Purpose

The management of moderate to large engaging Hill-Sachs lesions is controversial and surgical options include remplissage, allograft reconstruction, and partial resurfacing arthroplasty. Few in-vitro studies have quantified their biomechanical characteristics and none have made direct comparisons. The purpose of this study was to compare joint stability and range of motion (ROM) among these procedures using an in-vitro shoulder simulator. It was hypothesized that all procedures would prevent defect engagement, but allograft and partial resurfacing would most accurately restore intact biomechanics; while remplissage would provide the greatest stabilization, possibly at the expense of motion.

Purpose

The remplissage procedure may be performed as an adjunct to Bankart repair to address an engaging Hill-Sachs defect. Clinically, it has been reported that the remplissage procedure improves joint stability but that it may also restrict shoulder range of motion. The purpose of this biomechanical study was to examine the effects of the remplissage procedure on shoulder motion and stability. We hypothesized that the remplissage procedure would improve stability and prevent engagement but may have a deleterious effect on motion.

Purpose

The remplissage technique of insetting the infraspinatus tendon and posterior joint capsule into an engaging Hill-Sachs lesion has gained in popularity. However, a standardized technique for suture anchor and suture placement has not been defined for this novel procedure. The purpose of this biomechanical study was to compare three remplissage techniques by evaluating their effects on joint stiffness and motion.

Purpose

Coracoid transfer is an effective reconstructive procedure for complex glenohumeral joint instability. Recently, the congruent-arc Latarjet procedure has been described which orients the coracoid graft undersurface flush to the glenoid articular margin. The purported advantage of this modification is that the radii of curvature of the coracoid undersurface and the anterior glenoid rim are believed to be similar, and therefore, congruent. The purpose of this study was to determine the dimensions of the coracoid and to compare the radius of curvature (ROC) of the coracoid undersurface to the ROC of the intact glenoid and various glenoid bone-loss scenarios.

The aim was to evaluate the Intraobserver and Interobserver reliability of Pelvic Incidence as a fundamental parameter of sagittal spino-pelvic balance in patients with spondylolisthesis compared to controls with Idiopathic Adolescent Scoliosis.

A blinded test retest study including multi-surgeon assessment of Pelvic Incidence in patients with spondylolisthesis and Idiopathic Adolescent Scoliosis was carried out. We assessed the agreement between the pelvic incidence measurements using the Bland and Altman method and mean differences (95% confidence interval) are reported.

Forty patients seen at Starship Children’s Hospital between 1992 – 2003 by two spinal surgeons were retrospectively identified. The main group had 20 patients with spondylolisthesis (Isthmic and/or Dysplastic types) and the control group consisted of 20 patients with Idiopathic Adolescent Scoliosis. Five observers with different levels of experience included the two orthopaedic surgeons, one fellow, one senior trainee and one non-trainee registrar. Prior to the initial test phase, a consensus-building session was carried out. All five observers arrived at a standardised method for measuring the Pelvic Incidence. In the test phase randomly ordered lateral lumbosacral radiographs were independently evaluated by the five observers and pelvic incidence was measured. Assessment of the Pelvic Incidence was repeated one week later in the re-test phase. The radiographs were presented in a randomly pre-assigned order. Bland and Altman plots were constructed and mean differences (95% confidence interval) reported to evaluate the agreement between the Pelvic Incidence measurements among the five independent observers. All analysis was performed on the statistical software package SAS. P-value of 0.05 was considered statistically significant.

The spondylolisthesis group had 11 (55%) males and 9 (45%) females with an average age of 14 ± 4.2. 2 patients had high-grade (Meyerding Class III, IV, V) and 16 had low-grade (Meyerding Class I, II) spondylolisthesis. 2 patients were post-reduction of spondylolisthesis. In the Scoliosis group there were 2 (10%) males and 18 (90%) females with an average age of 15 ± 2.9. There was no significant difference between male and females pelvic incidence measurement (60° ± 18.7° vs. 57° ± 14.6°, p=0.540) or age (15 ± 2.9 vs. 14 ± 3.8, p=0.181). There was no difference in pelvic incidence across the Meyerding groups, p=0.257. There was a significant difference between spondylolisthesis and scoliosis pelvic incidence measurements 65° ± 15.6° vs. 51° ± 12.8°, p=0.003. In the Spondylolisthesis Group the interobserver reliability between five clinicians, expressed as the mean difference in pelvic incidence measurement was 0.6° (95%CI −0.81, 1.91) and was not significantly different from zero p=0.423. The agreement limits were from −12.8° to 13.9°. The intraobserver reliability of pelvic incidence showed the mean difference ranging from −2.1° to 1.4° (p=0.129 and 0.333 with 95% CI). One had marginal evidence of a significant difference of 3.3° (95% CI 0.05° to 6.55°, p=0.047). In the Scoliosis Group the interobserver reliability was 0.3° (95% CI −0.81, 1.49) and was not significantly different from zero p=0.726. The agreement limits were from −11.0° to 11.6°. The intraobserver reliability among four observers ranged from −1.7° to 0.5° (p=0.178 and 0.661). One had a significant difference in readings of 4.1° (95% CI of 0.70° to 7.40°, p= 0.020).

Scoliosis patients had a significantly smaller pelvic incidence than spondylolisthesis patients. The interobserver reliability of the pelvic incidence measurement was excellent across both groups. The intraobserver reliability was good with only one observer in each group demonstrating a marginally significant difference. Pelvic incidence is therefore a reliable measurement which can be used as a predictor in progression of spondylolisthesis.

Introduction and Aims: Children and adolescents with back pain are a challenging problem for the orthopaedic surgeon. The differential diagnosis includes tumors and infection. The aim of this retrospective review was to determine the incidence amongst the study population and ascertain the clinical markers that could help clinicians to diagnose the underlying pathology.

Method: A clinical records database search identified a cohort of 59 consecutive patients referred to one of two paediatric spinal surgeons with the diagnosis of back pain between January 2000 and July 2003. The record analysis included chart review, radiographic analysis and clinical follow-up at the Starship Children’s Hospital. Patients were excluded from the study if they were referred with a known cause of back pain, had previous spinal surgery or a cervical distribution of pain.

Results: New back pain referrals represented 1.7% of all new referrals to this tertiary level orthopaedic department. There were 59 patients with 32 (54%) females and 27 (46%) males. The average age at presentation was 12 years and the average duration of symptoms was 15.5 months. The most common site of pain was lumbosacral (61%). All patients had plain radiograph studies performed, 28 (47.5%) a bone scan, nine (15%) a CT scan and 15 (25.5%) an MRI. In addition, 21 patients (35.5%) had laboratory investigations including a FBC, ESR and c-reactive protein.

Thirty-four patients representing 58% of the study group had a definitive dignosis made. Fourteen patients (24%) had Scheuerman’s disease, seven (12%) were dignosed with spondylolisthesis and five (8.5%) had a painful scoliosis. Only one patient had osteomyelitis. We did not identify any patients with a tumor.

Patients older than 10 years were almost twice as likely to have a positive diagnosis than those under 10 years of age. There was no single reliable clinical sign or symptom that would help make the diagnosis. Significant haematological abnormalities were only found in one patient who was diagnosed with sacral osteomyelitis. Plain radiographs alone provided the diagnosis in 14 (23.5%) patients. Bone scan, CT and MRI were of variable diagnostic value.

Conclusion: Back pain in children has traditionally been regarded serious enough to warrant comprehensive investigation. We have found a definitive diagnosis in only 58% of patients despite thorough clinical assessment, and haematological and radiological evaluation. Clinicians must remain vigilant for any clues that may help lead to a diagnosis in this group of patients.

Spinal epidural sepsis is more widely recognised with MRI. Treatment includes antibiotics, multisystem support and drainage of pus. Neurological loss will often be stabilised but dramatic recovery is infrequent, explaining the importance of early intervention. This series highlights a very sinister spectrum of spinal infective disease despite ideal traditional treatment for spinal skeletal infection.

This is a retrospective case series review of five patients.

All patients presented with regional spinal pain, fever and regional musculoskeletal infective foci (e.g. discitis). Mild neurological abnormality existed in three patients. Rapid multisystem collapse occurred with the need for ventilatory support, despite institution of appropriate antibiotic treatment for all patients. All had grown Staphylococcus Aureus from blood cultures. Subsequent extensive quadriparesis/plegia developed, and repeat imaging demonstrated wide spread epidural pus in the cervical spine. Surgical treatment was considered but not performed when the prognosis was so poor neurologically and medically, and when the widespread epidural pus was so inaccessible. All patients died rapidly upon withdrawal of supportive treatment.

This paper describes a sinister spectrum of spinal infection with catastrophic complications despite “appropriate” treatment for previously diagnosed spinal foci infection. Positive blood cultures and fever alert to these dangers, and multisystem collapse heralded the development of cervical epidural infection. Possible interventions include early MRI scanning of the whole spine, more aggressive (than traditionally accepted) surgical treatment of infective foci in the spine in these circumstances, and minimally invasive cervical canal decompression procedures with multiple laminotomies.