Both of free fibula flap and the induced membrane technique are effective options for bone reconstructing long bones in children. These techniques yield good functional outcomes and have comparable consolidation times.
PubMed: 38889589
DOI: 10.1016/j.bjps.2024.05.033 -
Zhurnal Nevrologii I Psikhiatrii Imeni... 2024Based on an analysis of modern medical literature, to study the main clinical characteristics of pain in patients with transitional lumbosacral vertebrae. (Review)
Review
OBJECTIVE
Based on an analysis of modern medical literature, to study the main clinical characteristics of pain in patients with transitional lumbosacral vertebrae.
MATERIAL AND METHODS
A search was made for articles in the scientific electronic libraries CYBERLENINKA, eLIBRARY, Google Scholar, and the electronic database of biomedical publications PubMed. Sixty-eight scientific publications corresponded to the stated goal.
RESULTS
The review of literature shows that the localization of pain in patients with transitional vertebrae corresponds to the zone of pseudarthrosis between the enlarged transverse process of the L vertebra and the wing of the sacrum. In most patients, the pain is deep, not superficial. Pain intensity ranges from 3.0 to 8.4, reaching an average of 6.0 on the visual analog scale. Pain can radiate to one of the buttocks and the lower limb. The intensity of pain in the leg at the same time, on average, reaches 5.4 points. The pain syndrome can last for months, the course of the disease acquires a sluggish, undulating character with periodic exacerbations. The causes of exacerbations of pain may be excessive loads on the spine, concomitant vertebrogenic diseases and spinal injuries, excess weight, and in women, a history of pregnancy. Pain management can be either conservative or surgical. The scope of conservative treatment consists of using acupuncture and taking non-steroidal anti-inflammatory drugs. The greatest therapeutic effect is achieved with local injection therapy of analgesics and glucocorticoids at the neoarticulation point. The effectiveness of the course of therapeutic blockades reaches a period from several months to a year. The arsenal of surgical techniques includes pseudoartrectomy, radiofrequency denervation, minimally invasive endoscopic surgery, and transpedicular fusion. In most patients, after surgical treatment, complete relief of pain is noted.
CONCLUSION
The review provides information on the predominant localization of pain in patients with transitional vertebrae, its nature, intensity, irradiation, duration, causes of exacerbation, as well as the effectiveness of the methods of conservative and surgical treatment.
Topics: Humans; Lumbar Vertebrae; Pain Measurement; Low Back Pain; Sacrum; Female; Lumbosacral Region; Male
PubMed: 38884424
DOI: 10.17116/jnevro20241240517 -
European Spine Journal : Official... Jun 2024Surgical correction of neuromuscular scoliosis is often a challenging and extensive procedure. Due to this complexity and the high disease burden that these patients... (Review)
Review
PURPOSE
Surgical correction of neuromuscular scoliosis is often a challenging and extensive procedure. Due to this complexity and the high disease burden that these patients carry, per and post-operative complications are not uncommon. The purpose of this study was to systematically review and describe the pooled rates of postoperative complications and analyze risk factors for complications in neuromuscular scoliosis surgery described in the literature in the last ten years.
METHODS
A systematic review of the English literature across multiple databases was conducted using search criteria (neuromuscular scoliosis AND complications) and using PRISMA guidelines (Jan 2012-July 2022). Studies with less than 30 patients and follow-up of < 2 years were excluded. Data extraction and meta-analysis were performed using random mode effect. Statistical analysis was conducted using OpenMeta software. Meta-regression analysis was used to detect risk factors (surgical approach, intraoperative time, intraoperative blood loss, preoperative Cobb angle and patient diagnosis) associated with each complication group. Confidence interval (CI) was set at 95%.
RESULTS
Twenty-two studies met the inclusion criteria involving 2155 patients. The level of evidence among studies were III (9) and IV (13). The most common primary diagnosis was cerebral palsy (43%) followed by Duchenne muscle dystrophy (20%), myelomeningocele (7.4%), spinal muscle atrophy (7.1%), Rett syndrome (< 2%) and combined other pathologies (20.2%). The pooled incidence rate of wound complications was the highest, amongst all complications, at 13.3% (CI 10.838 to 16.861); closely followed by respiratory complications (11.8%;CI 5.7 to 19.7). Implant failure occurred in 7.1% cases (CI 6.418 to 11.465), gastrointestinal complications was 5.2%; CI 2.4 to 8), pseudarthrosis in (4.6%;CI 2.2 to 6.9) and neurological deficit in 2.9% (CI 1.989 to 6.086). The pooled rate of revision surgery was (9.6%; CI 6.2 to 12.9). Heterogeneity was assessed using I test which results were moderately heterogeneous. Meta-regression analysis revealed that the diagnosis of myelomeningocele or Duchenne muscle dystrophy or spinal muscle atrophy were strongly associated with wound and respiratory complications (p = 0.007 and p = 0.005, respectively).
CONCLUSION
Wound-related (13.3%) and respiratory complications (11.8%) remain the most common complications among studies after corrective surgery for neuromuscular scoliosis. Both are significantly associated with Duchenne muscle dystrophy, spinal muscle atrophy and myelomeningocele.
PubMed: 38869648
DOI: 10.1007/s00586-024-08338-y