JAAOS, Volume 26, No. 7

Percutaneous Pedicle Screw Stabilization: Surgical Technique, Fracture Reduction, and Review of Current Spine Trauma Applications

Percutaneous pedicle screw fixation has evolved as a useful tool in the management of spinal trauma. As a minimally invasive approach, it provides the stability of open instrumentation while limiting blood loss, avoiding excessive muscle/soft-tissue insult, and improving postoperative pain and mobilization. Muscle-dilating techniques also preserve greater paraspinal muscle volume and strength compared with open midline approaches. In patients with spinal trauma, the use of percutaneous instrumentation and indirect reduction can theoretically preserve the fracture hematoma and its osteogenic inflammatory factors. The evolution of spinal instrumentation and the refinement of indirect reduction techniques has improved the capacity for correction of traumatic deformity. Although perioperative and short-term results have been well described, few long-term outcomes data exist.

      • Subspecialty:
      • Spine

      • Spine

    Cervical Laminoplasty: Indications, Surgical Considerations, and Clinical Outcomes

    Cervical laminoplasty was initially described for the management of cervical myelopathy resulting from multilevel stenosis secondary to ossification of the posterior longitudinal ligament. The general concepts are preservation of the dorsal elements, preservation of segmental motion, and expansion of the spinal canal via laminar manipulation. No clear evidence suggests that laminoplasty is superior to either posterior laminectomy or anterior cervical diskectomy and fusion. However, laminoplasty has its own advantages, indications, and complications. Surgeons have refined the technique to decrease complication rates and improve efficacy. Recent efforts have highlighted less invasive approaches that are muscle sparing and associated with less postoperative morbidity. Although the long-term outcomes suggest that cervical laminoplasty is safe and effective, continued research on the development of novel modifications that decrease common complications, such as C5 nerve palsy, axial neck pain, and loss of lordosis, is required.

        • Subspecialty:
        • Spine

        • Spine

      Simultaneous Acute Femoral Deformity Correction and Gradual Limb Lengthening Using a Retrograde Femoral Nail: Technique and Clinical Results

      Introduction: Patients with limb-length discrepancies often have concomitant deformity. We describe the outcomes of acute, fixator-assisted deformity correction with gradual lengthening using the retrograde femoral Precice nail (NuVasive).

      Methods: We analyzed a retrospective series of 27 patients in whom an external fixator was combined with a Precice nail to correct angular or rotational deformity and limb-length discrepancy. The fixator was applied temporarily to restore normal alignment. The Precice nail was inserted and locked in place to hold the correction, with gradual restoration of limb length.

      Results: The 27 patients (mean age, 28 years) had a mean follow-up of 13 months. Secondary deformities were mainly valgus (15 patients) and varus (10 patients). Postoperatively, 93% of patients had correction of limb length to within 3 mm of the discrepancy (mean lengthening, 30 mm). Mechanical axis deviation was corrected to within 8 mm of neutral (ie, zero) in 81% of patients. The mechanical lateral distal femoral angle was corrected to a mean of 88° postoperatively. Final Association for the Study and Application of Methods of Ilizarov (ASAMI)–Paley scores were excellent for 96% of patients.

      Discussion: The use of intramedullary lengthening nails has revolutionized the field of limb lengthening. The results of our study show that a retrograde femoral Precice nail can be used safely and accurately to correct both limb-length discrepancy and deformity with minimal complications. The benefits of using this implant include the ability to maintain knee range of motion during the lengthening process. Rapid bone healing allows a relatively fast return to weight-bearing ambulation.

      Conclusions: The Precice nail was effectively used to correct both limb-length discrepancy and deformity, with excellent overall outcomes. This surgical technique may help avoid the complications that can occur with prolonged postoperative use of an external fixator.

      Level of Evidence: Level IV retrospective study

          • Subspecialty:
          • Foot and Ankle

        Discharge Destination After Shoulder Arthroplasty: An Independent Risk Factor for Readmission and Complications

        Introduction: Postdischarge disposition after shoulder replacement lacks uniform guidelines. The goal of this study was to identify complication and readmission rates by discharge disposition and determine whether disposition was an independent risk factor for adverse events, using a statewide database.

        Methods: Data from the California Office of Statewide Health Planning and Development discharge database were used. Patient information was assessed, and 30- and 90-day complication rates were identified. Univariate and multivariate analyses were used to determine the complication risk.

        Results: From 2011 to 2013, 10,660 procedures were identified, with 7,709 patients discharged home, 1,858 discharged home with home health support, and 1,093 discharged to postacute care (PAC) facilities. Patients discharged to PAC facilities or to home with health support tended to be older, female, and using Medicare. After controlling for confounders, at 30 and 90 days, patients discharged to PAC facilities were found to be more likely to experience a complication.

        Discussion: Discharge to a PAC facility was an independent risk factor for complications and readmission.

        Level of Evidence: Level III, retrospective cohort design, observational study.

            • Subspecialty:
            • Shoulder and Elbow

          Elimination of Preoperative Flexion Contracture as a Contraindication for Unicompartmental Knee Arthroplasty

          Introduction: Unicompartmental knee arthroplasty (UKA) is an effective alternative to total knee arthroplasty (TKA) for the management of unicondylar osteoarthritis. Historical contraindications limit patients’ eligibility for UKA. However, recent reports have suggested that some contraindications may not be absolute. This study evaluates preoperative flexion contracture with regard to UKA.

          Methods: This study was a retrospective review of 53 patients with preoperative flexion contracture between 11° and 20° who underwent fixed-bearing UKA and a matched cohort of 53 patients who underwent cruciate-retaining TKA.

          Results: Preoperatively, the average flexion contracture was 13.8° in the UKA group and 14.1° in the TKA group (P = 0.42). Mean preoperative motion was greater in the patients treated with UKA (106°) than in those treated with TKA (97°; P < 0.001). Postoperatively, patients who underwent UKA had greater motion than patients who underwent TKA had (121° versus 113°; P < 0.01). Residual flexion contracture was greater in the UKA group (4.1°) than in the TKA group (2.1°; P = 0.02). The two groups demonstrated similar improvements in Knee Society clinical scores (P = 0.32). However, patients treated with UKA demonstrated higher Knee Society functional scores, compared with patients treated with TKA (86 versus 75; P = 0.03).

          Discussion: Although residual flexion contracture was worse after UKA, this group had similar clinical improvement, greater postoperative motion, and greater function scores, compared with the matched TKA group. Preoperative flexion contracture >5° may not be an absolute contraindication to UKA.

          Conclusion: The contraindications to UKA regarding flexion contracture may not be as absolute as previously thought. Larger, prospective studies are needed to generalize these findings to a wider population.

              • Subspecialty:
              • Adult Reconstruction