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Failure to fuse following anterior cervical discectomy and fusion (ACDF) may result in symptomatic pseudoarthrosis. Traditional diagnosis involves computerized tomography to detect bridging bone and/or flexion-extension radiographs to assess whether segmental motion is above specific thresholds; however, there are currently no well-validated diagnostic tests. We propose a biomechanically rational approach to achieve a reliable diagnostic test for pseudoarthrosis. Develop and test a biomechanically based approach to the diagnosis of pseudoarthrosis. Literature review, development of theory, reanalysis of a previously published study with surgical exploration as the gold-standard, and retrospective analysis of pooled studies to understand time to fusion. Fully automated methods were used to measure disc space strains (change in disc space height divided by initial height). Measurement error combined with the reported failure strain of trabecular bone led to a proposed strain threshold for diagnosis of pseudoarthrosis following ACDF. We reanalyzed previously reported flexion-extension radiographs for asymptomatic volunteers to assess whether flexion-extension radiographs, in the absence of fusion surgery, can be expected to provide sufficient stress on motion segments to allow for reliable strain-based fusion assessment. The sensitivity and specificity of strain- and rotation-based pseudoarthrosis diagnosis were assessed by reanalysis of previously reported post-ACDF flexion-extension radiographs, where intraoperative fusion assessments were also available. Finally, we assessed changes in strain over time using 9,869 flexion-extension radiographs obtained 6 weeks to 84 months post-ACDF surgery from 1,369 patients. The estimated error in automated measurement of disc space strain from radiographs was approximately 3%, and the reported failure strain of bridging bone was less than 2.5%. On that basis, we propose a 5% strain threshold for pseudoarthrosis diagnosis. Reanalysis of a study in which intraoperative fusion assessments were available revealed 67% sensitivity and 82% specificity for strain-based diagnosis of pseudoarthrosis, which was comparable to rotation-based diagnosis. Analysis of post-ACDF flexion-extension radiographs revealed rapid strain reduction for up to 24 months, followed by a slower decrease for up to 84 months. When rotation is less than 2°, the strain-based diagnosis differed from the rotation-based diagnosis in approximately 14% of the cases. We propose steps for standardizing diagnosis of pseudoarthrosis based on the failure strain of bone, measurement error, and retrospective data. These steps include obtaining high-quality flexion-extension studies, the application of proposed diagnostic thresholds, and the use of image stabilization for conclusive diagnosis, when motion is near thresholds. The necessity for an accurate diagnosis with minimal radiation exposure underscores the need for further optimization and standardization in diagnosing pseudoarthrosis following ACDF surgery. In a symptomatic postspine fusion patient, it is important to diagnose or rule-out pseudoarthrosis. There are currently no well-validated diagnostic tests for this condition. Incorporating strain-based intervertebral motion analysis into the diagnosis could lead to a standardized and validated test for detecting spine pseudoarthrosis. [ABSTRACT FROM AUTHOR]

The aims of this study were to retrospectively assess the occurrence of complications or need for secondary wrist procedures after the Sauvé-Kapandji procedure, and to prospectively assess patient-reported outcomes at long-term follow-up. All patients treated with the Sauvé-Kapandji procedure in our tertiary referral hospital between January 2008 and September 2021 were identified and contacted to complete the Quick Disabilities of the Arm, Shoulder, and Hand and the Patient-Rated Wrist/Hand Evaluation outcome measures. In total, 30 patients, with a median follow-up of 82 months, were included in this study. Complications occurred in 6 of 30 patients, which resulted in six secondary wrist procedures. Mean Quick Disabilities of the Arm, Shoulder, and Hand and Patient-Rated Wrist/Hand Evaluation scores were 30.1 and 33.6, respectively. We conclude that in respect of long-term outcomes, the Sauvé-Kapandji procedure can still be deemed to be a useful procedure, especially in patients with few other reconstructive options. Level of evidence: IV [ABSTRACT FROM AUTHOR]

Background: Biportal endoscopic transforaminal lumbar interbody fusion (BE-TLIF) is a minimally invasive surgical technique for treating degenerative lumbar spine conditions. It offers advantages such as reduced soft tissue trauma and lower infection rates, but certain technical aspects may be challenging. The current study aims to identify strategies to enhance the fusion rate in BE-TLIF by addressing these specific challenges. Methods: A literature review was conducted on techniques to improve fusion rates in BE-TLIF. Results: The review suggests that lateral-based portals supplemented with medial portals allowed for safe insertion of interbody cages with large footprint. Direct visualization of the disc space with a 30° endoscope assisted with better disc space preparation. Facetectomies performed with osteotomes, rather than burrs, ensured maximum retrieval of autologous bone graft. Utilizing bone morphogenetic proteins with sustained release carriers such as hydroxyapatite can be useful to increase fusion rates of BE-TLIF. Conclusions: To our knowledge, the current literature is the first comprehensive review of strategies to enhance fusion rates in BE-TLIF. The proposed techniques and biological adjuncts are effective means to address key challenges associated with the procedure, and such strategies would potentially shorten the learning curve and improve clinical outcomes. Further clinical studies are required to validate these findings and establish standardized protocols. Clinical Relevance: These findings provide practical solutions to overcome common challenges in BE-TLIF. The suggested techniques would reduce the incidence of pseudarthrosis, improve patient outcomes, and ultimately offer a safer and more reliable option for lumbar interbody fusion patients. Level of Evidence: 5. [ABSTRACT FROM AUTHOR]

Study Design. Retrospective study. Objective. To determine the 8-year risk of revision lumbar fusion, pseudoarthrosis, mechanical failure, fragility fracture, and vertebral compression fracture in patients with a prior fragility fracture compared with those without. Summary of Background Data. Osteoporosis is a known modifiable risk factor for revision following lumbar fusion due to inadequate fixation. Patients with prior fragility fractures have been shown to have increased bone health-related complications following various orthopedic surgeries; however, there is a paucity of literature that identifies these complications in patients undergoing lumbar fusion. Patients and Methods. Patients aged 50 years and older who underwent elective lumbar fusion were identified in a large national database and stratified based on whether they sustained a fragility fracture within three years prior to fusion. These patients were propensity-score matched to a control based on age, gender, and Charlson the comorbidity index using a 1:1 ratio. Kaplan-Meier and Cox proportional hazards analyses were used to observe the cumulative incidences and risk of complications within eight years of index surgery. Results. After matching, 8805 patients were included in both cohorts. Patients who sustained a prior fragility fracture had a higher risk of revision [hazard ratio (HR): 1.46; 95% CI: 1.26-1.69; P<0.001), pseudoarthrosis (HR: 1.31; 95% CI: 1.17-1.48; P<0.001), mechanical failure (HR: 2.08; 95% CI: 1.78-2.45; P<0.001), secondary fragility fracture (HR: 6.36; 95% CI: 5.86-6.90; P<0.001), and vertebral compression fracture (HR: 7.47; 95% CI: 7.68-8.21; P<0.001) when compared with the control cohort. Conclusion. Patients who sustain a fragility fracture prior to lumbar fusion have an increased risk of revision, pseudoarthrosis, and mechanical failure within eight years. Surgeons should be aware of this high-risk patient population and consider bone health screening and treatment to reduce these preventable complications. [ABSTRACT FROM AUTHOR]

Introduction An analysis of the medical literature devoted to various aspects of transitional lumbosacral vertebrae shows that there are very few publications covering the course of this disease in the pediatric and adolescent population. Aim To study the issues of epidemiology, diagnosis, treatment and prevention of transitional lumbosacral vertebrae in paediatric and adolescent patients based on the analysis of current medical literature and illustrate the material with our own clinical observations. Material and methods To analyze the literature on the topic, 75 papers published between 1984 and 2023 were selected. Among them, there were 7 (9.3 %) domestic literary sources, 68 (90.7 %) were foreign. In the process of searching for scientific articles, the resources of the electronic databases of current medical information PubMed and CyberLeninka were used. Results and discussion The incidence of transitional vertebrae in children and adolescents is 16.8 % of clinical observations, as reported. In the structure of the transitional vertebrae in children, type II of the disease predominates according to the classification Castellvi et al (1984), 43.2 % of cases. The main clinical symptom of the pathology is pain of lumbosacral location, the intensity of which on the visual analog scale in children corresponds to an average of 3.0 points. In adult patients with similar pathology, the average pain intensity measured with the same scale is 7.5 points. The most informative method for diagnosing the disease is computed tomography, which allows obtaining both 3D images and sections at the level of pseudarthrosis between the enlarged transverse process (or processes) of the suprasacral vertebra and the wing of the sacrum. To relieve pain in children with transitional vertebrae, both conservative and surgical methods are used. The most commonly used procedure is pseudarthrectomy. The study of long-term results one year after the intervention allowed us to record the absence of pain in children who underwent surgery. Prevention measures for transitional lumbosacral vertebrae have not been developed. Conclusion The analysis of the published literature shows that transitional vertebrae are a frequently diagnosed pathology in children and adolescents. Current methods of imaging are able to accurately detect not only the presence of the disease, but also to differentiate its type. The main clinical symptom of transitional vertebrae is pain in the lumbosacral spine which is difficult to relieve with conservative therapy. Pseudarthrectomy is the most frequent surgical method of treatment in children and adolescents that provides stable relief of vertebrogenic pain syndrome. Measures for specific prevention of the disease have not been developed.

Bilateral cages are often used for interbody fusion. However, this procedure may not be possible in some cases making unilateral cages a reasonable alternative. The literature remains divided on the clinical and radiological distinctions when comparing unilateral to bilateral cages in lumbar interbody fusion. Thus, this meta-analysis will analyze the clinical and radiographic outcomes between these 2 groups. PubMed, Cochrane, and Google Scholar (page 1–20) were searched till January 2024. The clinical outcomes evaluated were the incidence of adverse events, surgery-related parameters, and patient reported outcomes. Lower rates of pseudoarthrosis, subsidence, were reported in the bilateral cages group (P = 0.01, P = 0.001, respectively) whereas shorter operative time (OR time), and lower estimated blood loss were seen in unilateral cage group (P < 0.001, and P = 0.003). There was no statistically significant difference in the remaining analyzed outcomes. Unilateral cages were shown to be superior due to their reduced OR time and estimated blood loss. As for the higher rate of pseudoarthrosis, this outcome may not be related to the cage numbers and it did not affect clinical outcomes. Nevertheless, one must consider other factors such as radiographic sagittal parameters before making a surgical decision. [ABSTRACT FROM AUTHOR]

The purpose of the study was to investigate whether arthroscopic treatment of carpal scaphoid nonunions by osteosynthesis with bone grafting represents a successful surgical technique. This systematic literature review, conducted following the PRISMA guidelines, explores the past 10 years of clinical studies concerning the arthroscopic treatment of scaphoid nonunions. The most relevant keywords were used to search the databases, and the Downs and Black 27-item checklist has been used as quality assessment tool. Twelve papers that meet the premised eligibility criteria have been identified. These studies demonstrate the efficacy of this surgical solution, achieving a postoperative union rate of 96% in the average time of 13.5 weeks. Regardless of the method of synthesis and the origin of the graft used, excellent results were obtained. Patients who underwent this procedure reported a pain reduction of almost 80% compared to the preoperative level, improvement in grip strength close to 40%, and recovery in wrist function during daily activities. Arthroscopy has numerous advantages compared to the open approach. These are technically recognized by the surgeon and by the patient. Some disadvantages include a longer intraoperative time and considerable significant technical difficulty. Arthroscopic treatment of scaphoid nonunion by osteosynthesis with bone graft achieves a 96% union rate of the treated scaphoid with satisfying clinical results. [ABSTRACT FROM AUTHOR]

Fibular hemimelia is a non-lethal congenital lower limb skeletal malformation. It encompasses a broad range from partial to complete absence of fibula. Its incidence is very low worldwide. It affects boys more than girls in a ratio of 2:1. It may occur as an isolated anomaly or associated with other lower extremity anomalies like genu valgum, tibial bowing, ball and socket ankle joint and absent lateral foot ray anomaly. It may be associated with other syndromes including Fuhrmann syndrome, Al-Awadi/Raas-Rothschild syndrome, Roberts syndrome, and femur-fibula-ulna syndrome and FACTO syndrome. This case is not only unique as a rare occurrence in Karachi, Pakistan, but also in bilateral involvement, demonstrated complete absence of fibula i.e. type II fibular hemimelia; in association with a bilateral proximal focal femoral deficiency with pseudoarthrosis and club foot on each side. [ABSTRACT FROM AUTHOR]

Introduction: This study aimed to compare the safety, efficacy, radiological changes, and long-term results of transpedicular stabilization systems using a rigid rod with lumbar dynamics (PEEK) in terms of reoperation requirements. Methods: Patients who underwent two-level lumbar stabilization with 92 rigid systems and 54 dynamic systems between January 2017 and January 2020 were included in the study. The VAS and ODI scores, segmental and total lumbar lordosis angles, and upper and lower segment vertebral heights of the patients were evaluated. Preop, postop 1st day, postoperative 12th month, and postoperative 24th month values were compared. Results: Of the patients included in our study, 59 were male and 87 were female. The mean age was 58 years. Revision surgery was performed in 12 patients with a rigid system and 6 patients with a dynamic rod system. Preoperative VAS values were 8 (2-10) in the rigid group and 9 (6-10) in the dynamic group (p<0.05). At the 12th postoperative month, it was 4 (2-7) in the rigid group and 4 (2-6) in the dynamic group (p<0.05). Preoperative lumbar lordosis was 48.8 (29.6-80.8) in the rigid system, while it was 47.9 (11.5-83.7) in the dynamic system (p>0.05). At the 24th postoperative month, it was 46.5 (25.9-73.7) in the rigid group and 43.3 (20.2-79.6) in the dynamic group (p>0.05). Discussion and Conclusion: Although the development time of adjacent segment disease is longer with PEEK rod dynamic systems compared to rigid rod systems, adjacent segment disease can be seen in both systems. [ABSTRACT FROM AUTHOR]

Abstract Background Purely isolated spinous processes fractures are rare and are usually treated conservatively, although a few authors have reported cases of nonunion that ultimately required surgical resection. Case presentation We present a case of an isolated T6 spinous process pseudoarthrosis that was treated by surgical resection of the tip of the spinous process. A 34-year-old Caucasian male patient was complaining of mid-thoracic back pain without neurologic impairment more than 2 years after an isolated spinous process fracture. Magnetic Resonance Imaging (MRI) and Single Photon Emission Computed Tomography (SPECT) revealed a nonunion. We performed a resection without further complication. Conclusion Although spinous process nonunions may in some cases be well tolerated, surgical resection appears to be a reliable option in case of persistent symptoms. This illustrated case shows the description of an isolated thoracic spinous process nonunion and its surgical treatment.

Background: Andersson lesion (AL), also known as aseptic spondylodiscitis, is a pathological condition characterized by a destructive lesion in the vertebral or discovertebral region. The aim of this study was to assess functional, radiological, and neurological outcome of midline posterior surgery with transfacetal/transpedicular decompression and long-segment instrumentation and fusion in all patients with AL. Materials and Methods: A total of 36 consecutive patients with AL with or without neurodeficit were managed with midline posterior approach with long-segment fixation, decompression and anterior vertebral reconstruction added by same midline approach. The demographic data, visual analogue scale (VAS), modified Oswestry Disability Index (mODI), ankylosing spondylitis quality of life (ASQoL), local and global kyphosis angle, Frankel neurological grade, blood loss, duration of surgery, perioperative complications, and fusion rate were compiled and assessed. Results: The mean age of the patients was 52 years (26 males and 10 females). Among the patients, 9 patients had thoracic, 25 patients had thoracolumbar, and 2 patients had lumbar vertebral involvement. All patients in the study achieved fusion at final follow-up period of 24 months. The mean duration of hospital stay, intraoperative blood loss, and surgery duration was 6.17 days, 252 mL, and 130 min, respectively. VAS improved from mean 7.69 ± 0.98 to 1.67 ± 0.72, mODI from mean 70.28 ± 3.55 to 21.14 ± 2.13, ASQoL from mean 14.22 ± 1.59 to 7.17 ± 1.25, local kyphosis from 23.61 ± 1.67 to 18.52 ± 1.05, and global kyphosis from 57.02 ± 0.72 to 36.16 ± 1.23, leading to better sagittal balance. Except two patients all had full neurological recovery. Conclusions: Posterior midline approach with long-segment instrumentation and anterior decompression by transpedicular/transfacetal approach and bone grafting with selective use of cages can give satisfactory results with excellent fusion rates and good functional outcomes.

Study design: An ambispective, observational study of the prospective, institutional adult spine deformity (ASD) database. Objectives: The study investigates the clinical and radiographic fusion rates with lateral interbody approach and rhBMP-2 in multiple-level lumbar fusion in the ASD population. Previous studies have reported over 10% pseudoarthrosis rate with multiple segment fusions. Lateral lumbar interbody fusion (LLIF) allows multiple-level, less-invasive access to the anterior lumbar spine. We hypothesized that fusion rates with lateral approach with rhBMP-2 use are superior to the published data on lumbar fusion in ASD patients. Methods: The institutional ASD database was searched to identify eligible patients with two or more levels of LLIF (T12-L5), >4 levels of posterior instrumentations and >2 years of follow-up between the years 2010 and 2018. Antero-posterior and lateral 36-inch standing radiographs for each patient and computed tomography scans in select patients were studied to ascertain fusion status and patients were divided into two groups based on fusion status. Results: The study included 179 patients with a mean age of 65.3 years and 74% female patients. The median number of interbody fusions was performed at 3 (IQR 3-4) levels. The mean follow-up duration was 4.4 years (SD = 1.9). 169 patients (94.5%) had successful arthrodesis, while 10 patients (5.5%) had radiological pseudoarthrosis at one level. Of the 10 patients, 8 (4.4%) were either clinically asymptomatic or had manageable back pain. Two patients (1.1%) required revision surgery for symptomatic pseudoarthrosis. Conclusion: This is the largest known series of ASD patients investigating the fusion rates with multiple-level LLIFs. LLIF along with rhBMP-2 can achieve high fusion success across interbody fusion levels in multi-segmental ASD surgeries. [ABSTRACT FROM AUTHOR]

We are presenting a rare case of a 29-year-old male patient with congenital pseudoarthrosis of the clavicle who presented in adulthood with a progressively growing lump on medial end of clavicle which after investigations tuned out to be pseudoarthrosis of the medial clavicle.

Abstract Background This case study evaluates the diagnosis and treatment of a 12 year old Caucasian male gymnast who had several diagnoses including an isolated first rib fracture, resultant pseudoarthrosis of the first rib, and the development of symptomatic thoracic outlet syndrome. We discuss the causes, prevalence, and suggestions for prompt diagnosis and treatment of these conditions in pediatric patients. Although all three conditions are rare in a child, this case highlights the importance of having a high clinical index of suspicion in recurrent pain in pre-pubertal athletes. Case presentation A 12 year old Caucasian male underwent several years of conservative treatment with physical therapy and rest without resolution of his left shoulder pain. He was subsequently diagnosed with pseudoarthrosis of the first rib and thoracic outlet syndrome, which was curative by surgical removal of the first rib, and allowed him to return to his baseline activity level. Conclusions Since each of these diagnoses are rare, especially in the pediatric population, we aim to educate the medical community on the prompt diagnosis and treatment of these conditions.

Study Design This study adopted a retrospective cohort study design. Purpose This study aimed to clarify the influence of diffuse idiopathic skeletal hyperostosis (DISH) on bone fusion after transforaminal lumbar interbody fusion (TLIF). Overview of Literature The negative effects of DISH on lumbar degenerative diseases have been reported, and DISH may be involved in the onset and severity of lumbar spinal canal stenosis. Patients with DISH have significantly more reoperations after posterior lumbar fusion, including TLIF. However, the effects of DISH on bone fusion after TLIF have not been reported. Methods The medical records of patients with intervertebral TLIF from 2012 to 2018 were retrospectively examined. The patients were divided into those with fusion and those with pseudoarthrosis, and the following data were compared: age, sex, DISH, diabetes mellitus, smoking, drinking, albumin levels, body mass index ≥30 kg/m2, and L5/S fixation. Statistical analyses were performed using regression models. Results In this study, 180 patients (78.6%) had fusion and 49 patients (21.4%) had pseudoarthrosis. The number of patients with DISH was significantly higher in the pseudoarthrosis group than in the fusion group (36.7% and 21.7%, respectively; univariate p=0.031, multivariate p=0.019). No significant differences in age, sex, diabetes mellitus, smoking, drinking, albumin levels, body mass index ≥30 kg/m2, and L5/S fixation were observed between the two groups. The risk factors for bone fusion were statistically analyzed in 57 patients with DISH. DISH with a caudal end below Th11 was an independent risk factor for pseudoarthrosis (univariate p=0.011, multivariate p=0.033). Conclusions DISH is an independent risk factor for pseudoarthrosis after one intervertebral TLIF, and DISH with a caudal end below Th11 is associated with a higher risk of pseudoarthrosis than DISH without a caudal end below Th11.

Abstract Objective This study aims to analyze outcomes and clinical and epidemiological data of infected tibial pseudarthrosis using the Ilizarov method and the Orr dressing. Methods Data from n = 43 patients diagnosed with infected tibial pseudarthrosis were analyzed by descriptive and inferential statistical methods. In addition, Paley's assessment criteria evaluated bone and functional outcomes. Qualitative variables were presented as the distribution of absolute and relative frequencies. The presentation of quantitative variables followed the D'Agostino-Pearson test. Results Thirty-seven (86.04%) subjects were males, and six (13.95%) were females. The most frequent age group among patients was 50 to 59 years old (25.6%), with a p-value = 0.8610. The treatment time was longer for the trifocal treatment (23.8 months) when compared to the bifocal treatment (15.6 months), with a p-value = 0.0010* (highly significant). Excellent bone outcomes represented 72.09% of the sample; 23.25% of outcomes were good. Functional outcomes were excellent in 55.81%, good in 6.97%, and regular in 27.90% of subjects. The Orr dressing (using Vaseline gauze) proved effective, achieving wound healing with soft tissue coverage in all patients evaluated. Conclusions The Ilizarov method resulted in a substantial change in the treatment of bone infections, especially infected pseudarthrosis. The versatility of this method has turned it into an effective tool, allowing the healing of the infectious process and the correction of potential deformities and shortening.

Abstract Background Pseudoarthrosis after anterior cervical discectomy and fusion (ACDF) is relatively common and can result in revision surgery. The aim of the study was to analyze the outcome of patients who underwent anterior revision surgery for pseudoarthrosis after ACDF. Methods From 99 patients with cervical revision surgery, ten patients (median age: 48, range 37–74; female: 5, male: 5) who underwent anterior revision surgery for pseudoarthrosis after ACDF with a minimal follow up of one year were included in the study. Microbiological investigations were performed in all patients. Computed tomography (CT) scans were used to evaluate the radiological success of revision surgery one year postoperatively. Clinical outcome was quantified with the Neck Disability Index (NDI), the Visual Analog Scale (VAS) for neck and arm pain, and the North American Spine Society Patient Satisfaction Scale (NASS) 12 months (12–60) after index ACDF surgery. The achievement of the minimum clinically important difference (MCID) one year postoperatively was documented. Results Occult infection was present in 40% of patients. Fusion was achieved in 80%. The median NDI was the same one year postoperatively as preoperatively (median 23.5 (range 5–41) versus 23.5 (7–40)), respectively. The MCID for the NDI was achieved 30%. VAS-neck pain was reduced by a median of 1.5 points one year postoperatively from 8 (3–8) to 6.5 (1–8); the MCID for VAS-neck pain was achieved in only 10%. Median VAS-arm pain increased slightly to 3.5 (0–8) one year postoperatively compared with the preoperative value of 1 (0–6); the MCID for VAS-arm pain was achieved in 14%. The NASS patient satisfaction scale could identify 20% of responders, all other patients failed to reach the expected benefit from anterior ACDF revision surgery. 60% of patients would undergo the revision surgery again in retrospect. Conclusion Occult infections occur in 40% of patients who undergo anterior revision surgery for ACDF pseudoarthrosis. Albeit in a small cohort of patients, this study shows that anterior revision surgery may not result in relevant clinical improvements for patients, despite achieving fusion in 80% of cases. Level of evidence Retrospective study, level III.

Background: This case study evaluates the diagnosis and treatment of a 12 year old Caucasian male gymnast who had several diagnoses including an isolated first rib fracture, resultant pseudoarthrosis of the first rib, and the development of symptomatic thoracic outlet syndrome. We discuss the causes, prevalence, and suggestions for prompt diagnosis and treatment of these conditions in pediatric patients. Although all three conditions are rare in a child, this case highlights the importance of having a high clinical index of suspicion in recurrent pain in pre-pubertal athletes. Case presentation: A 12 year old Caucasian male underwent several years of conservative treatment with physical therapy and rest without resolution of his left shoulder pain. He was subsequently diagnosed with pseudoarthrosis of the first rib and thoracic outlet syndrome, which was curative by surgical removal of the first rib, and allowed him to return to his baseline activity level. Conclusions: Since each of these diagnoses are rare, especially in the pediatric population, we aim to educate the medical community on the prompt diagnosis and treatment of these conditions. [ABSTRACT FROM AUTHOR]

Objective. To analyze the clinical efficacy of anterior fusion through a minimally invasive retroperitoneal approach in the treatment of patients with pseudoarthrosis after decompression and stabilization surgery for degenerative spinal stenosis. Material and Methods. Twenty six patients with previously performed decompression and stabilization surgeries for degenerative spinal canal stenosis underwent repeated surgical interventions using anterior/anterolateral fusion due to clinical and radiographic signs of pseudoarthrosis resistant to complex conservative therapy for at least 12 weeks. The outcomes of surgical treatment were analyzed based on the assessment of clinical and radiological characteristics before and after surgery. Results. At a follow-up examination 12 months after surgery, leg pain aggravated after exercise bothered 5 patients (19.2 %). According to CT data, 16 (61.5 %) patients had signs of the formation of grade 1 interbody bone block. In 2 (7.7 %) patients, instability of the fixation system developed and there were no signs of union, which required repeated surgical interventions. Conclusion. Anterior interbody fusion in the treatment of patients with pseudoarthrosis allows safe removal of the preinstalled interbody implant and creation of optimal conditions for the formation of interbody fusion. Despite clinical improvement, significant functional disorders persist in most patients.

Introduction: bone defects drastically alter the patient's quality of life, and can produce serious sequelae such as dysfunctional shortening, angular deformity, joint stiffness and irreversible gait disorder. Objective: to describe the experience of managing posttraumatic bone defects of long bones treated with the membrane induction technique. Material and methods: retrospective observational study of patients with bone defects greater than 3 cm in diaphyseal pseudoarthrosis of long bones, who underwent the Masquelet technique. Period taken from January 2019 to January 2021. All patients underwent vigorous debridement and stabilization of the fracture, to then place the cement spacer. Spacer removal was at 4-6 weeks. The degree of consolidation was assessed, as well as the evolution of the treatment. Result: 25 patients were included in the study; the mean age was 36.8 ± 8.9 years. Diameter of bone losses was 3 to 10 cm (84%) and > 10 cm (16%). Bone consolidation occurred in patients with a defect < 10 cm (16%). 32% of patients presented some complication. Conclusions: bone union was achieved only in a few patients with defects smaller than 10 cm, requiring alternative procedures in most cases. Proper selection of patients is required. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective study Objectives: The combination of oblique lateral interbody fusion (OLIF) with grade 2 posterior column osteotomy (PCO) is an effective treatment for adult spinal deformity. However, grade 2 PCO may lead to pseudoarthrosis because it involves complete removal of the bilateral posterior facet joints. The main study objective was to determine the achievement rate of anterior and posterolateral fusion resulting in circumferential fusion in patients who underwent combined OLIF and grade 2 PCO. Methods: This retrospective study included consecutive patients who underwent OLIF and grade 2 PCO. The group comprised a long fusion group, with fusion from the thoracic level to the ilium, and a short fusion group, with fusion within the lumbar region. The OLIF with percutaneous pedicle screw insertion group was also used for reference. The Brantigan–Steffee–Fraser classification was used to assess interbody fusion and Lenke classification for assessment of posterolateral fusion. Results: Sixty-six patients with 109 lumbar levels were included in the study. We observed 100% anterior fusion in all 3 groups. The fusion rate for posterolateral fusion between the OLIF-grade 2 PCO group was 97%, with very low (3%) non-circumferential fusion (pseudoarthrosis only at the osteotomy site). In most cases, solid posterolateral fusions (Lenke A) occurred within 24 months. Conclusions: The combination of OLIF and grade 2 PCO resulted in circumferential fusion for most (97%) of the cases within 24 months. OLIF and grade 2 PCO are considered a good combination treatment to achieve sufficient lumbar lordosis and solid bone fusion. [ABSTRACT FROM AUTHOR]

Background: Pseudoarthrosis after anterior cervical discectomy and fusion (ACDF) is relatively common and can result in revision surgery. The aim of the study was to analyze the outcome of patients who underwent anterior revision surgery for pseudoarthrosis after ACDF. Methods: From 99 patients with cervical revision surgery, ten patients (median age: 48, range 37–74; female: 5, male: 5) who underwent anterior revision surgery for pseudoarthrosis after ACDF with a minimal follow up of one year were included in the study. Microbiological investigations were performed in all patients. Computed tomography (CT) scans were used to evaluate the radiological success of revision surgery one year postoperatively. Clinical outcome was quantified with the Neck Disability Index (NDI), the Visual Analog Scale (VAS) for neck and arm pain, and the North American Spine Society Patient Satisfaction Scale (NASS) 12 months (12–60) after index ACDF surgery. The achievement of the minimum clinically important difference (MCID) one year postoperatively was documented. Results: Occult infection was present in 40% of patients. Fusion was achieved in 80%. The median NDI was the same one year postoperatively as preoperatively (median 23.5 (range 5–41) versus 23.5 (7–40)), respectively. The MCID for the NDI was achieved 30%. VAS-neck pain was reduced by a median of 1.5 points one year postoperatively from 8 (3–8) to 6.5 (1–8); the MCID for VAS-neck pain was achieved in only 10%. Median VAS-arm pain increased slightly to 3.5 (0–8) one year postoperatively compared with the preoperative value of 1 (0–6); the MCID for VAS-arm pain was achieved in 14%. The NASS patient satisfaction scale could identify 20% of responders, all other patients failed to reach the expected benefit from anterior ACDF revision surgery. 60% of patients would undergo the revision surgery again in retrospect. Conclusion: Occult infections occur in 40% of patients who undergo anterior revision surgery for ACDF pseudoarthrosis. Albeit in a small cohort of patients, this study shows that anterior revision surgery may not result in relevant clinical improvements for patients, despite achieving fusion in 80% of cases. Level of evidence: Retrospective study, level III. [ABSTRACT FROM AUTHOR]

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• Purpose: A systematic review to determine the effect of different types of joint preparation, joint fixation, and postoperative weight-bearing protocols on non-union frequency in first metatarsophalangeal joint (MTPJ) arthrodesis in patients with moderate-to-severe hallux valgus. • Material and methods: A systematic literature search (PubMed and EMBASE), adhering to PRISMA guidelines. Data on MTPJ preparation, fixation, weight-bearing, and non-union in patients with moderate-to-severe hallux valgus were collected. Quality assessment was performed using the Coleman Methodology Score. • Results: Sixteen studies (934 feet) were included, generally of medium quality. Overall nonunion rate was 7.7%. At 6.3%, convex/concave joint preparation had the lowest non-union rate vs 12.2% for hand instruments and 22.2% for planar cuts. Non-union of 2.8% was found for joint fixation with a plate combined with a lag screw vs 6.5% for plate fixation, 11.1% for crossed screw fixation, and 12.5% for a plate with a cross plate compression screw. A 5.1% non-union frequency was found following postoperative full weight-bearing on a flat shoe vs 9.3% for full weight-bearing on a heel weight-bearing shoe and 0% for a partial weight-bearing regimen. • Conclusion: Based on medium-quality papers, joint preparation with convex/concave reamers and joint fixation with a plate using a lag screw show the lowest non-union rate. Full postoperative weight-bearing in a stiff-soled postoperative shoe is safe and not associated with non-union vs a more protective load-bearing regimen. Further research should focus on larger sample sizes, longer follow-ups, and stronger study designs.

Spatial computing (SC) in a surgical context offers reconstructed interactive four-dimensional models of radiological imaging. Preoperative and postoperative assessment with SC can offer more insight into personalized surgical approaches. Spine surgery has benefitted from the use of perioperative SC assessment. Herein, we describe the use of SC to perform a perioperative assessment of a revision spinal deformity surgery. A 79-year-old wheelchair-bound male presented to the neurosurgery clinic with a history of chronic lumbar pain associated with bilateral lower extremity weakness. His surgical history is significant for an L2-L5 lumbar decompression with posterior fixation 1 year prior. On examination, there were signs of thoracic myelopathy. Imaging revealed his previous instrumentation, pseudoarthrosis, and cord compression. We perform a two-staged operation to address the thoracic spinal cord compression and myelopathy, pseudoarthrosis, and malalignment with a lack of global spinal harmony. His imaging is driven by a spatial computing and SC environment and offers support for the diagnosis of his L2-3 and L4-5 pseudoarthrosis on the reconstructed SC-based computed tomography scan. SC enabled the assessment of the configuration of the psoas muscle and course of critical neurovascular structures in addition to graft sizing, trajectory and approach, evaluation of the configuration and durability of the anterior longitudinal ligament, and the overlying abdominal viscera. SC increases the familiarity of the patient's specific anatomy and enhances perioperative assessment. As such, SC can be used to preoperatively plan for spinal revision surgery.

We reviewed scientific literature on the problem of osteosynthesis of long tubular human bones, published during the last 10 years. The Scopus, Web of Scince, Pubmed, RSCI databases were searched for the articles reporting the results of clinical studies and biomechanical experiments using plate osteosynthesis. The advantages and disadvantages of minimally invasive plate osteosynthesis for different segments have been revealed. The articles reported a lower probability of displacement development in minimally invasive plate osteosynthesis in comparison with intramedullary osteosynthesis, good biological conditions for fracture healing, decreased rate of complications of postoperative wounds due to reduced incisions. In the concept of biological osteosynthesis, the advantage of axial dynamization and fracture micro-mobility over absolute rigidity was noted. The study also revealed the influence of the parameters of a plate and osteosynthesis technique on the rigidity of the plate-bone system, such as: the working length of the plate, the number of screws on the plate, types of screws (cortical or locking), the plate material and its profile. The bone osteosynthesis seemed to have new directions of evolution. These include far cortical locking screws allowing micromobility under the plate, providing a "controlled dynamization". An experimental technology of Active Locking Plates has been reported, where the screws with angular stability are locked in holes on elastic sliding elements providing micromobility of the screw relative to the plate. In general, all the visible results differed in various studies and, sometimes, contradicted each other.

Abstract Background Previous studies have reported that vitamin D supplement could improve fracture healing, but evidence regarding the role of vitamin D supplements in spinal fusion was limited. Thus, this study aimed to evaluate the effectiveness of oral vitamin D supplements on fusion outcomes in patients undergoing lumbar spinal fusion. Methods This randomized, double-blind, parallel-designed, active-control trial included the patients who planned for elective lumbar spinal fusion. Eligible patients were randomly assigned to receive either daily vitamin D3 (cholecalciferol) 800 IU and daily calcium citrate 600 mg (experimental group) or only daily calcium citrate 600 mg (control group). All supplements were given from postoperative day 1 and lasted for 3 months. Primary outcome was postoperative 1-year fusion rate, and secondary outcomes included time to fusion, Oswestry Disability Index (ODI), and visual analogue scale (VAS) for pain. Results Among the included 34 patients (21 in the experimental group and 13 in the control group), baseline 25-hydroxyvitamin D (25[OHVitD) level was 26.7 (10.4) ng/ml. Preoperative prevalence of vitamin D deficiency and insufficiency were 23.5% and 47.1%, respectively. Postoperative 1-year fusion rate was not significantly different between the two groups (95.2% vs. 84.6%, P = 0.544). The experimental group had significantly shorter time to fusion (Kaplan–Meier estimated: 169 days vs. 185 days [interquartile range: 88–182 days vs. 176–324 days], log-rank test: P = 0.028), lower postoperative 6-month ODI (P

Modular megaprostheses (MPs) are commonly used after bone-tumor resection, but they can offer a limb salvage solution in massive bone defects. The aim of this systematic review of the Literature is to provide a comprehensive data collection concerning the use of MPs in non-oncologic cases, and to provide an overview of this topic, especially from an epidemiologic point of view. Three different databases (PubMed, Scopus, and Web of Science) were searched for relevant articles, and further references were obtained by cross-referencing. Sixty-nine studies met the inclusion criteria, reporting on cases of MP in non-oncologic cases. A total of 2598 MPs were retrieved. Among these, 1353 (52.1%) were distal femur MPs, 941 (36.2%) were proximal femur MPs, 29 (1.4%) were proximal tibia MPs and 259 (10.0%) were total femur MPs. Megaprostheses were most commonly used to treat periprosthetic fractures (1158 cases, 44.6%), in particular in the distal femur (859, 74.2%). Overall, complications were observed in 513 cases (19.7%). Type I (soft tissue failures) and type IV (infection) according to the Henderson classification were the most frequent (158 and 213, respectively). In conclusion, patients with severe post-traumatic deformities and/or significant bone loss who have had previous septic complications should be considered as oncologic patients, not because of the disease, but because of the limited therapeutic options available. The benefits of this treatment include relatively short operative times and immediate weight-bearing, thus making MP particularly attractive in the lower limb. [ABSTRACT FROM AUTHOR]

Background: Salvage surgery for a nonunion around the ankle is challenging. Poor bone stock, stiffness, scarring, previous (or persistent) infection, and a compromised soft tissue envelope are common in these patients. We describe 15 cases that underwent blade plate fixation as salvage for a nonunion around the ankle, including patient/nonunion characteristics, Nonunion Scoring System (NUSS), surgical technique, healing rate, complications, and long-term follow-up with 2 patient-reported outcome measures. Methods: This is a retrospective case series from a level 1 trauma referral center. We included all patients that underwent blade plate fixation for a long-standing nonunion of the distal tibia, talus, or failed subtalar fusion. All patients had autogenous bone grafting, including 14 with posterior iliac crest grafts and 2 with femoral reamer irrigator aspirator grafting. Median follow-up was 24.4 months (interquartile range [IQR], 7.7-40). Main outcome measures were (time to) union, and functional outcomes using the 36-item Short Form Health Survey (SF-36) physical component summary (PCS) and mental component summary (MCS), and the Foot and Ankle Outcome Score (FAOS). Results: We included 15 adults with a median age of 58 years (IQR, 54-62). The median NUSS score at the time of index surgery was 46 (IQR, 34-54). Union was achieved after the index procedure in 11 of 15 patients. Additional surgery was performed in 4 of 15 patients. Union was achieved in all patients at a median of 4.2 months (IQR, 2.9-11). The median score for the PCS was 38 (IQR, 34-48, range 17-58, P =.009), for the MCS 52 (IQR, 45-60, range 33-62, P =.701), and for the FAOS 73 (IQR, 48-83). Conclusion: In this series, our use of blade plate fixation with autogenous grafting was an effective method for managing a nonunion around the ankle allowing for alignment correction, stable compression and fixation, union, and fair patient-reported outcome scores. Level of Evidence: Level IV, therapeutic. [ABSTRACT FROM AUTHOR]

Introduction: Scaphoid fractures represent 5–10% of nonunion rate and the treatment options consist of an open reduction with correction of deformity, restoration of the scaphoid length with autologous wedge grafting and fixation. However, there is still no consensus in the literature on the best fixation method. Therefore, the purpose of the study is to compare plate fixation and screw fixation in treating scaphoid nonunion with humpback deformity and carpal instability. Methods: Prospective, non-randomised study comparing the treatment of two groups of patients with scaphoid nonunion. A total of 19 patients were included in the study, the first ten patients were included in group 1 (plate fixation), subsequently nine patients were included in group 2 (screw fixation). The nonunion duration was longer than 6 months and patients did not present type III Scaphoid Nonunion Advanced Collapse (SNAC). Clinical evaluations included pain intensity, range of motion, grip strength, pinch test and functional scales Disabilities of the Arm, Shoulder and Hand (DASH) and Mayo Wrist Score. Radiographic evaluations consisted of radiographs of both wrists in AP, AP with ulnar deviation, lateral and oblique views. Patients further underwent a tomography of the affected wrist for bone deformity, carpal collapse and later consolidation evaluation. Results: According to post-operative measurements, group 1 showed a significant improvement in the scapholunate angle (p = 0.011) and in the intrascaphoid angle (p = 0.002). Group 2 only showed an improvement in the scapholunate angle (p = 0.011). All patients in group 1 achieved consolidation in 8 weeks, while group 2 patients had a slower consolidation, with a mean of 14 weeks and standard deviation (SD) of 4.2, with statistical significance (p = 0.006). Conclusion: Our prospective study, despite the limitations, contributes to the literature for demonstrating a better fixation using plate, with a better correction of humpback deformity and Dorsal Intercalated Segment Instability (DISI) and a faster consolidation. Level of evidence: II, therapeutics studies; prospective comparative study. [ABSTRACT FROM AUTHOR]

Objectives: Complications are common in the treatment of lower extremity congenital or acquired deformities by Ilizarov method. The results to be obtained vary in specific patient groups. In this study, deformities who developed before the age of 16 were compared with those developed after this age regardless of the type of aetiology, in terms of results obtained, treatment durations and complications encountered. Methods: 53 bone deformities with an average of 9.5 (7.5-18) years of follow-up treated by the same surgeon were divided into 2 groups according to the age of deformity onset. Demographics and deformity characteristics of patients were defined, treatment times, bone healing indexes, consolidation/correction rates, problems encountered and results obtained were compared retrospectively. The results were compared with ASAMI functional and bone scoring. Complications were rated according to Paley and relative risk increases between groups were calculated. Results: 26 of the patients were men and 22 were women. The average age was 26.47 (7-57). The mean deformity was 23.98° (7-60) and the mean shortness in 39 patients was 38.65 (10-110)mm. Mechanical axis deviation was corrected in 83% of patients. The Lengthening index was 54.13days/cm in the development group and 63.69 days/cm in adults. Consolidation/correction rate was 2.54 in developmental age and 2.4 (p=0.698) in adults. The risk increased by 1.02 times in terms of problems encountered, 2 for obstacles, 3 times in complications and 1.34 times in total difficulties per case, according to Paley. The duration of stay in the fixator was higher in developmental group (p=0.023). ASAMİ functional (p=0.000148) and anatomical (p=0.000242) scores were better in the adult group. Conclusion: Congenital or acquired deformities in the lower extremity can be treated with satisfactory results by Ilizarov method. The development of deformity at an early age makes treatment difficult. Although the bone healing index is lower in this group of patients, which usually has a higher amount of shortness, the treatment is usually longer than that of adult deformities; complications are more frequent and serious. Functional and anatomical results are more unsuccessful. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the prevalence and risk factors and influence of pseudoarthrosis on activities of daily living (ADL) of patients with osteoporotic vertebral fracture (OVF). Methods: Spinal pseudoarthrosis is defined as the presence of a cleft in the vertebral body on a lateral X-ray image in the sitting position at 1 year after admission. Of the total 684 patients treated for OVF between January 2012 and February 2019 at our institution, 551 patients (mean age, 81.9 years; a male-to-female ratio, 152:399) who could be followed up to 1 year were included in this study. Prevalence, risk factors, and influence of pseudoarthrosis on the ADL of patients as well as fracture type and location were investigated. Pseudoarthrosis was set as the objective variable. Total bone mineral density, skeletal muscle mass index, sex, age, history of osteoporosis treatment, presence of dementia, vertebral kyphosis angle, fracture type (presence of posterior wall injury), degree of independence before admission, history of steroid use, albumin level, renal function, presence of diabetes, and diffuse idiopathic skeletal hyperostosis were set as explanatory variables for multivariate analysis of the influence of pseudoarthrosis on the walking ability and ADL independence before and 1 year after OVF. Results: In total, 54 (9.8%) patients were diagnosed with pseudarthrosis 1 year after injury (mean age, 81.3 ± 6.5 years; male-to-female ratio, 18:36). BKP was performed in nine patients who did not develop pseudoarthrosis after 1 year. In the multivariate analysis, only the presence of posterior wall injury was significantly correlated with the presence of pseudoarthrosis (OR = 2.059, p = 0.039). No significant difference was found between the pseudarthrosis group and the non-pseudarthrosis group in terms of walking ability and ADL independence at 1 year. Conclusions: The prevalence of pseudoarthrosis following OVF was 9.8%, and its risk factor was posterior wall injury. The BKP group was not included in the pseudoarthrosis group, which may have led to an underestimation of the prevalence of pseudoarthrosis. Summary: The prevalence, risk factors, and influence of spinal pseudoarthrosis on patients' ADL following osteoporotic vertebral fracture (OVF) were investigated. Pseudoarthrosis occurs in 9.8% 1 year after the injury in patients with OVF. Posterior wall injury was the risk factor of pseudoarthrosis. [ABSTRACT FROM AUTHOR]

The aim of this current study was to establish a metaphyseal femoral non-union model in osteoporotic rats by comparing a power tool versus a manual tool for fracture creation. Twelve adult female Sprague Dawley rats were ovariectomized (OVX) and received a special diet for 6 weeks. Biweekly pQCT measurements confirmed a significant reduction in the cancellous and total bone mineral density in OVX rats compared to control (CTRL) animals. After 6 weeks, OVX rats underwent surgery creating a distal metaphyseal osteotomy, either using a piezoelectric- (n = 6) or a manual Gigli wire (n = 6) saw. Fractures were stabilized with a Y-shaped mini-locking plate. Within each group, three rats received Alginate directly into the fracture gap. OVX animals gained more weight over 8 weeks compared to CTRL animals. pQCT analysis showed a significant difference in the volumetric cancellous bone mineral density between OVX and CTRL rats. A histological examination of the osteoporotic phenotype was completed. Radiographic evaluation and Masson–Goldner trichrome staining with the piezoelectric saw failed to demonstrate bony bridging or a callus formation. New bone formation and complete healing were seen after 6 weeks in the Gigli group. For the creation of a metaphyseal atrophic non-union in the osteoporotic bone, a piezoelectric saw should be used. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective cohort study. Objective: To report the clinical and radiological outcomes for screw track augmentation with fibular allograft in revision of loose pedicle screws associated with significant bone loss along the screw track. Methods: Thirty consecutive patients, 18 men (60%) and 12 women (40%), with a mean age 52 years (range 34- 68). Fibular allograft was prepared by cutting it into longitudinal strips 50 mm in length. Three allograft struts were inserted into the screw track. Six mm tap used to tap between the 3 fibular struts. Eight- or 9-mm diameter, and 45 or 50 mm in length screw was then inserted. The clinical outcomes were assessed by means of the Oswestry Disability Index (ODI), and visual analog scale (VAS) for back and leg pain for clinical outcome. Computed tomography scan (CT) performed at 12 months postoperative visit to assess fibular graft incorporation along the pedicle screw track, any screw loosening and the interbody as well as posterolateral fusion. Results: At a mean follow up of 29 months, there were statically significant improvement in the ODI and VAS for back and leg pain. CT scan obtained at last follow-up showed incorporation of fibular allograft and solid fusion in all patients except one. Conclusion: The fibular allograft augmentation of the pedicle screw track in revision of loose pedicle screws associated with significant bone loss is a viable option. It allows for biologic fixation at the screw-bone interface and has some key advantages when compared to currently available methods. [ABSTRACT FROM AUTHOR]