There has been debate in the literature over the years regarding whether
rib resection, and surgical approach have a significant impact on long term respiratory function following corrective surgery in idiopathic scoliosis patients. We undertook a minimum 10 year review of prospective data in patients who had undergone corrective surgery for idiopathic scoliosis. Patients had pre-operative, two year (where available) and 10 year follow-up respiratory function tests performed. Variables noted were sex, age at surgery, surgical approach, rib release (simple rib osteotomy, not resection), and percentage correction of curvature. All absolute respiratory function values were converted to percentages relative to a normal population of the same height, sex and age with reference to both arm span and height nomograms thus avoiding the need for a control group. Using accepted statistical norms and appropriate analysis we would be able to confirm a 10% difference in respiratory function. A literature review was also undertaken as part of this study. The only statistically significant change in respiratory function was a drop in FVC at 10 years in patients in whom a posterior approach had been used for correction without a rib release. In no other group (by other approach, sex, age, initial curvature, or curvature correction) was there a significant difference in long term respiratory function. In our study the surgical approach did not have a significant impact on long term respiratory function. Rib release is a safe procedure to undertake as part of scoliosis correction.
Posterior spinal fusion is performed for a variety of lumbar spine conditions for relief of low back pain. Success relies on an effective fusion. Autograft is associated with donor site comorbidity and limited supply. Allograft has the potential for infection and has limited osteoinductive activity. Bone morphogenic proteins (BMPs) have been promoted for use in posterior spinal fusion despite considerable cost and limited evidence to their efficacy. The aim of this study was to compare the clinical response, donor site morbidity and radiologic rates of fusion in patients undergoing posterior spinal fusion looking at the choice of bone graft or substitute. A retrospective review of 141 patients undergoing instrumented posterior lumbar spinal fusion by a single surgeon for degenerative disc disease, degenerative spondylolithesis or lytic spondylolithesis between 2000 and 2005 was undertaken. Patients were contacted and assessed for donor site morbidity and scored with the Oswestry Disability Index (ODI). Radiographs were taken and assessed by an independent blinded radiologist using the Ferguson score. Simple analysis was performed of these results to compare bone grafting techniques. One hundred and forty-one patients were available for review. Fusions were performed for lytic spondylolithesis in 12.4%, degenerative spondylolithesis in 46% and for degenerative disc disease in 41.6% of patients. BMP-2 was used in 19.6%, allograft in 59.8% and iliac crest bone graft in 20.5% of patients. The BMP-2 and non BMP-2 groups were equally spread between the diagnosis and levels of surgery. The overall Ferguson score radiographic fusion rates for these patients was A in 67.9%, B in 17.9% and C in 11.9%. The BMP-2 group patients scored 76.9% (A group) and 23.1% (B group). The non-BMP-2 group scored 57.1% (A group), 23.8% (B group) and 19.1% (C group). The Oswestry Disability Index for patients with BMP-2 improved from 49.7% to 19%, whereas with no BMP-2 improved from 50.0% to 20.9%. Donor site morbidity was not identified as a problem in patients who had an autograft procedure. Over the course of several years a single spinal surgeon’s posterior lumbar spinal fusion practice has evolved as a variety of bone grafting techniques have been trialled in an effort to increase the rate of bony fusion. There was no obvious difference in Oswestry Disability Index score but there was a modest difference in the Ferguson radiologic fusion score for the BMP-2 group. Morbidity in the autograft group was not a problem. These results have confirmed the efficacy of both allograft and autograft in fusion.
This is a retrospective study of patient out-come after spondylolytic repair using a Scott¦s or a Van Dam Procedure (tension band repair). We also looked at the use of plain static radiographs, and a reverse gantry computed tomography scanning in the assessment of healing of the spondylolytic defect. Tension band repair of spondylolysis has proved to be a useful procedure for refractory spondylolysis. However, there is no universally accepted method or determining fusion of the spondylolysis, and the definitive criteria for diagnosing a successful fusion remains controversial. The Oswestry Disability Index was measured in 2000 and in 2004. Plain static radiographs and computed tomography scans were performed on 14 patients one year after fixation of the spondylolysis. A radiologist and an independent orthopaedic surgeon assessed the presence of bridging trabecular bone in the scan and X rays. Results in 14 patients were rated as excellent and in 4 as good in year 2000 and results remained excellent to good in 16 of 17 patients followed up in year 2004. The fusion rate was 90%[18/20] on the plain radiographs. Fusion on the computed tomography scans was observed in 50% [7/14] A high rate of good-excellent clinical results can be obtained following a Scott or Van Dam Procedure. Radiological fusion rate was higher than assessment with thin-section computed tomography scans. CT tomography studies clearly demonstrated the presence or absence of bridging bone, a property not easy to see in plain static radiographs. However, clinical significance of CT non-union is not clear.
The patients were reviewed with the aim of determining whether extending the fusion to the sacrum was needed or would affect the pelvic obliquity over the long term. Twenty-four patients with quadriplegic cerebral palsy, (non-ambulators) aged between 5–23 who underwent corrective surgery for their scoliosis were included in the study Twelve patients were stabilized to the sacrum (LUQUE-Galveston technique) and 12 to L4 or L5 in the lumbar spine using pedicle screws. The patients were divided into two groups. Group 1 Pelvic obliquity less than 20° – no stabilisation to the pelvis. Group 2 Pelvic obliquity more than 20° – stabilisation to the pelvis. Group 1 – Patients with pre-operative pelvic obliquity less than 20° maintained their pre-operative pelvic obliquity without significant deterioration (less than 6° change). Group 2 – Patients with pelvic obliquity of 20° or more stabilised to the sacrum maintained or improved their correction until fusion. One patient had a draining sinus six months after the index operation for which removal of metalware (after fusion) was needed. No patient had a non union of the fusion mass. We believe that patients with a pelvic obliquity of less than 20 degrees at the time of surgery don’t need stabilization to the pelvis. Lumbar pedicle screws give sufficient stability to the distal construct and preserve mobility at the lumbosacral junction. Operative times and blood loss were reduced in those patients not fixed to the pelvis. There appears to be no significant loss of correction of the pelvis obliquity over time.
We report intermediate term results of a technique of acetabular augmentation using block femoral head autograft and the uncemented expansion cup for adult hip dysplasia. A retrospective review of one surgeon (BFH) series of consecutive total hip replacements for hip dysplasia using femoral head acetabular augmentation was carried out. The technique involves sectioning the femoral head longitudinally reversing and fixing it to the deficient acetabulum with 6.5mm AO screws. This is then reamed to accept the uncemented expansion cup. Patients were identified from audit databases. Patients completed clinical questionnaires, examination and radiographic evaluation. Fifteen hips were identified in twelve patients (three bilateral). The average at age at surgery was 54 (44–58) years. There were eight females (eleven hips). Three patients (three hips) were unable to be contacted. Average follow up was 8.4 (4.8–11.4) years. Preoperative centre edge angle was 14 (−10–30) degrees. One patient developed a deep infection requiring early staged revision. One patient was not satisfied with her results at follow up. Mean Harris Hip Score was 83 (63–100), mean WOMAC Score was 76 (50–95). Range of motion was well maintained in all patients. Four patients had other co-morbidities affecting their results. Radiological review shows all grafts to have united with no screw breakage and no cup loosening. At eight year follow up there is high satisfaction, good clinical and radiological results. These results demonstrate good intermediate term results using this technique in total hip replacement with acetabular dysplasia.
The mean blood loss as a percentage of calculated blood volume was 38% (SD 35). There was a strong suggestion that patients with medical abnormalities, particularly those with muscular dystrophies, had much higher blood losses (63%, SD 59). There were no differences between the different patient groups in the pre-operative haematological investigations.
