Aims

Preoperative diagnosis is important for revision surgery after prosthetic joint infection (PJI). The purpose of our study was to determine whether reverse transcription-quantitative polymerase chain reaction (RT-qPCR), which is used to detect bacterial ribosomal RNA (rRNA) preoperatively, can reveal PJI in low volumes of aspirated fluid.

Anterior instrumentation is an established method of correcting King I adolescent idiopathic scoliosis. Posterior segmental pedicle screw instrumentation, with its more powerful corrective force over hooks, could offer significant advantages. The purpose of our study is to compare the results of anterior instrumentation versus segmental pedicle screw instrumentation in adolescent idiopathic thoracolumbar scoliosis. A retrospective analysis was conducted on 36 consecutive female patients with adolescent idiopathic thoracolumbar scoliosis who had surgery from December 1997. All had a minimum of two year follow-up. Eleven patients had posterior surgery performed on them.

Mean age at surgery was similar between both groups. Length of surgery was significantly shorter in the posterior group (189 minutes versus 272 minutes). Length of hospital stay was shorter in the posterior group (6.2 days versus eight days). Estimated blood loss, duration of analgesia, and ICU stay did not differ significantly between the two groups. No complications were encountered in both groups at latest follow-up. The magnitudes and flexibility of the thoracolumbar curves did not differ significantly between the two groups. The number of levels in the major curve was also similar between the groups. Fusion levels were shorter in the anterior group (mean 4.1 versus 5.0). The percentage correction of scoliosis was similar between the two groups at all stages of follow-up, being 74% at one week post-surgery, 70% at six months post-surgery, 68% at one year post-surgery and latest follow-up in the anterior group; and 71% at one week post-surgery, 67% at six months post-surgery, 68% at one year post-surgery, and 67% at latest follow-up in the posterior group.

Thoracolumbar sagittal alignment at T11 to L2 was maintained for both groups throughout the follow-up period. The incidence of proximal junctional kyphosis was higher in the posterior group (p < 0.01).

In conclusion, surgical correction of both the frontal and sagittal plane deformity are comparable to anterior instrumentation. Shorter length of surgery and hospital stay are the potential benefits of posterior surgery. Posterior segmental pedicle screw instrumentation offers significant advantage, and is a viable alternative to standard anterior instrumentation in idiopathic thoracolumbar scoliosis.

Thoracoscopic spinal instrumentation and fusion has emerged as a viable alternative to open anterior and posterior techniques for the treatment of thoracic adolescent idiopathic scoliosis. Furthermore, the morbidity associated with thoracoscopy is limited, and the cosmetic result more desirable because of the minimal skin and chest wall dissection required with this method. However, the technique is technically demanding and has been perceived as having a steep learning curve. The objective of our study is to anal the initial series of 50 patients performed by a single surgeon, with respect to the coronal and sagittal alignment on radiographs, as well as a review of the peri-operative data and complications.

Fifty consecutive patients who underwent thoraco-scopic instrumentation and fusion were divided into two groups for the purpose of this study: the first 25 cases (1st group) and the second 25 cases (2nd group). The minimum follow-up of these cases was 12 months (range 12 to 67 months). Data collected included the operative time, intra-operative blood loss, number of levels instrumented, length of the hospital stay, the number of days in the ICU, and the duration of analgesia.

No major complications, such as neurological deficit, vascular injury, or implant failure were observed. No significant difference was encountered between the groups in terms of age and menarche at surgery, pre-operative curve magnitude and flexibility, sagittal profile, as well as the number of levels in the curve pre-operatively. The second group had significantly better coronal deformity correction at one week post-operatively (9.5 degrees versus 16.3 degrees, p < 0.001), six months post-operatively (12.1 degrees versus 18.9 degrees, p < 0.001), and at latest follow-up (15.1 degrees versus 19.5 degrees, p < 0.05). The percentage correction of scoliosis was significantly better in the second group at one week postoperatively (p < 0.001), six months post-operatively (p < 0.001), and at latest follow-up (p = 0.014). The percentage change in thoracic kyphosis and lumbar lordosis after surgery was not significantly different between both groups at various times of follow-up. There was no difference between both groups with regards to the number of levels fused, hospital stay, and duration of parenteral analgesia. Operative time was significantly less in the second group (302 minutes versus 372 minutes, p < 0.001). Estimated blood loss was also less in the second group (170 cc versus 266 cc, p = 0.04). The length of ICU stay was also shorter in the second group (1.8 days versus three days, p = 0.004). From the loess (locally-weighted regression) fit, the learning curve is estimated to be 30 cases with regards to the operative time, ICU duration, and the coronal plane deformity correction.

The learning curve associated with thoracoscopic spinal instrumentation is acceptable. The complication rates remained stable throughout the surgeon’s experience. Thoracoscopic anterior instrumented fusion is a viable surgical alternative to standard posterior fusion and instrumentation for adolescent idiopathic scoliosis requiring selective thoracic fusion.

Study Design: Compartative cohort study.

Objective: To compare the safety and efficacy of conventional posterior instrumented fusion versus thoracoscopic instrumented fusion for the surgical treatment of King Type III adolescent idiopathic scoliosis.

Methods: The results of 34 consecutive patients with King type 3 scoliosis treated with one of the above techniques were analyzed independantly. Twenty-two patients underwent posterior spinal fusion (PSF) and instrumentation (Moss-Miami). Twelve patients had thoracoscopic fusion (TF) and instrumentation (Eclipse).

Results: Baseline demographics (age at menarche and surgery, pre-operative Cobb angles in coronal and sagittal planes), estimated blood loss at surgery and duration of parenteral analgesia did not differ between the two groups. PSF patients had significantly higher transfusion requirements (p=0.032). Operative time (p = 0.0001), ICU stay (p = 0.005), and hospital stay (p = 0.037) were longer in TF cases. There were no complications in PSF patients. Complications in TF patients included lobar collapse (1 patient) and scapula winging (1 patient). Improvement in scoliosis among PSF patients averaged 75% (1 week), 70% (6 months), and 65% (1 year). In TF patients, mean improvement in scoliosis was 66% (1 week), 62% (6 months), and 62% (1 year). The differences between the two groups in terms of scoliosis improvement were not significant. Curves with apex at T8 or higher had better correction of scoliosis (p = 0.05). The sagittal alignment (thoracic kyphosis and lumbar lordosis) after surgery was similar between the two groups at 1 week, 6 months, and 1 year post-operatively.

Conclusion: The efficacy of thoracoscopic anterior fusion and instrumentation is similar to standard posterior instrumented fusion. The advantages of the thoracoscopic technique are the avoidance of a long posterior midline scar, and lower transfusion requirement. A longer operative time, ICU and hospital stay was attributed to the steep learning curve of this endoscopic technique.