Study Design/Objective: Prospective two-leg cohort study on anterior cervical fusion versus cervical arthroplasty with emphasis on clinical outcome measures.

Patients and Methods: Between August 2003 and May 2005 21 consecutive patients underwent anterior cervical fusion with or without anterior decompression with 26 levels fused. Between December 2004 and August 2006 24 patients had cervical arthroplasty with 30 levels replaced. The mean age at operation of the fusion group was 52 years and 5 months (46–69) and for the arthroplasty group 51 years and 2 months (42–62). To establish fusion the Cervios® cage (Synthes) with or without anterior plating was used. In the arthroplasty group the Prodisc C® disc prothesis (Synthes) was used. Contraindication for arthroplasty were osteoporosis, osteopathies, spinal canal stenosis, hypertrophic spondylarthrosis, spondylolisthesis, tumors and privious infection. Both groups were comparable with respect to age and gender, diagnosis, level distribution and preoperative clinical outcome measures (VAS for nack pain and arm pain, neck disability index and SF-36–sub-scores pain, function, vitality).

Results: Postoperatively all of the clinical outcome measures significantly improved in both groups. After three months postoperatively no significant further improvement was evident.

VAS neck pain: Fusion group/arthroplasty group: Preoperatively 6.2/5.9 n.s., 6 weeks 3.5/3.1 n.s., 12 weeks 2.1/1.9 n.s, 1 year 2/2.1 n.s.

In the fusion group we had 1 recurrent radiculopathy and 1 non union without the need of further intervention. In the arthroplasty group we faced 1 recurrent laryngeus recurrens nerve palsy and 3 spontaneus fusions within 1 year postoperatively, which might not be classified as complication.

Conclusion: Short term outcome after both procedures is excellent in terms of pain relief and function. 10% spontaneus fusion after disc replacement within the first year was evident. In our series we found better results after 3 months to 1 year postoperatively with respect to the neck disability index and SF-36 subscore pain within the arthroplasty group.

Periacetabular osteotomy (PAO) is a well established method to treat hip dysplasia in the adult. There are, however, a number of complications associated with this procedure as well as a time related deterioration in the grade of osteoarthritis that can influence the long term result. It is essential that patients are fully informed as to the effectiveness of PAO, the likelihood of complications and their influence on the subjective outcome prior to giving consent for surgery. Generic outcome measures offer the opportunity to determine treatment efficacy and the influence on the outcome by complications.

60 PAOs on 50 patients were investigated retrospectively after a mean follow up of 7.4 years. The patients’ self reported assessment of health and function was evaluated by the SF-36 and the WOMAC questionnaires at last follow-up. 40 healthy persons served as a control group.

The centre-edge angle improved from a mean of 8.7° to 31.5°. The weight bearing surface improved from a mean lateral opening of 8.7° to 4.2°. The degree of osteoarthritis improved in one case, remained unchanged in 20 and deteriorated in 17. There was a tendency of higher CE-angles towards a higher rate of deterioration, indicating that overcorrection may increase osteo-arthritic degeneration. 13 of the 60 interventions had no complications. Minor complications occurred in 25 (41%) interventions and in 22 (37%) at least one major complication occurred. SF-36 summary measure was 76.4 for PAO patients and 90.3 for the control group. Mean WOMAC score was 25.1. The severity of ectopic bone formation, incidence of postoperative peroneal nerve dysfunction and delayed wound closure did not influence the subjective result. Patients with major complications had a similar subjective outcome as patients with minor or no complications, but persistent dysesthesia due to lateral femoral cutaneous nerve dysfunction led to a worse subjective function as assessed with the WOMAC score.

Study Design. Retrospective clinical and radiographic review of patients after Bernese periacetabular osteotomy for symptomatic congenital hip dysplasia. Introduction. The Bernese periacetabular osteotomy for the treatment of symptomatic congenital hip dysplasia is known to be a complex operative procedure. Several authors reported significant percentages of peri- and postoperative complications.

Objective.The aim of our study was to reveal whether the incidence as well as the grade of complications affect the postoperative outcome which was determined by the short form (SF) 36 and the Western Ontario McMasters osteoarthritis (WOMAC) questionnaires.

Methods. A consecutive series of 50 patients with 60 hips operated between 1988 and 2000 were investigated retrospectively with a mean follow up period of 32 months.

Results. With an incidence of 30% a lesion of the lateral cutaneus nerve occurred. In 10% a peroneal nerve palsy was diagnosed immediate postoperatively, with 4% persistent neurological deficit presented at one year follow up. Several other minor and major complications occurred with an overall complication rate of 68%. According to the severity of complications two groups of patients were identified. Statistical analysis did not reveal any difference between the results of the SF-36 (p=0.2) and WOMAC (p=0.09) questionnaires. Radiological analysis revealed a deterioration of osteoarthritis in 32% of our patients. These patients predominantly judged their postoperative results poor to fair (r=0.71). 76% rated the operation as successful and 64% would have surgery again. The subjective estimation of patients health status postoperatively was significantly reduced compared to an age matched healthy reference group (p=0.0001).

Conclusion. Despite the high incidence of complications 76% of the patients rated the operation as successful. 32% of the patients faced a deterioration of osteoarthritis. The postoperative results after Bernese periacetabular osteotomy are rather more influenced by the progression of osteoarthritis than by the occurrence of perioperative complications.

Component migration after THR is directly correlated with loosening and reported to be predictive for the long-term survival rate. In literature, four different patterns of stem-migration are reported. Likewise, periprothetic osteolytic zones indicate the risk of loosening and revision in the further course. Nevertheless, little is known about the distinguish migration behaviour between cemented and uncemented stems throughout the process of loosening. The aim of this study was to evaluate the influence of cementing on migration behaviour of loose femoral components after THR. A total of 207 stem-revisions have been performed at our institution between 1996 and 2001. Only patients with aseptic loosening after primary hip replacements were included in the present study. Thus, 75 patients had to be excluded due to other reasons for loosening. Migration analysis was done with the EBRA-FCA method (Einzel-Bild-Röntgen-Analyse, Femoral Component Analysis). In addition, a radiographic analysis was performed following Gruen et al. For migration analysis, a minimum of four x-rays per series are required. Hence, another 72 patients had to be excluded due to insufficient x-ray documentation. A total of 40 cemented (Group A) and 20 uncemented (Group B) femoral components could be analysed. There were no significant differences between the two groups with regard to age (60 years for Group A, 56 years for Group B), gender or side. Mean number of radiographs per series was 7.2 for Group A and 7.9 for Group B respectively. Mean stem survival differed between the two groups (11.3 years for Group A and 8.8 years for Group B), but without statistical significance (T-Test: p> 0.05). Differences in migration behaviour and distinct types of loosening after cemented and uncemented total hip replacement will be presented.

Objective: We evaluated retrospectively whether there is a role for selective posterior thoracic correction and fusion in double major curves with third generation instrumentation systems.

Methods: In a retrospective review the radiographs of 36 patients with Lenke 3C type curve patterns and having had a selective posterior thoracic correction and fusion with either the Cotrel-Dubousset instrumentation or the Universal Spine System, were evaluated in terms of coronal and sagittal plane balance, curve flexibility, and curve correction with a minimum follow up of two years. Postoperative coronal spinal decompensation was investigated with respect to preoperative radiographic parameters on standing AP, thoracic and lumbar supine side-bending as well as lateral standing radiographs. Coronal spinal decompensation was defined as plumbline deviation of C7 of more than 2 cm with respect to the center sacral vertical line within two years postoperatively. Two groups of patients were analyzed.

Results: 26 patients (72%) showed satisfactory frontal plane alignment by means of C7 plumb line deviation (group A, 1.2 cm to the left), whereas 10 patients (28%) showed coronal spinal decompensation (group B: 2.7 cm to the left; p=0.003). Group differences, could be revealed for lumbar apical vertebral rotation (Perdriolle) (p=0.02, A: 16°, B: 22°) and the percentage correction (derotation) of lumbar apical vertebrae in lumbar supine side-bending films in comparison to AP standing radiographs (p=0.002, A: 49%, B: 27%). Average thoracic curve correction was 51% in group A and 41% in group B (p=0.05). Average lumbar curve correction was 34% in group A and 23% in group B (p=0.09).

High correlation was revealed between postoperative decompensation and derotation of lumbar apical vertebrae (P=0.62, p< 0.001) with a critical value of 40%. A 2x2 table showed that in patients with lumbar apical vertebral derotation of less than 40% specificity was 90% with regard to postoperative decompensation.

Conclusion: Lumbar apical vertebral derotation of less than 40%, determined on lumbar supine side-bending films in comparison to AP standing radiographs, provided the radiographic prediction of postoperative coronal spinal imbalance. We advice close scrunity of the transverse plane in the lumbar supine side-bending film when planning surgical strategy.

Objective: Retrospective analysis of consecutive paediatric patients treated surgically for high-grade spondylolisthesis by one of three circumferential surgical procedures with emphasis on complications and patient outcome measurements.

Methods: Between 1980 and 1998 fourty patients underwent anterior-posterior correction for Meyerding Grade 3 or 4 isthmic dysplastic spondylolisthesis. Ten patients were treated with an anterior reduction according to Louis and anterior interbody fusion followed by posterior decompression and instrumented fusion (group A). Fourteen patients underwent posterior decompression followed by anterior reposition and fusion with tricortical iliac bone crest and posterior instrumented fusion (group B). Sixteen patients underwent progressive reduction by halopelvic traction followed by anterior and posterior fusion (group C). All patients completed the North American Spine Society (NASS) outcome questionnaire and the SF-36. The cosmetic assessment was performed by means of a VAS. The mean follow-up period for group A was 13,5 years, for group B 5,5 years and for group C 15,4 years, respectively.

Results: The three groups were comparable with respect to age at operation, radiographic measurement of the slip, lumbosacral kyphosis and lumbar lordosis. The incidence of postoperative extensor hallucis longus weakness was 33% in group A, 50% in group C and 0% in group B (p< 0.001). Pearson correlation coefficient revealed a positive correlation between extensor hallucis longus weakness and the degree of correction of the lumbosacral kyphosis (P=0.56, p=0.024). Postoperative reduction of the sagittal slip (A: 64%, B: 44%, C: 50%) and lumbosacral kyphosis (A: 27°, B: 16°, C: 27°) was significant in all three groups. The incidence of pseudarthrosis was 10% in group A, 7% in group B and 6% in group C. SF-36 and NASS outcome questionnaire results have not been found statistically significant among the groups.

Conclusion: Outcomes of function, satisfaction and cosmesis are satisfactory in all three surgical groups. Posterior decompression followed by anterior reduction and fusion using tricortical iliac crest bone graft and posterior instrumented fusion lack neurogenic complications. Therefore it is the standard surgical procedure for severe isthmic dysplastic spondylolisthesis at our department.

Objective: To identify radiographic parameters which could predict postoperative spinal decompensation in the frontal plane in King type II adolescent idiopathic scoliosis after posterior thoracic correction and fusion with third generation instrumentation systems.

Design: Retrospective radiographic analysis.

Subjects: The radiographs of 36 patients with King type II adolescent idiopathic scoliosis (AIS) who had had posterior thoracic correction and fusion, either with the Cotrel-Dubousset instrumentation (CDI) or the Universal Spine System (USS), were evaluated in terms of frontal and sagittal plane balance, curve flexibility, and curve correction with a minimum follow up of two years. Postoperative spinal decompensation in the frontal plane was investigated with respect to preoperative radiolographic parameters on standing upright AP, thoracic and lumbar supine side-bending as well as lateral standing radiographs. Spinal decompensation in the frontal plane was defined as plumbline deviation of C7 of more than 2 cm with respect to the centre sacral line within two years postoperatively. Two groups of patients were analyzed.

Outcome measures: 26 patients (72%) showed satisfactory frontal plane alignement by means of C7 plumb line deviation (group A, 1.2 cm to the left), whereas 10 patients (28%) showed spinal decompensation (group B: 2.7 cm to the left). Group differences were significant (p=0003).

Results: The two groups were found statistically equivalent in terms of preoperative C7 plumbline deviation (p=0.112, group A: 0.8 cm, group B: 0.7 cm to the left), thoracic cobb angles (p=0.093, group A: 56°, group B: 62°), lumbar cobb angles (p=0.115, group A: 42°, group B: 47°), lumbar curve flexibility (p=0.153, group A: 78%, group B: 67%); thoracic kyphosis (p=0.153) and lumbar lordosis (p=0.534) and age at operation (p=0.195), Significant group differences, however could be revealed for thoracic curve flexibility (p=0.03, group A: 43%, groupB: 25%) and the percentage of derotation of lumbar apical vertebrae in lumbar supine side-bending films in comparison to AP upright standing radiographs (p=0.002, group A: 49%, group B: 27%). Average thoracic curve correction was 51% in group A and 41% in group B. Group differences were significant (p=0.05). Average lumbar curve correction was 34% in group A and 23% in group B (p=0.09). No group differences could be revealed for postoperative thoracic kyphosis and lumbar lordosis measurements. Logistic regression analysis with C7 plumbline deviation of more than 2 cm postoperatively as the dependent variable yielded the amount of lumbar apical vertebral derotation in lumbar supine side-bending films as the only risk-factor (p=0.007).

Conclusion: Fixed lumbar rotation, measured in terms of the percentage of derotation of lumbar apical vertebrae in lumbar supine side-bending films in comparison to AP upright standing radiographs, provided the radiographic prediction of spinal decompensation in the frontal plane after posterior thoracic correction and fusion of King II type curves.

Objective: To compare multi surgeon reliability of the classification systems of H. A. King and R.W. Coonrad and to analyse controversial classified curve patterns.

Design: Three scoliosis surgeons and one orthopedic fellow were presented the AP radiographs of seventy adolescent idiopathic scoliosis patients. All reviewers assigned a type to each curve according to the classification systems of H. A. King [1] and R. W. Coonrad [2].

Subjects: Interobserver agreement and intraobserver reproducibility were tested. Kappa coefficients were used to test reliability. Between the observers, the divergent assignments to curve patterns were analysed in quantitative as well as in qualitative terms. An error analysis was performed.

Results: For King’s classification, paired comparisons revealed a mean interobserver kappa coefficient of 0.45, and for Coonrad’s classification system 0.38, respectively. According to Svanholm et al., these values indicate poor reliability in terms of interobserver agreement. Error analyses for both classification systems revealed that the reason for poor reproducibility is disagreement on structural upper thoracic and structural lumbar curves among the observers.

Conclusion: Neither King’s nor Coonrad’s method appear to have sufficient interobserver reliabilty. In order to improve reliability we recommend unequivocal description of structural stigmata of upper thoracic and lumbar curves.

Objective: To evaluate the subjective clinical outcomes, radiographic results and complications associated with single solid rod anterior instrumentation in neuromuscular scoliosis.

Design: Retrospective clinical case series with a mean follow up of 30 months (range 24 – 42 months).

Subjects: 9 consecutive cases (6F, 3M) with a mean age 15 years (range 11 – 24 years), underwent single solid rod anterior instrumentation of their neuromuscular thoracolumbar scoliosis between 1994 and 2000. The heterogeneous patient group consisted of 5 spinal dysraphism, and 1 each of prune belly syndrome, arthrogryposis, myotonic dystrophy and congenital myopathic dystrophy (muscle eye brain syndrome). All patients were ambulatory and had minimal pelvic obliquity (< 15 degrees).

Outcome measures: Pre-operative, post-operative and final follow up measurements were collected for 1) Cobb angles, 2) apical vertebral translation (AVT), 3) thoracic kyphosis (T5-12) and 4) lumbar lordosis (L1-5). Operative complications, pseudarthrosis, metalwork failure and loss of correction were also recorded.

Results: There was 1 each of rod breakage and upper thoracic curve progression requiring supplementary posterior surgery. For the remaining 7 patients, the average follow-up corrections for Cobb angle was 56% (49 to 22 degrees), AVT was 49% (5.1 to 2.6 cms), and both the thoracic kyphosis and lumbar lordosis remained unchanged. No significant loss in correction occurred during the post-operative period to final follow-up in all the above parameters. No pseudarthrosis, vascular or neurological complications were encountered. Subjectively, there were 6 excellent and 1 good results.

Conclusions: In this limited case review, selective anterior instrumentation for neuromuscular scoliosis using a single solid rod system resulted in acceptable clinical and radiographic outcomes. Our results appear to compare favourably with those published for the recommended method of posterior instrumentation. Advantages include preservation of distal lumbar motion segments whilst maintaining segmental saggital and coronal alignment. We believe that this method of scoliosis correction has a definite yet select role in patients who are ambulatory, have minimal pelvic obliquity (< 15 degrees), non-progressive pathology and near normal mental function.

Objective: To assess the radiological and back surface correction achieved following anterior USS in the treatment of thoracic adolescent idiopathic scoliosis (AIS).

Design: Prospective study of back surface correction, retrospective radiological review.

Subjects: 14 patients with thoracic AIS (age 11–18 yrs) were treated with anterior USS between 1995 and 2000. There are 12 females and 2 males, all with 2 year follow-up. 8 patients have complete surface data. Data from a further 6 patients will shortly be available as they reach 2 year follow-up.

Outcome measures: Cobb angle, apical vertebral rotation (AVR), apical vertebral translation (AVT), frontal plane imbalance, kyphosis and lordosis were measured from the radiographs. A Scoliometer was used to assess the maximal angle of trunk inclination (max ATI) in the thoracic region. All measurements were obtained before surgery and at 8 weeks, 1 year and 2 years after surgery. Complications were recorded.

Results: Significant initial corrections are observed for each of: Cobb angle (51%, p< 0.001), AVR (40%, p=0.003),AVT (64%,p< 0.001),maxATI (47%,p=0.001). There is no significant correction loss during the 2 year follow-up. Three patients had spinal imbalance (> 2cm) before surgery with one patient after surgery. The kyphosis significantly increased from 24° to 29° immediately after surgery with no significant change during follow-up. There was no change in lordosis. There were no neurological complications and no instrumentation failures were observed. In two cases the upper screw partially pulled out of T5 with some loss of correction.

Conclusions: Anterior scoliosis correction for thoracic AIS achieves good and stable radiological and particularly back surface corrections (max ATI – 47% compared with 22% correction after posterior surgery). Rigid anterior instrumentation has eliminated the 20% rod failure seen with Zielke. New techniques for preventing upper screw pull out will be discussed and new retractor systems allow smaller thoracotomies. There remains a small but significant increase in kyphosis which is less of a problem in the thoracic spine than at the thoracolumbar junction where anterior scoliosis correction is most commonly advocated.

Anterior instrumentation for thoracic AIS has advanced to a point where it can be widely adopted, particularly if the patient expresses concerns regarding the rib hump or is hypokyphotic.

Objective: To evaluate the long term radiological and clinical outcome after posterior correction of adolescent right thoracic idiopathic scoliosis with Cotrel-Dubousset instrumentation (CDI) and Harrington rod instrumentation (HRI).

Design: Retrospective comparative analysis.

Subjects: Out of preoperative standing radiographs of 229 patients 30 pairs of female patients, one patient with Harrington rod instrumentation (HRI) and the other with Cotrel-Dubousset instrumentation (CDI), could be identified. Curves within pairs were comparable with regard to curve magnitude (thoracic and lumbar) and level of stable and neutral vertebrae. Follow up examination included a clinical review, long cassette upright PA and lateral radiographs of the spine and two patient outcome questionnaires. Mean follow up time for CDI patients was 128 months and for HRI patients 198 months respectively.

Outcome measures: The pain questionnaire according to Moskowitz [1] was used to assess back pain. A customized questionnaire was used to assess whether patients were satisfied with their postoperative cosmetic appearance.

Results: In 92 per cent of the patients L2 was the lowest instrumented vertebra. The thoracic Cobb angle in the HRI group was corrected from 64° to 42° (34%) and in the CDI group from 66° to 24° (58%). Group differences were significant (p=0.004). The lumbar Cobb angle in the HRI group was corrected from 41° to 24° (41%) and in the CDI group from 44° to 21° (52%) respectively. Group differences were significant (p=0.03). The lumbar lordosis below the fusion could be improved postoperatively in CDI patients (L2–L5: 31° to 37°), whereas it remained unchanged in HRI patients (L2–L5: 32°). Group differences were significant (p=0.005). The overall cosmetic appearance was better in the CDI group (CDI 76% excellent and good, HRI 71%, p=0.04).

15% of the CDI patients and 24% of the HRI patients reported frequent low back pain episodes. Group differences were significant (p=0.008). A high correlation between incidence of low back pain and low degrees of lumbar lordosis below the fusion was revealed in HRI patients (p=0.02).

Conclusion: With Cotrel-Dubousset instrumentation better correction of the thoracic and lumbar curves in the frontal plane and better restoration of the lumbar lordosis distal the fusion is achievable. The lack of restoration of lumbar lordosis below the fusion in HRI patients may have some impact on the higher incidence of low back pain episodes found in this group. The postoperative cosmetic result was better in patients with Cotrel-Dubousset instrumentation.

The aim of our study was to determine whether preoperative preparation by means of a video film could influence postoperative hip motion. The video shows a patient undergoing total hip replacement surgery covering the time period from admission to discharge, and keeping strictly to the patient’s perspective.

In 1958 Janis opened up the field of research on preoperative psychological states and postoperative recovery. Since then, numerous studies have been performed and a variety of variables were demonstrated to influence postoperative outcome. Our study takes into consideration the results of previous research and provides a new combination of methods for psychological preparation prior to surgery.

One hundred patients scheduled for elective total hip replacement surgery for osteoarthritis of the hip joint were randomly assigned to a control group (n=54) and a preparation group (n=46). The preparation group was shown the videotape on the evening before surgery. The video gives the pre-surgical patient the opportunity to identify with a patient who had successfully undergone surgery before. Physical examination, including motion analysis of the hip, was performed. Range of hip motion was documented in degrees with reference to neutral joint position.

Flexion/extension, abduction/adduction, and external/ internal rotation in 90° hip flexion were investigated. For range of motion analysis, sum scores were calculated.

Motion analysis revealed no preoperative difference between the groups. Three months after surgery, the increase of joint mobility (preoperative versus postoperative) in prepared patients was significantly better for internal rotation (32%, p=0.005), rotational range of motion (21%, p=0.03) and abduction (22%, p=0.04). Heterotopic ossifications were identified on plain AP radiographs and were judged according to the score of Brooker, et al. Incidence did not differ between groups. Twelve months postoperatively, the increase (preoperative versus follow-up) of rotational range of motion (24%, p=0.01) remained unchanged in prepared patients, whereas an increase of abduction could no longer be revealed. Flexion/extension and sagittal range of motion did not show any differences three and twelve months postoperatively.

Our videotape preparation led to an increase of motion after total hip replacement. Regarding rotational range of motion, this effect still remained twelve months after surgery.

This study was performed to evaluate whether derotation and/or translation are the correct mechanisms of bracing with the Chenau brace in treatment of adolescent idiopathic scoliosis. Bracing in the treatment of adolescent idiopathic scoliosis is an accepted procedure. Variable types of braces with different correction principles are in use. The Boston and the Milwaukee brace correction mechanisms seem to be clear, but not for the Chenau brace which is said to be an inspiration/ derotation device.

Curves were measured according to Cobb and rotation of the apex vertebra was determined according to Perdriooe. Translation of the apex vertebra perpendicular to the centre sacral line was measured according to Mason and Carango. Measurements were performed on standing radiographs AP and were taken immediately before starting therapy, six months afterwards to ascertain initial correction, and at least one year after treatment. Compliance was judged as follows: regular and frequent control examinations, an obviously used brace, and visible skin signs. Two groups were formed (Group A: good compliance, n=33, Group B: bad compliance, n=22).

In Group A, continuous curve correction of 6° Cobb angle was evident. Patients in Group B showed a mean curve progression of 4° (t=test, p=0.003). After six months of therapy, both groups demonstrated signifi- cant apex translation (Group A: p=0.0001, Group B: p=0.0003). The difference between the groups was not significant, but no significant derotation of the apex vertebrae.

At follow-up patients with good compliance showed almost the same apex distance as before therapy, whereas deterioration was evident in Group B (p=0.01). The difference of p=0.04 between the two groups was significant. Apex rotation was significantly increased in both groups (Group A: p=0.02, Group B: p=0.03) and the difference between the two groups was not significant.

Curve correction in idiopathic scoliosis with the Chenau brace is a translation process and can be determined as a shift of the apex vertebra to the centre sacral line. Therefore, the Chenau brace is not a derotation device.