Spinal surgery deals with the treatment of different pathological conditions of the spine such as tumors, deformities, degenerative disease, infections and traumas. Research in the field of vertebral surgery can be divided into two main areas: 1) research lines transversal to the different branches; 2) specific research lines for the different branches. The transversal lines of research are represented by strategies for the reduction of complications, by the development of minimally invasive surgical techniques, by the development of surgical navigation systems and by the development of increasingly reliable systems for the control of intra-operative monitoring. Instead, specific lines of research are developed within the different branches. In the field of oncological pathology, the current research concerns the development of in vitro models for the study of metastases and research for the study of targeted treatment methods such as electrochemotherapy and mesenchymal stem cells for the treatment of aneurysmal bone cysts. Research in the field of spinal deformities is focused on the development of increasingly minimally invasive methods and systems which, combined with appropriate pharmacological treatments, help reduce trauma, stress and post-operative pain. Scaffolds based on blood clots are also being developed to promote vertebral fusion, a fundamental requirement for improving the outcome of vertebral arthrodesis performed for the treatment of degenerative disc disease. To improve the management and the medical and surgical treatment of vertebral infections, research has focused on the definition of multidisciplinary strategies aimed at identifying the best possible treatment path. Thus, flow-charts have been created which allow to manage the patient suffering from vertebral infection. In addition, dedicated silver-coated surgical instrumentation and bone substitutes have been developed that simultaneously guarantee mechanical stability and reduce the risk of further local infection. In the field of vertebral traumatology, the most recent research studies have focused on the development of methods for the biostimulation of the bone growth in order to obtain, when possible, healing without surgery. Methods have also been developed that allow the minimally invasive percutaneous treatment of fractures by means of vertebral augmentation with PMMA, or more recently with the use of silicone which from a biomechanical point of view has an elastic modulus more similar to that of bone. It is clear that scientific research has changed clinical practice both in terms of medical and surgical management of patients with spinal pathologies. The results obtained stimulate the basic research to achieve even more. For this reason, new lines of research have been undertaken which, in the oncology field, aim at developing increasingly specific therapies against target receptors. Research efforts are also being multiplied to achieve regeneration of the degenerated intervertebral disc and to develop implants with characteristics increasingly similar to those of bone in order to improve mechanical stability and durability over time. Photodynamic therapies are being developed for the treatment of infections in order to reduce the use of antibiotic therapies. Finally, innovative lines of research are being launched to treat and regenerate damaged nerve structures with the goal, still far from today, of making patients with spinal cord injuries to walk

The risk of AVN is high in Unstable Slipped Capital Femoral Epiphysis (SCFE) and the optimal surgical treatment remains controversial. Our AVN rates in severe, unstable SCFE remained unchanged following the introduction of the Modified Dunn Procedure (MDP) and as a result, our practice evolved towards performing an Anterior Open Reduction and Decompression (AOR) in an attempt to potentially reduce the “second hit” phenomenon that may contribute. The aim of this study was to determine the early surgical outcomes in Unstable SCFE following AOR compared to the MDP. All moderate to severe, Loder unstable SCFEs between 2008 and 2022 undergoing either an AOR or MDP were included. AVN was defined as a non-viable post-operative SPECT-CT scan. Eighteen patients who underwent AOR and 100 who underwent MPD were included. There was no significant difference in severity (mean PSA 64 vs 66 degrees, p = 0.641), or delay to surgery (p = 0.973) between each group. There was no significant difference in the AVN rate at 27.8% compared to 24% in the AOR and MDP groups respectively (p = 0.732). The mean operative time in the AOR group was 24 minutes less, however this was not statistically significant (p = 0.084). The post-reduction PSA was 26 degrees (range, 13–39) in the AOR group and 9 degrees (range, -7 to 29) in the MDP group (p<0.001). Intra-operative femoral head monitoring had a lower positive predictive value in the AOR group (71% compared to 90%). Preliminary results suggest the AVN rate is not significantly different following AOR. There is less of an associated learning curve with the AOR, but as anticipated, a less anatomical reduction was achieved in this group. We still feel that there is a role for the MDP in unstable slips with a larger remodelling component

Introduction Transcranial motor evoked potentials are routinely used at The Children’s Hospital at Westmead to monitor the spinal cord in spinal surgery. This study is a prospective review of all spinal cord monitoring procedures from 1999 to 2004 in patients undergoing elective spinal deformity correction surgery at The Children’s Hospital at Westmead and Westmead Hospital. Spinal cord monitoring with Somatosensory Evoked Potentials (SSEP) and MEP has been widely used in combination during spinal surgery with good sensitivity and specificity. The use of CMAP as the only modality has not been widely used and its efficacy has not been fully elucidated. Using MEP and CMAP only may increase the sensitivity of spinal cord monitoring compared with combined SSEP and MEP monitoring. Methods The intra-operative monitoring outcomes were compared with patient’s post-operative clinical outcomes. The sensitivity and specificity were calculated and determined for our monitoring protocol. Results Transcranial MEPs were measured in 146 patients in 175 procedures. In 2 patients (2 procedures) we were unable to record any CMAPS. There were 15 intra-operative monitoring changes (8.7%). There were no new post-operative neurological deficits. Our results compare favourably to the literature with respect to the false-negative rate or new neurological events. Discussion Using our anaesthetic protocol and spinal monitoring criteria, we were able to successfully monitor patients undergoing elective spinal deformity correction surgery for a variety of diagnoses. The monitoring criteria are sufficiently strict to achieve a sensitivity of 1.0 (95%CI = 0.66–1.00) and a specificity of 0.97 (95%CI = 0.83–0.99). Monitoring of CMAPs alone has been adequate to avoid clinical neurological deficits

Purpose: To document the incidence of neurological lesions and functional outcome following displaced acetabular fractures. Patients and Methods: Prospective review of patients who underwent stabilisation of acetabular fractures in a University Hospital trauma centre. From December 1994 to November 2000 136 patients were identified with acetabular fractures. The open reduction and internal fixation of the acetabular fixation was performed by standard operative techniques. The time from the initial injury to the operation ranged from 24 hours to I4days. Patients with sciatic nerve injuries were prospectively followed up and long-term outcome recorded. Weakness or absence of dorsiflexion or plantar flexion was graded according to the standard Medical Research Council. Abnormalities of sensation, including absent or diminished sensation to light touch and pinprick as well as dysesthesia or hyperesthesia of the dorsal and plantar aspects of the foot were recorded. None of the patients had an injury of the spinal cord. Intra-operative monitoring was performed in most cases, and routine electromyography and nerve -conduction studies were done post-operatively and at least on one more occasion to record the level and severity of the lesion and to monitor progress of recovery. All the patients were followed up clinically in the trauma clinics and functional improvement was routinely assessed. The mean follow up of the patients was 3.4 years (range 1.5–6 years). Results: Out of 136 patients who underwent stabilisation of acetabular fractures there were 27 (19.8 %) cases of neurological lesions. In 12 cases the femoral head was dislocated posteriorly. Twenty were men and eight were woman. The mean age was 33.8 (range 16–66). 15 patients had associated injuries. The mean ISS was 12.6 (range 9–34). At initial presentation there were 13 patients with a complete dropped foot lesion, 10 patients with foot weakness and 4 patients with burning pain and altered sensation over the dorsum of the foot. Intra-operative monitoring was performed in 16 cases. All the patients had EMG studies for neurophysiological assessment of the lesion. EMG studies revealed sciatic nerve lesions in all the cases but in nine patients with a dropped foot there was evidence of a proximal (sciatic) and distal (neck of fibula) lesion, “double crush syndrome”. Only in 3 of these cases there was documentation of an ipsilateral knee injury. In two patients there was deterioration of foot function after surgery due to iatrogenic damage. At final follow-up, clinical examination and associated EMG studies revealed full recovery in 5 cases with initial muscle weakness (mean time 4.2 years (2–5)) and complete resolution of sensory symptoms (burning pain and hyposthesia) in 4 cases (mean time 3 years (2–4)). There was improvement of functional capacity (motor and sensory) in two cases with initially complete drop foot and in 4 cases with muscle foot weakness (mean time 3.6 years (range 2–6). In 11 of the cases with dropped foot (all nine with “double crush”) at presentation, there was no improvement in function, (mean time 3.9 years (range 2–6). Conclusion: Acetabulum fractures associated with sciatic nerve injuries continue to be a significant cause of long-term morbidity in trauma patients. In cases where there is evidence of “double crush lesions” the prospect of functional recovery is low as seen in this group of patients. Single lesions appear to be associated with a more favourable prognosis

Introduction. Correct alignment is important for a successful result after total knee arthroplasty (TKA). During most activities of daily living, the knee is loaded not only in full extension but also in mid-flexion. However, there are few methods to evaluate mid-flexion varus-valgus alignment, despite its clinical significance. Computer navigation systems are useful for intra-operative monitoring of joint positioning and movements. Knee ligaments contribute to induce kinematics of the joint. It is likely that the presence of posterior cruciate ligament has some effects on kinematics throughout flexion. The purpose of this study was to evaluate changes in the varus–valgus alignment of the femoral–tibial mechanical axis in each flexion angle before and after TKA by using a navigation system, and to evaluate varus–valgus kinematic patterns throughout flexion, and compare preoperative and postoperative changes of kinematic patterns in CR-TKA and PS-TKA procedures. Material and Method. Forty knees that underwent TKA with computer navigation system were evaluated (CR-TKA 20; PS-TKA 20). CR and PS TKRs were implanted in alternating sequence. The investigator applied manual mild passive knee flexion, while moving the leg from full extension to flexion and the varus-valgus angle of femoral-tibial mechanical axis was measured automatically by the navigation system at every 10 ° throughout flexion. We classified kinematic patterns in the varus–valgus direction throughout flexion. Results. The mean change in size of the varus–valgus angle associated with full movement was 8.0º preoperatively and 5.3º postoperatively. There was no difference between CR-TKA and PS-TKA. We then evaluated the distribution of changes in size of the varus–valgus angle. Postoperatively, this was limited to 3º or less in many patients, but was also around 6º in many cases, and in some cases it exceeded 10º. For CR-TKA, it was 7º or less in all except one patient, but conversely the change was around 6º in most cases. For PS-TKA, it was limited to 3º or less in most patients, but did exceed 10º in some cases. (Fig.1). We could classify kinematic patterns throughout flexion movement into five broad types. Type A: Varus movement associated with flexion; Type B: Valgus movement associated with flexion; Type C: Same angle position maintained; Type D: Varus movement in the intermediate flexed position; Type E: Valgus movement in the intermediate flexed position. (Fig.2) Kinematic patterns changed before and after TKA in some patients, but in others they remained similar. Among those who underwent CR-TKA, preoperative and postoperative kinematic patterns were similar in 61% of patients, whereas they were different in 80% of those who underwent PS-TKA. Discussion). Our results showed that with respect to postoperative varus–valgus kinematic patterns, the effect of the preoperative varus–valgus kinematic pattern persisted more strongly after CR-TKA compared with PS-TKA. This may have been because in CR-TKA the conserved PCL affects the restriction of varus–valgus movement throughout flexion movements, whereas in PS-TKA it is the post-cam that restricts knee joint movement while also affecting the induction of varus−valgus kinematics with loss of PCL influence

Introduction: The intra-operative blood-loss data on scoliosis surgery patients at Dunedin Hospital during 1992–2000 were analysed retrospectively. Various measures had been tried to reduce the intra-operative blood loss and included use of fibrinogen, DDAVP and antifibrinolytic agents. Patients with medical abnormalities, particularly those with muscular dystrophies/myopathies appeared to have a high incidence of intra-operative blood loss. Aim: To evaluate the amount of bleeding. any pre-operative factors identifiable as contributing to the bleeding and any preventive measures which have been identified. Methods: An audit of intra-operative blood loss on all cases presented for corrective surgery for scoliosis in Dunedin Hospital during the period 1992–2000 was undertaken. Results: A total of 160 operations were performed during the eight years. The mean age of the cohort was 14.8 years (SD 6.8) and the mean weight of the cohort was 44kg (SD 18.9). Fifty-six percent of the patients were idiopathic cases with no medical abnormalities, where as 44% had congenital/medical abnormalities. The mean blood loss as a percentage of calculated blood volume was 38% (SD 35). There was a strong suggestion that patients with medical abnormalities, particularly those with muscular dystrophies, had much higher blood losses (63%, SD 59). There were no differences between the different patient groups in the pre-operative haematological investigations. Conclusions: We have noted a definite overall improvement in the amount of blood loss since 1995. The reasons included intra-operative monitoring of coagulation factors, early use of fibrinogen, use of DDAVP and antifibrinolytic agents

Introduction: A cementless femoral implant is currently available for hip resurfacing with several theoretical advantages over cemented fixation, one of which is a potential reduction in systemic emboli. A prospective study was undertaken to evaluate the occurrence of systemic emboli using a cementless femoral component for hip resurfacing in comparison to cemented femoral fixation. Methods: Between November 2004 and December 2005 patients scheduled for elective hip resurfacing for osteoarthritis were consented to undergo hip resurfacing using a cemented femoral component (Articular Surface Replacement or Birmingham Hip Resurfacing) or a cementless femoral component (Bi-coat Cormet Hip Resurfacing). Each case was randomised to femoral venting or no femoral venting. Intra-operative monitoring with a Transcranial Doppler device was used to identify and record systemic emboli throughout each case. Demographic and peri-operative data were collected including mental score and vital observations at day 1 and day 3, and blood loss. Results: 8 patients (5 vented, 3 unvented) underwent cemented resurfacing and 7 patients (4 vented, 3 unvented) had cementless resurfacing. There was no difference between the two groups for age (mean 56yrs), gender, weight, or ASA status. The mean number of significant emboli (> 12dB) in the cemented group was 8.1 and in the cementless group was 1.7 (significant, p=0.009). Peri-operatively both groups were similar for vital observations, haemoglobin, mental scores and SaO. 2. Venting did not influence rate of emboli. However, venting was independently associated with significantly higher drainage (mean 604mls compared to 335mls without venting, p=0.018). Discussion: This study has shown significantly less systemic emboli occur with the use of a cementless femoral component during hip resurfacing in comparison to a cemented implant. We propose this is due to intra-osseus pressure generated when using cement. The number of emboli is unaffected by femoral venting, but more blood loss occurs after venting

Functional joint stability and accurate component alignment are crucial for a successful clinical outcome after TKA. However, there are few methods to evaluate joint stability during TKA surgery. Activities of daily living often cause mechanical load to the knee joint not only in full extension but also in mid-flexion. Computer navigation systems are useful for intra-operative monitoring of joint positioning and movements. The purpose of this study was to compare the varus-valgus stability between knees treated with cruciate-retaining (CR) and posterior-stabilized (PS) TKA at different angles in the range of motion (ROM) especially in mid-flexion, using the navigation technique. Thirty two knees that underwent TKA with computer navigation technology (precisionN Knee Navigation Software version 4.0, Stryker, Kalamazoo, MI) were evaluated (CR:16; PS:16). The investigator gently applied physiologically allowable maximal manual varus-valgus stress to the knee without angular acceleration, while moving the leg from full extension to flexion, and the mechanical femoral-tibial angle was measured automatically by the navigation system at every 10 degrees throughout the ROM. This measurement cycle was repeated for 3 to 4 times, and maximal varus-valgus laxity was determined as the sum of varus and valgus stress angles for each of the predetermined knee flexion angles. The results of the navigated measurements were used to evaluate varus-valgus instability throughout the ROM and the differences in varus-valgus laxity between pre-TKA (Prior to bone cutting, after navigation registration and suturing of the joint capsule) and post-TKA(After confirming that the TKA components and inserts were firmly placed in an appropriate position, the surgical incision was completely closed). The differences in varus-valgus laxity between the CR and PS groups were compared using the Student's t-test. The knees examined showed the greatest preoperative laxity at 20 to 40 degrees of flexion, with no statistically significant difference between the CR and PS groups (See Figure 1). However, postoperative assessment revealed that PS knees had more varus-valgus laxity than CR knees at all ROM angles examined, and the differences were statistically significant in the flexion range of 10 to 70 degrees (See Figure.2). The differences between preoperative and postoperative joint laxity were analyzed separately for the CR and PS groups. After CR-TKA, joint laxity decreased across all degrees of knee flexion. The differences between preoperative and postoperative joint laxity were statistically significant for the flexion range of 110 to 120 degrees (See Figure.3). On the other hand, knees treated with PS-TKA showed an increase in joint laxity for the flexion range of 10 to 90 degrees. The differences between the preoperative and postoperative values were statistically significant for the flexion range of 10 to 20 degrees in PS-TKA (See Figure.4). We successfully evaluated varus-valgus laxity in this study using a navigation system. The results showed that PS knees had greater varus-valgus laxity than CR knees throughout the ROM, and the differences were statistically significant for the flexion range of 10 to 70 degrees. Altogether, we conclude that PS knees have more mid-flexion laxity than CR knees

Introduction and Aims: While scoliosis is known to be associated with Charcot-Marie-Tooth disease, little is known about the response to treatment of spinal deformity in this population. The purpose of this study was to characterise scoliosis in CMT, and to assess the effect of bracing and the efficacy and safety of surgery. Method: A retrospective review of medical records and radiographs of patients with CMT from a major neuro-muscular clinic was performed to calculate the prevalence of scoliosis and to characterise the deformity in affected patients. Orthotic and operative records were reviewed in patients who were braced and/or had spinal fusions. Results: Forty-three of 271 patients with CMT had scoliosis, for a prevalence of 15.9%. There were 18 females and 25 males, and the age at diagnosis of scoliosis averaged 12.7 years (range 7.8–17.8 years). Thirty-one of 43 curves were in the thoracic spine, with 15 curves being left thoracic. Curve magnitude at diagnosis averaged 27.8 degrees (11–65 degrees), and 18 of 34 curves with available lateral radiographs had hyperkyphosis. Curve progression of more than five degrees was present in 67.9% of those curves with follow-up. All five non-ambulatory patients progressed and had surgery. Bracing was prescribed in 39.5% of patients, and 11 of 15 braced patients progressed and had surgery. Surgery was scheduled in 32.6% of patients. The average age at surgery was 13.8 years (11.5–15.8 years), and curve magnitude averaged 63.1 degrees (50–80 degrees), with 78.6% of surgical curves being kyphotic. Posterior spinal fusion was performed in 11, anterior/posterior fusion in one, and halo traction followed by posterior spinal fusion in one. All curves were instrumented. Curve correction averaged 51.7%. Intra-operative neurologic monitoring (SSEP’s +/− MEP’s) was successful in only three of 11 patients. No neurologic complications occurred. One re-operation for delayed infection was necessary. Conclusion: Scoliosis occurs in 15.9% of CMT patients. It is associated with thoracic kyphosis and an increased incidence of left thoracic curves. Bracing is usually unsuccessful. Surgery was necessary in 32.6% overall, and 100% of non-ambulators who had scoliosis. Instrumentation was safe and effective, but intra-operative neurologic monitoring is usually impossible

Clinical nerve injury has been reported in 0.6–4.8% of shoulder arthroplasties. Classical teaching is that 70–85% of injuries recover. Despite recovery of motor function, overall shoulder function may be negatively affected and residual pain is common. Complex regional pain syndromes may develop and become permanent. Consequently, methods to limit nerve injury have been investigated. In the early 2000's I became concerned about the incidence of nerve injuries in my arthroplasty practice. I became intrigued with the idea of peripheral nerve monitoring as a method to alert the surgeon intra-operatively about impending nerve insults so that evasive measures could be taken to prevent any clinically significant nerve injuries. The results of our first 30 consecutive patients were published in JSES in 2007. Seventeen patients (56.7%) had 30 episodes of nerve dysfunction (i.e. nerve alerts) during surgery. Twenty-three of thirty alerts (76.7%) returned to normal after repositioning the arm to a neutral position. Post-operative EMG was positive in 4 of 7 (57.1%) patients who did not have a return to normal motor latency intra-operatively and in 1 of 10 (10%) patients whose intra-operative nerve function did return to normal. None had clinical nerve injuries. This early experience indicated that nerve injury was potentially more common than previously thought but intra-operative nerve monitoring seemed to have a relatively high false positive rate. Our group subsequently studied 440 shoulder arthroplasty cases. The protocol used to identify a nerve alert was made more restrictive than the first study as an attempt to decrease the false positive rate. In this larger group, nerve alerts occurred in 185 cases (42.0%), and 37 (8.4%) cases did not have signals return to above the alert threshold at closure. There were no permanent post-operative nerve injuries and 5 transient nerve injuries (1.1%). Cases in which MEP amplitudes remained below alert threshold were significantly more likely to have a post-operative nerve injury (p = 0.03). There were no false negatives, (i.e. a post-operative nerve injury occurred while MEPs were normal at closure), making sensitivity 100%. There were 32 false positives, leading to a specificity of 92.6%, a positive predictive value (PPV) of 13.5%, a negative predictive value (NPV) of 100%, and an accuracy (ACC) of 92.3%. In my opinion, the high false positive rate and the low PPV make the technique difficult to justify for routine clinical use

Aim:. Recent guidelines have been published by the Association of Neurophysiological Scientists / British Society for Clinical Neurophysiology (ANS/BSCN) regarding the use of intra-operative neurophysiological monitoring (IOM) during spinal deformity procedures. We present our unit's experience with IOM and the compliance with national guidelines. Method:. All patients undergoing intra-operative spinal cord monitoring during adult and paediatric spinal deformity surgery between Jan 2009 and Dec 2012 were prospectively followed. The use of somatosensory-evoked potentials (SSEPs) and motor-evoked potentials (MEPs) was recorded and monitoring outcomes were compared to post-operative clinical neurological outcomes. Compliance with the national ANS/BSCN guidelines was assessed. Results:. 333 patients were included in this study. IOM was successful in 312 patients (94%), with both MEPs and SSEPs obtained in 282 patients (85%). SEPs were achieved in 91% and MEPs in 87%. Aetiology was idiopathic in 199 cases, 53 neuromuscular, 28 degenerative, 16 congenital, 16 other. Nine patients had changes in IOM related to surgical activity; six had MEP changes only, three had MEPs and SSEPs changes. All but one of these changes returned to baseline following surgical action; the one remaining patient had a temporary postoperative neurological deficit. One patient had a post-operative single radiculopathy requiring surgical exploration, without change in initial IOM. Final IOM findings demonstrated a positive predictive value (PPV) of 1 and a negative predictive value (NPV) of 0.996. Discussion:. IOM is essential during spinal deformity surgery and, using MEPs, has a high PPV and NPV. Our unit meets guidelines for MEP use and frequently meets guidelines for SSEP use. Conflict Of Interest Statement: No conflict of interest

Introduction. The British Scoliosis Society published a document in 2008 which set out the minimum standards for paediatric spinal deformity services to achieve over a period of time. But how do the UK paediatric spinal deformity centres measure up to these benchmarks?. Methods. We performed a telephonic survey, contacting every UK spinal deformity centre. The questionnaire probed how each unit compared to the recommended standards. Results. Twenty three centres were interviewed, covering 81 surgeons in total (range 1-8 surgeons per centre). Four centres (17%) did not have 24-hour access to a MRI scanner and all but 2 centres had on-site facilities for long-cassette films/scoliograms. Five centres (22%) always had 2 consultant surgeons per case, 9 centres (39%) routinely have only 1 consultant surgeon per case, and the rest had 1 or 2 consultant surgeons depending on seniority. Six centres (26%) did not routinely have shared care of their patients with the paediatric team. All centres used intra-operative SSEP monitoring, a minority used MEP monitoring (34%), and all but 2 centres had either direct or indirect supervision by a consultant neurophysiologist. All centres have cell saver units available with over half using them routinely (14/23). None of the centres used routine chemoprophylaxis. All units used thromboembolic stockings, with five centres (22%) routinely using foot pumps. Nineteen centres (83%) routinely sent their spinal deformity patients to ITU/PICU postoperatively. Our survey also asked each center what supporting facilities were available, whether they ran adolescent clinics, and whether they participate in multi-disciplinary meetings and audit. In addition, we questioned what typed of drains each center used and the length of time that patients were followed-up. Conclusion. This survey shows how the UK spinal deformity units stand up against the BSS standards, provides an insight in to current UK practice and highlights areas for improvement

The April 2012 Children’s orthopaedics Roundup³⁶⁰ looks at osteonecrosis of the femoral head and surgery for dysplasia, femoral head blood flow during surgery, femoroacetabular impingement and sport in adolescence, the Drehmann sign, a predictive algorithm for septic arthritis, ACL reconstruction and arthrofibrosis in children, spinal cord monitoring for those less than four years old, arthroereisis for the flexible flat foot, fixing the displaced lateral humeral fracture, and mobile phones and inclinometer applications