Search

BACKGROUND: Decompression surgery for lumbar spinal stenosis (LSS) is the most common spinal procedure in the elderly. To avoid persisting low back pain, adding arthrodesis has been recommended, especially if there is a coexisting degenerative spondylolisthesis. However, this strategy remains controversial, resulting in practice-based variation.PURPOSE: To evaluate in a pragmatic study if surgical selection criteria and variation in use of arthrodesis in three Scandinavian countries can be linked to variation in treatment effectiveness.STUDY DESIGN: An observational study based on a combined cohort from the national spine registries of Norway, Sweden, and Denmark.PATIENT SAMPLE: Patients aged 50 and higher operated 2011-2013 for LSS were included.OUTCOME MEASURES: Patient-reported outcome measures (PROMs) Oswestry disability index (ODI) (primary outcome), numeric rating scale (NRS) for leg pain and back pain, and health-related quality of life (EQ-5D). Analysis included case-mix adjustment. In addition, we report differences in hospital stay.METHODS: Analyses of baseline data were done by analysis of variance (ANOVA), Chi-square, or logistic regression tests. The comparisons of the mean changes of PROMs at one-year follow-up between the countries were done by ANOVA (crude) and analyses of covariance (ANCOVA, case mix adjustment). There are no conflicts of interest. Funding was received from the Danish Society of Spinal Surgery ($5,925), the Northern Norway Regional Health Authority ($5,925) and from Swedish Association of Local Authorities and Regions ($11,885). The sponsor had no role in the acquisition of data, analysis, or preparation of the manuscript.RESULTS: Out of 14,223 included patients, 10,890 (77%) responded at one-year follow-up. Apart from fewer smokers in Sweden and higher comorbidity rate in Norway, baseline characteristics were similar. The rate of additional fusion surgery (patients without, with spondylolisthesis) was: Norway 11% (4%, 47%), Sweden 21% (9%, 56%) and Denmark 28% (15%, 88%). At one-year follow-up the mean improvement for ODI (95%CI) was: Norway 18 (17 to 18), Sweden 17 (17 to 18), and Denmark 18 (17 to 19). Patients operated with arthrodesis had prolonged hospital stay.CONCLUSIONS: Real life data from three national spine registers showed similar indications for decompression surgery, but significant differences in the use of concomitant arthrodesis in Scandinavia. Additional arthrodesis was not associated with better treatment effectiveness.

Sciatica due to lumbar disc herniation refractory to conservative treatment is effectively treated by surgery. The primary goal of surgery is retrieval of herniated disc fragments and decompression of the nerve root. After the historical publication of Mixter and Barr [1], who performed extensive laminectomy with transdural excision of the herniated disc, lumbar disc surgery became one of the most frequently performed surgical procedures worldwide. With the introduction of the microscope in the late 1960s, Yasargil and Caspar launched the unilateral microdiscectomy [2]. Presently, unilateral transflaval microdiscectomy by using the microscope or headlight with loupe magnification, is regarded as the golden standard. However, a shift towards minimally invasive approaches to the spine has started. The rationale behind minimally invasive spine surgery is less tissue damage, shorter hospitalisation, and faster recovery while achieving a good clinical outcome comparable with that of open conventional surgery. Minimally invasive spine surgery has adopted several techniques from other fields and has been influenced by endoscopy, biochemical advances, lasers, and image guidance systems. Intradiscal chymopapaine has been used more than 30 years but has been abandoned since it is less effective than surgical nerve root decompression [3]. Hijikata and Kambin are credited for their first report of percutaneous nucleotomy by inserting a 7 mm diameter tube under local anaesthesia with partial resection of disc material [4]. Choi and Ascher reviewed the first results of percutaneous laser disc decompression aiming at decreasing intradiscal pressure and subsequent nerve root relief [5]. The concept of posterolateral endoscopic discectomy changed from central nucleotomy to transforaminal nerve root decompression, which was launched by Hoogland [6] A few years later, Foley and Smith introduced the transmuscular approach of microendoscopic tubular discectomy with advanced optics and instruments applicated in laparoscopic surgery [7], which was later modified with the operative microscope.

BACKGROUND CONTEXT: Percutaneous laser disc decompression (PLDD) is a minimally invasive treatment for lumbar disc herniation, with Food and Drug Administration approval since 1991. However, no randomized trial comparing PLDD to conventional treatment has been performed. PURPOSE: In this trial, we assessed the effectiveness of a strategy of PLDD as compared with conventional surgery. STUDY DESIGN/SETTING: This randomized prospective trial with a noninferiority design was carried out in two academic and six teaching hospitals in the Netherlands according to an intent-to-treat protocol with full institutional review board approval. PATIENT SAMPLE: One hundred fifteen eligible surgical candidates, with sciatica from a disc herniation smaller than one-third of the spinal canal, were included. OUTCOME MEASURES: The main outcome measures for this trial were the Roland-Morris Disability Questionnaire for sciatica, visual analog scores for back and leg pain, and the patient's report of perceived recovery. METHODS: Patients were randomly allocated to PLDD (n=57) or conventional surgery (n=58). Blinding was impossible because of the nature of the interventions. This study was funded by the Healthcare Insurance Board of the Netherlands. RESULTS: The primary outcome, Roland-Morris Disability Questionnaire, showed noninferiority of PLDD at 8 (-0.1; [95% confidence interval (CI), -2.3 to 2.1]) and 52 weeks (-1.1; 95% CI, -3.4 to 1.1) compared with conventional surgery. There was, however, a higher speed of recovery in favor of conventional surgery (hazard ratio, 0.64 [95% CI, 0.42-0.97]). The number of reoperations was significantly less in the conventional surgery group (38% vs. 16%). Overall, a strategy of PLDD, with delayed surgery if needed, resulted in noninferior outcomes at 1 year. CONCLUSIONS: At 1 year, a strategy of PLDD, followed by surgery if needed, resulted in noninferior outcomes compared with surgery. (C) 2015 Elsevier Inc. All rights reserved.

The choice of a specific surgical technique should be based on its benefits and harms. Previous reviews have shown that the benefit of surgery over conservative care is not clearly demonstrated in patients with disorders of the cervical spine. Also, no additional benefit of fusion upon anterior decompression techniques could be found. A clear overview of other surgical techniques is lacking. We therefore aimed to assess the benefits and harms of cervical spinal surgery in patients with cervical disorders. We searched MEDLINE, EMBASE, CINAHL, and CENTRAL up to June 2012. Randomized controlled trials (RCTs) were selected which included adults with cervical disorders receiving a surgical intervention and that reported at least 1 clinically relevant outcome measure (eg, pain, function, recovery). Two authors independently assessed the risk of bias using the criteria recommended by the Cochrane Back Review Group and extracted the data. The quality of the evidence was rated using the GRADE method. We included 39 RCTs comparing different surgical interventions. We found low-quality evidence for no difference in effectiveness between various surgical techniques used for anterior discectomy. There is a small, clinically irrelevant benefit on recovery and pain in favour of prosthetic disc surgery when compared with fusion techniques. Unfortunately, in these studies the authors had a clear conflict of interest. The differences in benefits and harms between the various surgical techniques are small. The surgeon, patient, and health care provider can therefore make the choice of any surgical technique based on experience, preferences, or costs. © 2013 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.

Objective: Odontoid fractures are the most common cervical spine fractures in elderly patients. The optimal treatment in this age group remains controversial. The goal of this study was to compare outcomes of surgical and conservative treatments. Methods: A retrospective cohort study was conducted in three tertiary referral centers in the Netherlands. Patient records were reviewed for patients who met the selection criteria (i.a. age ≥55 years, type II/III odontoid fractures). Fracture healing (union/stability) and clinical outcomes (Likert scale) were assessed. The influence of age, applied treatment, and treatment strategy (‘fracture based approach’ or ‘primarily conservative’) was studied. Results: A total of 105 patients were included (18 treated surgically, 87 treated conservatively; 52 treated with ‘fracture based approach’, 53 treated ‘primarily conservative’). No difference was found in fracture union (68% overall) and fracture stability (88% overall). Data on clinical outcome were scarce, but did not differ between treatment groups. Patients ≥80 years had worse outcomes in both applied treatment- and treatment strategy arms. Conclusion: No radiological differences in outcome between surgical or conservative treatment (strategies) were observed. The majority of patients achieved fracture healing. The exact correlation between the quality of fracture healing (union or stability) and clinical outcome remains unclear. Advanced age (>80 years) negatively influenced outcome.

Item does not contain fulltext STUDY DESIGN: A systematic review of randomized controlled trials. OBJECTIVE: To determine which technique of anterior cervical interbody fusion (ACIF) gives the best outcome in patients with cervical degenerative disc disease. SUMMARY OF BACKGROUND DATA: The number of surgical techniques for decompression and ACIF as treatment for cervical degenerative disc disease has increased rapidly, but the rationale for the choice between different techniques remains unclear. METHODS: From a comprehensive search, we selected randomized studies that compared anterior cervical decompression and ACIF techniques, in patients with chronic single- or double-level degenerative disc disease or disc herniation. Risk of bias was assessed using the criteria of the Cochrane back review group. RESULTS: Thirty-three studies with 2267 patients were included. The major treatments were discectomy alone and addition of an ACIF procedure (graft, cement, cage, and plates). At best, there was very low-quality evidence of little or no difference in pain relief between the techniques. We found moderate quality evidence for few secondary outcomes. Odom's criteria were not different between iliac crest autograft and a metal cage (risk ratio [RR]: 1.11; 95% confidence interval [CI]: 0.99-1.24). Bone graft produced more fusion than discectomy (RR: 0.22; 95% CI: 0.17-0.48). Complication rates were not different between discectomy and iliac crest autograft (RR: 1.56; 95% CI: 0.71-3.43). Low-quality evidence was found that iliac crest autograft results in better fusion than a cage (RR: 1.87; 95% CI: 1.10-3.17); but more complications (RR: 0.33; 95% CI: 0.12-0.92). CONCLUSION: When fusion of the motion segment is considered to be the working mechanism for pain relief and functional improvement, iliac crest autograft appears to be the golden standard. When ignoring fusion rates and looking at complication rates, a cage as a golden standard has a weak evidence base over iliac crest autograft, but not over discectomy.

This chapter discusses key aspects in the diagnosis, prognosis, and surgical treatment of lumbar disc herniation with persistent complaints. The importance of natural history, clinical assessments, and imaging with MRI is viewed with regard to decision for surgery. The appropriate wait and see time before indicating surgery is regarded in relation to the comparison of conservative treatment with surgery. Existing evidence shows that short-term improved outcome should be balanced against the surgical burden and associated risks. Further, comparative evidence between different surgical techniques shows no clear advantage of different techniques.

Patella position can be measured on axial radiographs and many measurement techniques have been described in literature. The goal of this study was to evaluate the inter- and intraobserver reproducibility of measurement techniques available in the literature for patients with a knee prosthesis. Fifty axial patella radiographs from knee prostheses were used to measure the reproducibility of five measurement techniques. Reproducibility was calculated using the Bland and Altman method. The Patellar Displacement (>or=4 mm) and the Lateral Patellar Tilt (>10 degrees) were found to be useful and clinically relevant. Based on our study we recommend that the most reproducible method to use for measurement of tilt, is Lateral Patellar Tilt; to measure displacement, the surgeon should use the Patellar Displacement technique.

Goal of this study is to determine the anterior-posterior laxity in 30 degrees of knee flexion for a posterior cruciate retaining total knee arthroplasty with a relative dished insert and implanted with a ligament tensor. Furthermore, the correlation between these AP laxities and the postoperative range of motion (ROM) and postoperative Knee Society Score (KSS) is analysed. Fifty-one balanSys total knee arthroplasties were performed in 49 patients between 1998 and 2000. These arthroplasties are analysed with respect to AP laxity (Rolimeter), ROM and KSS with a mean follow-up of 4.6 years. The mean anterior laxity is 2.8 mm with no posterior laxities at all. The average postoperative ROM is 110 degrees with an average KSS of 142. No correlations between AP-laxity and postoperative ROM or between AP-laxity and postoperative KSS are found. A posterior cruciate retaining TKA with a relative dished insert and implanted with a tensor is very stable in the anterior-posterior direction in 30 degrees of knee flexion. This limited laxity does not seem to disadvantage the mean postoperative ROM and KSS, when compared to other TKA studies.

Background It is unclear whether there are differences in benefits and harms between mobile and fixed prostheses for total knee arthroplasty (TKA). The previous Cochrane review published in 2004 included two articles. Many more trials have been performed since then; therefore an update is needed. Objectives To assess the benefits and harms of mobile bearing compared with fixed bearing cruciate retaining total knee arthroplasty for functional and clinical outcomes in patients with osteoarthritis (OA) or rheumatoid arthritis (RA). Search methods We searched The Cochrane Library, PubMed, EMBASE, CINAHL and Web of Science up to 27 February 2014, and the trial registers ClinicalTrials.gov, Multiregister, Current Controlled Trials and the World Health Organization (WHO) International Clinical Trials Registry Platform for data from unpublished trials, up to 11 February 2014. We also screened the reference lists of selected articles. Selection criteria We selected randomised controlled trials comparing mobile bearing with fixed bearing prostheses in cruciate retaining TKA among patients with osteoarthritis or rheumatoid arthritis, using functional or clinical outcome measures and follow-up of at least six months. Data collection and analysis We used standard methodological procedures as expected by The Cochrane Collaboration. Main results We found 19 studies with 1641 participants (1616 with OA (98.5%) and 25 with RA (1.5%)) and 2247 knees. Seventeen new studies were included in this update. Quality of the evidence ranged from moderate (knee pain) to low (other outcomes). Most studies had unclear risk of bias for allocation concealment, blinding of participants and personnel, blinding of outcome assessment and selective reporting, and high risk of bias for incomplete outcome data and other bias. Knee pain We calculated the standardised mean difference (SMD) for pain, using the Knee Society Score (KSS) and visual analogue scale (VAS) in 11 studies (58%) and 1531 knees (68%). No statistically significant differences between groups were reported (SMD 0.09, 95% confidence interval (CI) -0.03 to 0.22, P value 0.15). This represents an absolute risk difference of 2.4% points higher (95% CI 0.8% lower to 5.9% higher) on the KSS pain scale and a relative percent change of 0.22% (95% CI 0.07% lower to 0.53% higher). The results were homogeneous. Clinical and functional scores The KSS clinical score did not differ statistically significantly between groups (14 studies (74%) and 1845 knees (82%)) with a mean difference (MD) of -1.06 points (95% CI -2.87 to 0.74, P value 0.25) and heterogeneous results. KSS function was reported in 14 studies (74%) with 1845 knees (82%) as an MD of -0.10 point (95% CI -1.93 to 1.73, P value 0.91) and homogeneous results. In two studies (11%), the KSS total score was favourable for mobile bearing (159 vs 132 for fixed bearing), with MD of -26.52 points (95% CI -45.03 to -8.01, P value 0.005), but with a wide 95% confidence interval indicating uncertainty about the estimate. Other reported scoring systems did not show statistically significant differences: Hospital for Special Surgery (HSS) score (seven studies (37%) in 1021 knees (45%)) with an MD of -1.36 (95% CI -4.18 to 1.46, P value 0.35); Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score (two studies (11%), 167 knees (7%)) with an MD of -4.46 (95% CI -16.26 to 7.34, P value 0.46); and Oxford total (five studies (26%), 647 knees (29%) with an MD of -0.25 (95% CI -1.41 to 0.91, P value 0.67). Health-related quality of life Three studies (16%) with 498 knees (22%) reported on health-related quality of life, and no statistically significant differences were noted between the mobile bearing and fixed bearing groups. The Short Form (SF)-12 Physical Component Summary had an MD of -1.96 (95% CI -4.55 to 0.63, P value 0.14) and heterogeneous results. Revision surgery Twenty seven revisions (1.3%) were performed in 17 studies (89%) with 2065 knees (92%). In all, 13 knees were revised in the fixed bearing group and 14 knees in the mobile bearing group. No statistically significant differences were found (risk difference 0.00, 95% CI -0.01 to 0.01, P value 0.58), and homogeneous results were reported. Mortality In seven out of 19 studies, 13 participants (37%) died. Two of these participants had undergone bilateral surgery, and for seven participants, it was unclear which prosthesis they had received; therefore they were excluded from the analyses. Thus our analysis included four out of 191 participants (2.1%) who had died: one in the fixed bearing group and three in the mobile bearing group. No statistically significant differences were found. The risk difference was -0.02 (95% CI -0.06 to 0.03, P value 0.49) and results were homogeneous. Reoperation rates Thirty reoperations were performed in 17 studies (89%) with 2065 knees (92%): 18 knees in the fixed bearing group (of the 1031 knees) and 12 knees in the mobile group (of the 1034 knees). No statistically significant differences were found. The risk difference was -0.01 (95% CI -0.01 to 0.01, P value 0.99) with homogeneous results. Other serious adverse events Sixteen studies (84%) reported nine other serious adverse events in 1735 knees (77%): four in the fixed bearing group (of the 862 knees) and five in the mobile bearing group (of the 873 knees). No statistically significant differences were found (risk difference 0.00, 95% CI -0.01 to 0.01, P value 0.88), and results were homogeneous. Authors' conclusions Moderate- to low-quality evidence suggests that mobile bearing prostheses may have similar effects on knee pain, clinical and functional scores, health-related quality of life, revision surgery, mortality, reoperation rate and other serious adverse events compared with fixed bearing prostheses in posterior cruciate retaining TKA. Therefore we cannot draw firm conclusions. Most (98.5%) participants had OA, so the findings primarily reflect results reported in participants with OA. Future studies should report in greater detail outcomes such as those presented in this systematic review, with sufficient follow-up time to allow gathering of high-quality evidence and to inform clinical practice. Large registry-based studies may have added value, but they are subject to treatment-by-indication bias. Therefore, this systematic review of RCTs can be viewed as the best available evidence.

In this retrospective cohort, the results of step-cut tibial tubercle osteotomy (TTO) in 39 revision total knee arthroplasty, using the Continuum Knee System (CKS), are determined. In 39 revision, total knee arthroplasties, adequate exposure was obtained after step-cut TTO. All knees were recently reviewed for clinical and radiological results. Symptomatic TTO-related complications occurred in three out of 39 patients. Two patients had proximal migration of the tibial tubercle due to an insufficient step-cut. Another patient had posttraumatic avulsion of the tibial tubercle. No TTO-related extensor lag or tibial fracture occurred We conclude that, when adequate exposure cannot be obtained, step-cut TTO is a safe and reproducible procedure if strict attention is paid to technique and fixation. It does not compromise the functional results of TKA.

There is no consensus as to whether to use a posterior cruciate ligament (PCL) retaining design or a posterior-stabilized design for total knee arthroplasty. The objective of this study was to establish the difference in functional, clinical, and radiological outcome between retention and removal of the PCL.We conducted a search in Medline, EMBASE, the Cochrane database, and Current Contents, along with reference checks and citation tracking. Randomized controlled trials were selected and methodological quality was assessed with the van Tulder and Jadad checklists by 2 independent reviewers.We found 8 randomized controlled trials. 2 treatment options were compared against PCL retention: PCL removal without post and cam mechanism (2 studies), and posterior-stabilized design (5 studies). 1 study included all 3 options. Range of motion was found to be 8 degrees higher (105 degrees vs. 113 degrees ) in the posterior-stabilized group compared to the PCL retention group (p = 0.01, 95% CI (1.7, 15)).These results should be interpreted with caution, as the methodological quality of the studies was highly variable. Suggestions are given to improve future research on this specific aspect of knee arthroplasty.

Purpose: Literature is ambiguous on the incidence of deep venous thrombosis and pulmonary embolism by neurosurgical patients. The objective of this systematic review is to assess the incidence of thromboembolic complications associated with neurosurgical interventions, evaluate current prophylaxis methods and propose a prophylaxis strategy. Methods: PubMed, Embase and Cochrane Central were searched systematically and studies involving neurosurgical procedures describing postoperative complications DVT and PE. The risk of bias was assessed using (adjusted) Cowley criteria. Results: Twenty studies (14 case series, 3 comparative studies, 3 RCT’s) were included, describing 8905 neurosurgical patients. Without prophylaxis the incidence of DVT was reported in 28% of neurosurgical cases (range 21-34%). Studies that provided any kind of prophylaxis, in which clinical evaluation was used to diagnose DVT, reported a 2.5% incidence of DVT (range 0 to 5%), however, when systematically assessed with ultrasound the occurrence was 6.4% (range 0-17%). Pulmonary embolism was presented in 0 to 4% of all cases. Venous thromboembolic events were more frequent in intracranial procedures compared to spinal procedures. Patients, receiving a combination of low molecular weight heparins and compression stockings, showed a 50% lower incidence of DVT than patients receiving mechanical or chemical prophylaxis alone. Conclusion: Optimal antithrombotic prophylaxis regime in neurosurgical interventions lowers the incidence of DVT’s from 28% to about 3 to 6%. We recommend a combination of LMWH and compression stockings for intracranial procedures. For spinal procedures this same prophylactic regimen is indicated, however it is defendable to choose single treatment with LMWH or compression stockings alone.

Background Various surgical and non-surgical treatments for lumbar spinal stenosis (LSS) are widely adopted in clinical practice, but high quality randomised controlled trials to supporttheseareoftenlacking,especiallyintermsoftheirrelative benefitandriskcomparedwithothertreatmentoptions.Therefore, an evaluation of agreement among clinicians regarding the indications and the choice for particular treatments seems appropriate. Methods One hundred and six Dutch neurosurgeons and orthopaedic spine surgeons completed a questionnaire, which evaluated treatment options for LSS and expectations regarding the effectiveness of surgical and non-surgical treatments. Results Responders accounted for 6,971 decompression operations and 831 spinal fusion procedures for LSS annually. Typical neurogenic claudication, severe pain/disability, and a pronounced constriction of the spinal canal were considered the most important indications for surgical treatment by the majority of responders. Non-surgical treatment was generally regarded as ineffective and believed to be less effective than surgical treatment. Interlaminar decompression was the preferred technique by 68 % of neurosurgeons and 52 % orthopaedic surgeons for the treatment of LSS. Concomitant fusion was appliedin 12%of allsurgeryfor LSS.Mostsurgeonsconsidered spondylolisthesis as an indication and spinal instability as a definite indication for additional fusion. Conclusions The current survey demonstrates a wide variety of preferred treatments of symptomatic LSS by Dutch spine surgeons. To minimise variety, national and international protocols based on high-quality randomised controlled trials and systematic reviews are necessary to give surgeons more tools to support everyday decision-making.

Key points Low back pain (LBP) ranks as the number one disorder in terms of years lived with disability; estimated global one year incidences range from 22% to 65%.1 Back pain as a symptom, not attributable to spinal instability caused by trauma, infection, progressive deformity, or tumour, and not associated with radicular symptoms, is labelled non-specific LBP (see box). Many of patients with non-specific LBP may have degenerative intervertebral disc and bony joint changes, including disc herniations and spinal stenosis on imaging, but these findings are not more common than in the general population, including people without LBP.2 Guidelines discourage surgery for non-specific back pain3; some recommend surgery only after two years of failed conservative treatments in carefully selected patients.4 However, despite these recommendations, the rate of back surgery is rising, with considerable geographical variation.5 The rates of spinal fusion, including use of surgical implants, for all degenerative disorders of the lumbar spine show an unexplained exponential increase,6 7 with a corresponding rise in serious perioperative complications, including stroke and cardiopulmonary events.7 These rises are unexpected, as the incidence of spinal diseases causing instability of vertebral elements has not risen, and nor has the incidence of surgery for herniated discs and stenosis. …

Contains fulltext : 137225.pdf (Publisher’s version ) (Open Access) BACKGROUND: Cervical radicular syndrome (CRS) due to a herniated disc can be safely treated by surgical decompression of the spinal root. In the vast majority of cases this relieves pain in the arm and restores function. However, conservative treatment also has a high chance on relieving symptoms. The objective of the present study is to evaluate the (cost-) effectiveness of surgery versus prolonged conservative care during one year of follow-up, and to evaluate the timing of surgery. Predisposing factors in favour of one of the two treatments will be evaluated. METHODS/DESIGN: Patients with disabling radicular arm pain, suffering for at least 2 months, and an MRI-proven herniated cervical disc will be randomised to receive either surgery or prolonged conservative care with surgery if needed. The surgical intervention will be an anterior discectomy or a posterior foraminotomy that is carried out according to usual care. Surgery will take place within 2-4 weeks after randomisation. Conservative care starts immediately after randomisation. The primary outcome measure is the VAS for pain or tingling sensations in the arm one year after randomisation. In addition, timing of surgery will be studied by correlating the primary outcome to the duration of symptoms. Secondary outcome measures encompass quality of life, costs and perceived recovery. Predefined prognostic factors will be evaluated. The total follow-up period will cover two years. A sample size of 400 patients is needed. Statistical analysis will be performed using a linear mixed model which will be based on the 'intention to treat' principle. In addition, a new CRS questionnaire for patients will be developed, the Leiden Cervical Radicular Syndrome Functioning (LCRSF) scale. DISCUSSION: The outcome will contribute to better decision making for the treatment of cervical radicular syndrome. TRIAL REGISTRATION: NTR3504.

The goal of this study was to evaluate the ability of Ray threaded fusion cages, when used in an anterior approach, to restore intervertebral height and to improve the functional and occupational performance of the patients. The present study was initiated because insertion of fusion cages through a posterior approach causes destruction of facet joints and violation of the spinal canal. The anterior approach for insertion of threaded fusion cages to accomplish lumbar interbody fusion was evaluated in a series of 13 patients suffering monosegmental disc disease. The patients’ functional and occupational performance was evaluated using the Prolo score. Radiological measurements were used to evaluate disc height and degree of penetration into the endplates, and to confirm fusion. Seven of the 13 patients were short-term failures and had to be revised within 2 years. The study found that revised patients had poorer Prolo scores than non-revised patients. Although for the non-revised patients, the mean Prolo scores remained relatively stable during the 1st year, they dropped after 3 years. We were not able to identify any further clinical or radiological differences between the groups. These results indicate that although the anterior approach seems technically suitable for insertion of threaded fusion cages, destruction of the anterior longitudinal ligament and the anterior part of the annulus fibrosis appears to result in destabilisation of the motion segment.

The goal of this systematic literature review was to determine, for patients with degenerative disc disease, which method of single-level anterior cervical interbody fusion using the anterior approach gives the best clinical and radiological outcome. The number of new techniques for obtaining a solid fusion has increased rapidly, but the rationale for choosing between different techniques is unclear. Randomised comparative studies on anterior cervical interbody fusions were identified in a sensitive Medline, Cochrane and Current Contents database search. Two independent reviewers evaluated the articles that met the selection criteria, using a checklist. The search yielded eight randomised, controlled trials for the systematic literature review. Three of these studies were judged to be of sufficient quality with regard to methodology and the information provided. In the three articles, five different treatment methods were investigated, four of which were interbody fusions. Fusion rates varied between 28% for an allograft method and 63% for a discectomy-alone method. In one study, kyphosis varied from 40% to 62% between treatments. Good clinical outcome (disability, pain and symptoms) ratings varied from 66% to 82%. A meta-analysis to determine the best method for an anterior interbody fusion could not be performed due to the heterogeneity of the methods reported and because no standard outcome parameter was used. From this systematic literature review, a gold standard for the treatment of degenerative disc disease could not be identified.

Background Fractures of the odontoid process of the axis are the most common fractures of the geriatric cervical spine. As the population ages, their incidence is expected to increase progressively, as is the number of very old patients (>80 years) with an odontoid fracture. No consensus exists on the optimal treatment (surgical or conservative) and the most relevant outcome parameter (osseous union, fracture stability or clinical outcome). The aim of the INNOVATE (INterNational study on Odontoid frActure Treatment in the Elderly) Trial is to prospectively assess fracture healing and clinical outcome after surgical and conservative treatment for odontoid fractures in the elderly patient, with a specific focus on the very old patient. Methods/Design The trial is an observational study in which eleven centres in five European countries are involved. All patients admitted to one of these centres who meet the selection criteria (≥55 years, acute (

Background The functional and clinical basis on which to choose whether or not to retain the posterior cruciate ligament during total knee arthroplasty surgery remained unclear after a Cochrane systematic review and meta-analysis in 2005, which contained eight clinical trials. Several new trials have been conducted since then. Hence, an update of the review was performed. Objectives Our aim was to assess the benefits and harms of retention compared to sacrifice of the posterior cruciate ligament in total knee arthroplasty in patients with osteoarthritis of the knee. Search methods An extensive search was conducted in CENTRAL, MEDLINE (PubMed), EMBASE, Web of Science, CINAHL, Academic Search Premier, Current Contents Connect and Science Direct. All databases were searched, without any limitations, up to 6 December 2012. References of the articles were checked and citation tracking was performed. Selection criteria Randomised and quasi-randomised controlled trials comparing retention with sacrifice of the posterior cruciate ligament in primary total knee arthroplasty in patients with osteoarthritis of the knee. Data collection and analysis Data were collected with a pre-developed form. Risk of bias was assessed independently by two authors (WV, LB). The level of evidence was graded using the GRADE approach. Meta-analysis was performed by pooling the results of the selected studies, when possible. Subgroup analyses were performed for posterior cruciate ligament retention versus sacrifice using the same total knee arthroplasty design, and for studies using a posterior cruciate ligament retaining or posterior stabilised design, and when sufficient studies were available subgroup analyses were performed for the same brand. Main results Seventeen randomised controlled trials (with 1810 patients and 2206 knees) were found, described in 18 articles. Ten of these were new studies compared to the previous Cochrane Review. One study from the original Cochrane review was excluded. Most new studies compared a posterior cruciate ligament retaining design with a posterior stabilised design, in which the posterior cruciate ligament is sacrificed (a posterior stabilised design has an insert with a central post which can engage on a femoral cam during flexion). The quality of evidence (graded with the GRADE approach) and the risk of bias were highly variable, ranging from moderate to low quality evidence and with unclear or low risk of bias for most domains, respectively. The performance outcome 'range of motion' was 2.4 ° higher in favour of posterior cruciate ligament sacrifice (118.3 ° versus 115.9 °; 95% confidence interval (CI) of the difference 0.13 to 4.67; P = 0.04), however the results were heterogeneous. On the item 'knee pain' as experienced by patients, meta-analysis could be performed on the Knee Society knee pain score; this score was 48.3 in both groups, yielding no difference between the groups. Implant survival rate could not be meta-analysed adequately since randomised controlled trials lack the longer term follow-up in order to evaluate implant survival. A total of four revisions in the cruciate-retention and four revisions in the cruciate-sacrifice group were found. The well-validated Western Ontario and McMaster Universities osteoarthritis index (WOMAC) total score was not statistically significantly different between the groups (16.6 points for cruciate-retention versus 15.0 points for cruciate-sacrifice). One study reported a patient satisfaction grade (7.7 points for cruciate-retention versus 7.9 points for cruciate-sacrifice on a scale from 0 to 10, 10 being completely satisfied) which did not differ statistically significantly. Complications were distributed equally between both groups. Only one study reported several re-operations other than revision surgery; that is patella luxations, surgical manipulation because of impaired flexion. The mean functional Knee Society Score was 2.3 points higher (81.2 versus 79.0 points; 95% CI of the difference 0.37 to 4.26; P = 0.02) in the posterior cruciate ligament sacrificing group. Results from the outcome Knee Society functional score were homogeneous. All other outcome measures (extension angle, knee pain, adverse effects, clinical questionnaire scores, Knee Society clinical scores, radiological rollback, radiolucencies, femorotibial angle and tibial slope) showed no statistically significant differences between the groups. In the subgroup analyses that allowed pooling of the results of the different studies, no homogeneous statistically significant differences were identified. Authors' conclusions The methodological quality and the quality of reporting of the studies were highly variable. With respect to range of motion, pain, clinical, and radiological outcomes, no clinically relevant differences were found between total knee arthroplasty with retention or sacrifice of the posterior cruciate ligament. Two statistically significant differences were found; range of motion was 2.4 ° higher in the posterior cruciate ligament sacrificing group, however results were heterogeneous; and the mean functional Knee Society Score was 2.3 points higher in the posterior cruciate ligament sacrificing group. These differences are clinically not relevant.

INTRODUCTION: Disc herniation with sciatica accounts for five percent of low-back disorders but is one of the most common reasons for spine surgery. The goal of this study was to update the Cochrane review on the effect of surgical techniques for sciatica due to disc herniation, which was last updated in 2007.MATERIALS AND METHODS: In April 2011, we conducted a comprehensive search in CENTRAL, MEDLINE, EMBASE, CINAHL, PEDRO, ICL, and trial registries. We also checked the reference lists and citation tracking results of each retrieved article. Only randomized controlled trials (RCT) of the surgical management of sciatica due to disc herniation were included. Comparisons including chemonucleolysis and prevention of scar tissue or comparisons against conservative treatment were excluded. Two review authors independently selected studies, assessed risk of bias of the studies and extracted data. Quality of evidence was graded according to the GRADE approach.RESULTS: Seven studies from the original Cochrane review were included and nine additional studies were found. In total, 16 studies were included, of which four had a low risk of bias. Studies showed that microscopic discectomy results in a significantly, but not clinically relevant longer operation time of 12 min (95% CI 2-22) and shorter incision of 24 mm (95% CI 7-40) compared with open discectomy, but did not find any clinically relevant superiority of either technique on clinical results. There were conflicting results regarding the comparison of tubular discectomy versus microscopic discectomy for back pain and surgical duration.CONCLUSIONS: Due to the limited amount and quality of evidence, no firm conclusions on effectiveness of the current surgical techniques being open discectomy, microscopic discectomy, and tubular discectomy compared with each other can be drawn. Those differences in leg or back pain scores, operation time, and incision length that were found are clinically insignificant. Large, high-quality studies are needed, which examine not only effectiveness but cost-effectiveness as well.

In a mobile-bearing unicompartmental knee arthroplasty (UKA), stability is of utmost importance to promote knee function and to prevent dislocation of the insert. Gap balancing can be guided by the use of spacers or a tensioner. The goal of this study is to compare laxity of a tension-guided implantation technique versus a spacer-guided technique for medial UKA with a mobile bearing. Also clinical function was compared between the groups. The tension-guided UKA system (BalanSys™, Mathys Ltd, Bettlach, Switzerland) was compared with a retrospective group with a spacer-guided system (Oxford, Biomet Ltd, Bridgend, UK). A total of 30 tension-guided medial UKAs were implanted and compared with 35 spacer-guided medial prostheses. In both groups, valgus laxity was measured at least 4 months postoperatively in extension and 70° flexion using stress radiographs. Knee Society Scores (KSS) were obtained at the 6-month follow-up. Valgus laxity in flexion was significantly higher in the tension-guided group compared with the spacer-guided group: 3.9° (SD 1.8°) versus 2.4° (SD 1.2°), respectively, P

Total hip arthroplasty has been a very succesful orthopaedic procedure. The optimal fixation method of the acetabular component however, has not yet been defined.We performed a systematic review using the Medline and Embase databases to find evidence for the superiority of cemented or cementless acetabular components on short- and long-term clinical and radiological parameters. Methodological quality for randomised trials was assessed using the van Tulder checklist, and for the non randomised studies we used the Newcastle-Ottawa quality assessment scale.Our search strategy revealed 16 randomised controlled trials (RCT) and 19 non RCT studies in which cemented and cementless acetabular components are compared. A best evidence analysis for complications, wear, osteolysis, migration and clinical scores showed no superiority for either cemented or cementless socket in the RCTs. A best evidence analysis for non RCT studies revealed better osteolysis, migration properties and aseptic loosening survival for cementless sockets; however, wear and overall survival favoured the cemented sockets.We recommend that an orthopaedic surgeon should choose an established cemented or cementless socket for hip replacement based on patient characteristics, knowledge, experience and preference.

Contains fulltext : 98350.pdf (Publisher’s version ) (Open Access) BACKGROUND: The number of surgical techniques for decompression and solid interbody fusion as treatment for cervical spondylosis has increased rapidly, but the rationale for the choice between different techniques remains unclear. OBJECTIVES: To determine which technique of anterior interbody fusion gives the best clinical and radiological outcomes in patients with single- or double-level degenerative disc disease of the cervical spine. SEARCH STRATEGY: We searched CENTRAL (The Cochrane Library 2009, issue 1), MEDLINE (1966 to May 2009), EMBASE (1980 to May 2009), BIOSIS (2004 to May 2009), and references of selected articles. SELECTION CRITERIA: Randomised comparative studies that compared anterior cervical decompression and interbody fusion techniques for participants with chronic degenerative disc disease. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed risk of bias using the Cochrane Back Review Group criteria. Data on demographics, intervention details and outcome measures were extracted onto a pre-tested data extraction form. MAIN RESULTS: Thirty-three small studies ( 2267 patients) compared different fusion techniques. The major treatments were discectomy alone, addition of an interbody fusion procedure (autograft, allograft, cement, or cage), and addition of anterior plates. Eight studies had a low risk of bias. Few studies reported on pain, therefore, at best, there was very low quality evidence of little or no difference in pain relief between the different techniques. We found moderate quality evidence for these secondary outcomes: no statistically significant difference in Odom's criteria between iliac crest autograft and a metal cage (6 studies, RR 1.11 (95% CI 0.99 to1.24)); bone graft produced more effective fusion than discectomy alone (5 studies, RR 0.22 (95% CI 0.17 to 0.48)); no statistically significant difference in complication rates between discectomy alone and iliac crest autograft (7 studies, RR 1.56 (95% CI 0.71 to 3.43)); and low quality evidence that iliac crest autograft results in better fusion than a cage (5 studies, RR 1.87 (95% CI 1.10 to 3.17)); but more complications (7 studies, RR 0.33 (95% CI 0.12 to 0.92)). AUTHORS' CONCLUSIONS: When the working mechanism for pain relief and functional improvement is fusion of the motion segment, there is low quality evidence that iliac crest autograft appears to be the better technique. When ignoring fusion rates and looking at complication rates, a cage has a weak evidence base over iliac crest autograft, but not over discectomy alone. Future research should compare additional instrumentation such as screws, plates, and cages against discectomy with or without autograft.

BACKGROUND: The functional and clinical basis on which to choose whether or not to retain the posterior cruciate ligament during total knee arthroplasty surgery remained unclear after a Cochrane systematic review and meta‐analysis in 2005, which contained eight clinical trials. Several new trials have been conducted since then. Hence, an update of the review was performed. OBJECTIVES: Our aim was to assess the benefits and harms of retention compared to sacrifice of the posterior cruciate ligament in total knee arthroplasty in patients with osteoarthritis of the knee. SEARCH METHODS: An extensive search was conducted in CENTRAL, MEDLINE (PubMed), EMBASE, Web of Science, CINAHL, Academic Search Premier, Current Contents Connect and Science Direct. All databases were searched, without any limitations, up to 6 December 2012. References of the articles were checked and citation tracking was performed. SELECTION CRITERIA: Randomised and quasi‐randomised controlled trials comparing retention with sacrifice of the posterior cruciate ligament in primary total knee arthroplasty in patients with osteoarthritis of the knee. DATA COLLECTION AND ANALYSIS: Data were collected with a pre‐developed form. Risk of bias was assessed independently by two authors (WV, LB). The level of evidence was graded using the GRADE approach. Meta‐analysis was performed by pooling the results of the selected studies, when possible. Subgroup analyses were performed for posterior cruciate ligament retention versus sacrifice using the same total knee arthroplasty design, and for studies using a posterior cruciate ligament retaining or posterior stabilised design, and when sufficient studies were available subgroup analyses were performed for the same brand. MAIN RESULTS: Seventeen randomised controlled trials (with 1810 patients and 2206 knees) were found, described in 18 articles. Ten of these were new studies compared to the previous Cochrane Review. One study from the original Cochrane review was excluded. Most new studies compared a posterior cruciate ligament retaining design with a posterior stabilised design, in which the posterior cruciate ligament is sacrificed (a posterior stabilised design has an insert with a central post which can engage on a femoral cam during flexion). The quality of evidence (graded with the GRADE approach) and the risk of bias were highly variable, ranging from moderate to low quality evidence and with unclear or low risk of bias for most domains, respectively. The performance outcome 'range of motion' was 2.4 ° higher in favour of posterior cruciate ligament sacrifice (118.3 ° versus 115.9 °; 95% confidence interval (CI) of the difference 0.13 to 4.67; P = 0.04), however the results were heterogeneous. On the item 'knee pain' as experienced by patients, meta‐analysis could be performed on the Knee Society knee pain score; this score was 48.3 in both groups, yielding no difference between the groups. Implant survival rate could not be meta‐analysed adequately since randomised controlled trials lack the longer term follow‐up in order to evaluate implant survival. A total of four revisions in the cruciate‐retention and four revisions in the cruciate‐sacrifice group were found. The well‐validated Western Ontario and McMaster Universities osteoarthritis index (WOMAC) total score was not statistically significantly different between the groups (16.6 points for cruciate‐retention versus 15.0 points for cruciate‐sacrifice). One study reported a patient satisfaction grade (7.7 points for cruciate‐retention versus 7.9 points for cruciate‐sacrifice on a scale from 0 to 10, 10 being completely satisfied) which did not differ statistically significantly. Complications were distributed equally between both groups. Only one study reported several re‐operations other than revision surgery; that is patella luxations, surgical manipulation because of impaired flexion. The mean functional Knee Society Score was 2.3 points higher (81.2 versus 79.0 points; 95% CI of the difference 0.37 to 4.26; P = 0.02) in the posterior cruciate ligament sacrificing group. Results from the outcome Knee Society functional score were homogeneous. All other outcome measures (extension angle, knee pain, adverse effects, clinical questionnaire scores, Knee Society clinical scores, radiological rollback, radiolucencies, femorotibial angle and tibial slope) showed no statistically significant differences between the groups. In the subgroup analyses that allowed pooling of the results of the different studies, no homogeneous statistically significant differences were identified. AUTHORS' CONCLUSIONS: The methodological quality and the quality of reporting of the studies were highly variable. With respect to range of motion, pain, clinical, and radiological outcomes, no clinically relevant differences were found between total knee arthroplasty with retention or sacrifice of the posterior cruciate ligament. Two statistically significant differences were found; range of motion was 2.4 ° higher in the posterior cruciate ligament sacrificing group, however results were heterogeneous; and the mean functional Knee Society Score was 2.3 points higher in the posterior cruciate ligament sacrificing group. These differences are clinically not relevant.

The objective of this study was to evaluate which fusion technique provides the best clinical and radiological outcome for adult low-grade lumbar isthmic spondylolisthesis, and to assess the overall clinical and radiological outcome of each fusion technique. A systematic review was performed. Medline, Embase, Current Contents, and Cochrane databases as well as reference lists of selected articles were searched. Randomised controlled trials (RCTs) were used to evaluate the best treatment; controlled studies and non-controlled studies were used to determine the outcomes after surgery. Two independent reviewers evaluated the studies with the methodological checklists of van Tulder and Jadad for the randomised studies and of Cowley for the non-randomised studies. The search resulted in 684 references and eventually 29 studies met the inclusion criteria, of which eight were RCTs, four were prospective, and 17 were retrospective case series. Ten of the case series did not clearly identify consecutive patient selection. All the eight RCTs evaluated the effect of different techniques of posterolateral fusion (PLF). Evidence was found that the PLF was superior to non-operative treatment (exercise). Circumferential fusion was compared to PLF, but no difference could be found. PLF with or without instrumentation was evaluated in three studies, but no benefits from additional instrumentation were found. Other comparisons within PLF showed no effect of decompression, alternative instrumentation, or bone graft substitute. The 21 case series included 24 patient groups. PLF was used in 15 groups, good or excellent clinical outcome varied from 60 to 98% and fusion rate varied from 81 to 100%. Anterior interbody fusion was used in five groups, good or excellent clinical outcome varied from 85 to 94% and fusion rate varied from 47 to 90%. Posterior interbody fusion was used in two groups, good or excellent clinical outcome was 45% and fusion rate was 80 and 95%, respectively. Reduction, loss of reduction, and lordotic angles before and after the treatment was reported in only four studies. Average reduction achieved was 12.3%, average loss of reduction at follow-up was 5.9%. Preoperative lordotic angles were too heterogeneous to pool the results. Adjacent segment degeneration was not reported in any of the publications. A wide variety of complications were reported in 18 studies and included neurological complications, instrument failure, and infections. Fusion for low-grade isthmic spondylolisthesis has better outcomes than non-operative treatment. The current study could not identify the best surgical technique (PLF, PLIF, ALIF, instrumentation) to perform the fusion. However, instrumentation and/or decompression may play a beneficial role in the modern practice of reduction and fusion for low-grade isthmic spondylolisthesis, but there are no studies yet available to confirm this. The outcomes of fusion are generally good, but reports vary widely.

The results of lumbar fusion in chronic low back pain (LBP) patients vary considerably, and there is a need for proper patient selection. Lumbosacral orthoses have been widely used to predict outcome, however, with little scientific support. The aim of the present study was to determine the value of a pantaloon cast test in selecting chronic LBP patients for lumbar fusion or conservative management. First, a systematic review of the literature was carried out in which two independent reviewers identified studies in Medline, Cochrane and Current Contents databases. Three papers met the selection criteria. In the only study with a control group, a significantly better outcome after fusion compared to conservative treatment was found in patients who reported significant pain relief while in a cast (i.e. a positive cast test). The results of lumbar fusion, however, were not significantly different for patients with a positive and those with a negative cast test. In addition to the review, a clinical cohort study of 257 LBP patients, who had been allocated to either lumbar fusion or conservative management by a temporary external transpedicular fixation trial, was performed. Prior to allocation, all had undergone a pantaloon cast test. Patients with no history of prior spine surgery and with a positive pantaloon cast test had a better outcome after lumbar fusion than those treated conservatively (P = 0.002, chi (2 )test). In patients with previous spine operations the outcomes were poor and the test was of no value. From the literature and the present patient cohort, it was concluded that only in chronic LBP patients without prior spine surgery, a pantaloon cast test with substantial pain relief suggests a favorable outcome of lumbar fusion compared to conservative management. The test has no value in patients who have had previous spine surgery.

In revision total knee arthroplasty (TKA), control of the patellar height and the joint line is difficult. Therefore, we developed an adjustable flexion-extension spacer, the Knee Joint-line Balancer (KJB(R)). This device simulates femur component sizes, polyethylene sizes, the joint-line level, and distal femur wedges. The goal of this study is to evaluate the use of an adjustable knee spacer to control patellar height and joint-line during revision total knee surgery. The subjects of the study were the first 10 consecutive patients who had undergone revision of a primary TKA where the KJB was used. A reference group composed of the last 10 patients treated without the use of the KJB was also evaluated. The joint-line position and the patellar height were determined before and after revision TKA. The method described by Figgie et al. was used. The patellar height in the reference group averaged 7.7 mm. Seven of 10 patients had a patella baja, and two of these patients had patellar impingement. One patient needed a proximalisation of the tuberositas. The patellar height in the KJB group averaged 14.6 mm after revision, with only one patient having a patella baja. This new device, adjustable kneespacer for revision TKA ("the KJB"), seems to provide better control of the patellar position in total knee revision.

Study design Fifty-two patients with degenerative disc disease underwent single- or double-level anterior lumbar interbody fusion with SynCage and additional posterior fixation as treatment for degenerative disc disease and were prospectively followed for 4 years. Objectives To test the clinical performance of anterior lumbar interbody fusion with SynCage, with emphasis on the safety and efficacy of the surgical procedure and the ability to restore anatomy and fuse the motion segment. Summary of background data Anterior lumbar interbody fusion using femoral allograft and/or autologous bone has a high complication rate. With cage technology, some of these complications can be avoided. The design characteristics of the SynCage offer advantages in restoring and maintaining intervertebral height and restoration of lumbar lordosis. Methods Thirty-three patients underwent single-level and 19 patients double-level anterior lumbar interbody fusion with SynCage and additional posterior fixation (translaminar screws, n = 32 or pedicle screws, n = 10). Radiologic and functional results (VAS and Oswestry score) were evaluated. Results Intervertebral height was corrected from an average of 8.7 to 17.6 mm. Lordosis of the fused segment was significantly increased (average 10.6 degrees for the fused segment and 8 degrees for lumbosacral lordosis). After 2 years, there was radiologic evidence for fusion in 70 of 71 (98.6%) levels. Functional scores showed a significant improvement in pain and function up to the 2-year follow-up observation. At the 4-year follow-up observation, there was some loss of the initial improvement in VAS and Oswestry scores. Despite this loss, they remained significantly better than the preoperative scores. Conclusions Anterior lumbar interbody fusion with SynCage and additional posterior fixation is a safe and effective procedure. Intervertebral height is corrected, and lumbosacral lordosis is restored. An initial improvement in VAS and Oswestry scores is partly lost at the 4-year follow-up observation, but 4-year results are still significantly better than the preoperative scores.

To prevent patella infera in open wedge high tibial osteotomy, a new operation technique was developed. Instead of a proximal tibial tuberosity osteotomy, a distal osteotomy was performed and the tuberosity was fixed with one screw to the tibia. Initial experience in 17 patients was evaluated and compared with results of 20 patients with open wedge high tibial osteotomy with proximal tuberosity osteotomy. Distal tuberosity osteotomy in open wedge high tibial osteotomy appears effective in preventing patella infera.

In this paper the rationale for total disc replacement is discussed, and the authors suggest seven requirements that should be met before the implantation of these devices can be accepted as regular procedures. In an attempt to answer the questions raised, a systematic literature search was performed. The search yielded no controlled trials and nine case series with a total of 564 arthroplasties in 411 patients. The devices used were SB Charite in eight and Acroflex in one study. The percentage results classified as “good” or “excellent” in the studies varied from 50 to 81%. Complications were observed in 3–50% of the patients. Twenty-two of the operated levels were fused either spontaneously or after additional surgery. A meta-analysis to compare the results with other treatments could not be performed due to the lack of comparative studies. Despite the fact that these devices have been implanted for almost 15 years, on the basis of this literature survey there are currently insufficient data to assess the performance of total disc replacement adequately. There is no evidence that disc replacement reliably, reproducibly, and over longer periods of time fulfils the three primary aims of clinical efficacy, continued motion, and few adjacent segment degenerative problems. Total disc replacement seems to be associated with a high rate of re-operations, and the potential problems that may occur with longer follow-up have not been addressed. Therefore, total disc replacements should be considered experimental procedures and should only be used in strict clinical trials.

Background: An important factor in the functional results after total knee arthroplasty is the achieved maximal flexion. The main purpose of this study was to compare the maximal knee flexion one year after surgery in patients who received either the bicruciate substituting knee system or the conventional posterior stabilized system. Methods: In a prospective randomized controlled trial, 124 patients presenting with osteoarthritis received the bicruciate substituting or the conventional posterior stabilized prosthesis. The primary outcome was the maximum flexion angle at one year postoperatively on a lateral radiograph made with the supine patient using manual force to bend the knee. Secondary outcomes were active flexion (lying and standing), the Knee Society Score, the Patella Scoring System score, the University of California Los Angeles score, the number and type of adverse device effects, and visual analog scale satisfaction up to two years postoperatively. The outcome measures of both groups were compared using one-sided t tests and non-parametric alternatives, with a significance level of p < 0.05. Results: No significant differences between the two groups were observed in maximal flexion on radiographs and in active flexion at baseline. The median maximal flexion on radiographs was 127° (range, 83° to 150°) for the bicruciate substituting group and 125° (range, 74° to 145°) for the conventional posterior stabilized group. The two groups showed comparable two-year results with respect to the Knee Society Score, the Patella Scoring System, the University of California Los Angeles score, and visual analog scale satisfaction. In the bicruciate substituting group, forty-one adverse device effects in twenty-six patients were reported, including three total system revisions and fourteen manipulations under anesthesia, compared with the conventional posterior stabilized group, in which sixteen adverse device effects were observed in thirteen patients, including six manipulations under anesthesia (p = 0.012). Conclusions: Patients who receive a bicruciate substituting system compared with those who receive a conventional posterior stabilized system have comparable knee flexion characteristics and clinical and functional outcomes but more complications by two years after total knee arthroplasty. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Background The polyethylene insert in a total knee replacement (TKR) can be fixed to the tibial plateau or it can have freedom of rotation and / or translation. It is not yet clear whether there are differences in functional or clinical results between the two prosthesis types. Objectives The goal of this review is to assess if a mobile bearing total knee prosthesis provides a better range of motion (ROM) and a better functional outcome than a fixed bearing prosthesis in patients with rheumatoid arthritis or osteoarthritis after total knee arthroplasty. Search methods We searched the Cochrane Library (issue 2002-3), Current contents (1996 to September 2002), and MEDLINE (1966 to September 2002). Reference lists of selected articles were also included. Selection criteria Randomised controlled trials or controlled clinical trials were selected which used a functional or clinical outcome measure comparing mobile (rotating and/or sliding) with fixed bearing types. Data collection and analysis Data was collected on relevant demographic data and functional outcome measures like Range of Motion, specific measures of activities with daily tasks, and composite knee scores such as Knee Society Score, Hospital for Special Surgery score and similar scores. Only controlled studies comparing a fixed bearing with a mobile bearing type of TKP were considered. Main results Two randomised studies were encountered evaluating the difference in functional or clinical outcome of the two prosthesis types. The methodological quality of the studies was low. The study with the best quality found no difference in ROM, but found a superiority of the mobile bearing on Knee Society Score and Oxford Knee Score and the pain sub scores of these clinical measures. The second study found no differences. Authors' conclusions We could find no evidence of superiority for one of the two prosthesis types with regard to ROM or functional performance of the patients. The majority (96%) of patients in the 2 included studies had OA. Therefore, the results reflect primarily results in OA patients.

Femoral component rotation from a total knee prosthesis can be determined by either a measured resection technique or a balanced gap technique. With the balanced gap implantation technique, femoral component rotation can vary freely within the restrictions produced by soft tissue structures. Because internal rotation might cause patella problems, the effect of ligament releases on femoral component rotation in a prospective clinical study was studied. Femoral component rotation was measured intraoperatively with a tensor applied in flexion at 150 N in 87 knees. Great interpatient variability was found; femoral component rotation, reference from the posterior condyles, ranged from −4° to 13°. There was no difference in femoral component rotation of knees with or without ligament releases in extension. However, knees with major medial release had less external femoral component rotation than knees with minor lateral releases. Preoperative alignment had no influence on femoral component rotation. The use of the balanced gap implantation technique theoretically will result in a balanced flexion gap, but the amount of femoral component rotation will be variable owing to patient variability and variation in ligament releases. Level of Evidence: Level II, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

In the search for better surgical treatment of chronic low-back pain (LBP) in the presence of disc degeneration, total disc replacement has received increasing attention in recent years. A possible advantage of total disc replacement compared with fusion is maintained mobility at the operated level, which has been suggested to reduce the chance of adjacent segment degeneration.The aim of this systematic review was to assess the effect of total disc replacement for chronic low-back pain in the presence of lumbar disc degeneration compared with other treatment options in terms of patient-centred improvement, motion preservation and adjacent segment degeneration.A comprehensive search in Cochrane Back Review Group (CBRG) trials register, CENTRAL, MEDLINE, EMBASE, BIOSIS, ISI, and the FDA register was conducted. We also checked the reference lists and performed citation tracking of included studies.We included randomised controlled trials (RCTs) comparing total disc replacement with any other intervention for degenerative disc disease.We assessed risk of bias per study using the criteria of the CBRG. Quality of evidence was graded according to the GRADE approach. Two review authors independently selected studies and assessed risk of bias of the studies. Results and upper bounds of confidence intervals were compared against predefined clinically relevant differences.We included 40 publications, describing seven unique RCT's. The follow-up of the studies was 24 months, with only one extended to five years. Five studies had a low risk of bias, although there is a risk of bias in the included studies due to sponsoring and absence of any kind of blinding. One study compared disc replacement against rehabilitation and found a statistically significant advantage in favour of surgery, which, however, did not reach the predefined threshold for clinical relevance. Six studies compared disc replacement against fusion and found that the mean improvement in VAS back pain was 5.2 mm (of 100 mm) higher (two studies, 676 patients; 95% confidence interval (CI) 0.18 to 10.26) with a low quality of evidence while from the same studies leg pain showed no difference. The improvement of Oswestry score at 24 months in the disc replacement group was 4.27 points more than in the fusion group (five studies; 1207 patients; 95% CI 1.85 to 6.68) with a low quality of evidence. Both upper bounds of the confidence intervals for VAS back pain and Oswestry score were below the predefined clinically relevant difference. Choice of control group (circumferential or anterior fusion) did not appear to result in different outcomes.Although statistically significant, the differences between disc replacement and conventional fusion surgery for degenerative disc disease were not beyond the generally accepted clinical important differences with respect to short-term pain relief, disability and Quality of Life. Moreover, these analyses only represent a highly selected population. The primary goal of prevention of adjacent level disease and facet joint degeneration by using total disc replacement, as noted by the manufacturers and distributors, was not properly assessed and not a research question at all. Unfortunately, evidence from observational studies could not be used because of the high risk of bias, while these could have improved external validity assessment of complications in less selected patient groups. Non-randomised studies should however be very clear about patient selection and should incorporate independent, blinded outcome assessment, which was not the case in the excluded studies. Therefore, because we believe that harm and complications may occur after years, we believe that the spine surgery community should be prudent about adopting this technology on a large scale, despite the fact that total disc replacement seems to be effective in treating low-back pain in selected patients, and in the short term is at least equivalent to fusion surgery.