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

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

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

Aims

This study analysed the clinical and radiological outcome of anatomical reduction of a moderate or severe stable slipped capital femoral epiphysis (SCFE) treated by subcapital osteotomy (a modified Dunn osteotomy) through the surgical approach described by Ganz.

Aims

Clinical and radiological data were reviewed for all patients with mucopolysaccharidoses (MPS) with thoracolumbar kyphosis managed non-operatively or operatively in our institution.

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

Sciatic nerve palsy following total hip arthroplasty (THA) is a relatively rare yet potentially devastating complication. The purpose of this case series was to report the results of patients with a sciatic nerve palsy who presented between 2000 and 2010, following primary and revision THA and were treated with neurolysis. A retrospective review was made of 12 patients (eight women and four men), with sciatic nerve palsy following THA. The mean age of the patients was 62.7 years (50 to 72; standard deviation 6.9). They underwent interfascicular neurolysis for sciatic nerve palsy, after failing a trial of non-operative treatment for a minimum of six months. Following surgery, a statistically and clinically significant improvement in motor function was seen in all patients. The mean peroneal nerve score function improved from 0.42 (0 to 3) to 3 (1 to 5) (p < 0.001). The mean tibial nerve motor function score improved from 1.75 (1 to 4) to 3.92 (3 to 5) (p = 0.02).The mean improvement in sensory function was a clinically negligible 1 out of 5 in all patients. In total, 11 patients reported improvement in their pain following surgery.

We conclude that neurolysis of the sciatic nerve has a favourable prognosis in patients with a sciatic nerve palsy following THA. Our findings suggest that surgery should not be delayed for > 12 months following injury.

Cite this article: Bone Joint J 2015;97-B:1345–9

The modified Smith–Petersen and Kocher–Langenbeck approaches were used to expose the lateral cutaneous nerve of the thigh and the femoral, obturator and sciatic nerves in order to study the risk of injury to these structures during the dissection, osteotomy, and acetabular reorientation stages of a Bernese peri-acetabular osteotomy.

Injury of the lateral cutaneous nerve of thigh was less likely to occur if an osteotomy of the anterior superior iliac spine had been carried out before exposing the hip.

The obturator nerve was likely to be injured during unprotected osteotomy of the pubis if the far cortex was penetrated by > 5 mm. This could be avoided by inclining the osteotome 45° medially and performing the osteotomy at least 2 cm medial to the iliopectineal eminence.

The sciatic nerve could be injured during the first and last stages of the osteotomy if the osteotome perforated the lateral cortex of ischium and the ilio-ischial junction by > 10 mm.

The femoral nerve could be stretched or entrapped during osteotomy of the pubis if there was significant rotational or linear displacement of the acetabulum. Anterior or medial displacement of < 2 cm and lateral tilt (retroversion) of < 30° were safe margins. The combination of retroversion and anterior displacement could increase tension on the nerve.

Strict observation of anatomical details, proper handling of the osteotomes and careful manipulation of the acetabular fragment reduce the neurological complications of Bernese peri-acetabular osteotomy.

Cite this article: Bone Joint J 2015;97-B:636–41.

C5 nerve root palsy is a rare and potentially debilitating complication of cervical spine surgery. Currently, however, there are no guidelines to help surgeons to prevent or treat this complication.

We carried out a systematic review of the literature to identify the causes of this complication and options for its prevention and treatment. Searches of PubMed, Embase and Medline yielded 60 articles for inclusion, most of which addressed C5 palsy as a complication of surgery. Although many possible causes were given, most authors supported posterior migration of the spinal cord with tethering of the nerve root as being the most likely.

Early detection and prevention of a C5 nerve root palsy using neurophysiological monitoring and variations in surgical technique show promise by allowing surgeons to minimise or prevent the incidence of C5 palsy. Conservative treatment is the current treatment of choice; most patients make a full recovery within two years.

Cite this article: Bone Joint J 2014;96-B:950–5.

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

We investigated the detailed anatomy of the gluteus maximus, gluteus medius and gluteus minimus and their neurovascular supply in 22 hips in 11 embalmed adult Caucasian human cadavers. This led to the development of a surgical technique for an extended posterior approach to the hip and pelvis that exposes the supra-acetabular ilium and preserves the glutei during revision hip surgery. Proximal to distal mobilisation of the gluteus medius from the posterior gluteal line permits exposure and mobilisation of the superior gluteal neurovascular bundle between the sciatic notch and the entrance to the gluteus medius, enabling a wider exposure of the supra-acetabular ilium. This technique was subsequently used in nine patients undergoing revision total hip replacement involving the reconstruction of nine Paprosky 3B acetabular defects, five of which had pelvic discontinuity. Intra-operative electromyography showed that the innervation of the gluteal muscles was not affected by surgery. Clinical follow-up demonstrated good hip abduction function in all patients. These results were compared with those of a matched cohort treated through a Kocher–Langenbeck approach. Our modified approach maximises the exposure of the ilium above the sciatic notch while protecting the gluteal muscles and their neurovascular bundle.

Cite this article: Bone Joint J 2014;96-B:48–53.

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

We undertook a retrospective analysis of 306 procedures on 233 patients, with a mean age of 12 years (1 to 21), in order to evaluate the use of somatosensory evoked potential (SSEP) monitoring for the early detection of nerve compromise during external fixation procedures for limb lengthening and correction of deformity. Significant SSEP changes were identified during 58 procedures (19%). In 32 instances (10.5%) the changes were transient, and resolved once the surgical cause had been removed. The remaining 26 (8.5%) were analysed in two groups, depending on whether or not corrective action had been performed in response to critical changes in the SSEP recordings. In 16 cases in which no corrective action was taken, 13 (81.2%, 4.2% overall) developed a post-operative neurological deficit, six of which were permanent and seven temporary, persisting for five to 18 months. In the ten procedures in which corrective action was taken, four patients (40%, 1.3% overall) had a temporary (one to eight months) post-operative neuropathy and six had no deficit.

After appropriate intervention in response to SSEP changes, the incidence and severity of neurological deficits were significantly reduced, with no cases of permanent neuropathy. SSEP monitoring showed 100% sensitivity and 91% specificity for the detection of nerve injury during external fixation. It is an excellent diagnostic technique for identifying nerve lesions when they are still highly reversible.

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

We reviewed 31 consecutive patients with Friedreich’s ataxia and scoliosis. There were 24 males and seven females with a mean age at presentation of 15.5 years (8.6 to 30.8) and a mean curve of 51° (13° to 140°). A total of 12 patients had thoracic curvatures, 11 had thoracolumbar and eight had double thoracic/lumbar. Two patients had long thoracolumbar collapsing scoliosis with pelvic obliquity and four had hyperkyphosis. Left-sided thoracic curves in nine patients (45%) and increased thoracic kyphosis differentiated these deformities from adolescent idiopathic scoliosis. There were 17 patients who underwent a posterior instrumented spinal fusion at mean age of 13.35 years, which achieved and maintained good correction of the deformity. Post-operative complications included one death due to cardiorespiratory failure, one revision to address nonunion and four patients with proximal junctional kyphosis who did not need extension of the fusion. There were no neurological complications and no wound infections. The rate of progression of the scoliosis in children kept under simple observation and those treated with bracing was less for lumbar curves during bracing and similar for thoracic curves. The scoliosis progressed in seven of nine children initially treated with a brace who later required surgery. Two patients presented after skeletal maturity with balanced curves not requiring correction. Three patients with severe deformities who would benefit from corrective surgery had significant cardiac co-morbidities.

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

Peripheral nerve injury is an uncommon but serious complication of hip surgery that can adversely affect the outcome. Several studies have described the use of electromyography and intra-operative sensory evoked potentials for early warning of nerve injury. We assessed the results of multimodal intra-operative monitoring during complex hip surgery. We retrospectively analysed data collected between 2001 and 2010 from 69 patients who underwent complex hip surgery by a single surgeon using multimodal intra-operative monitoring from a total pool of 7894 patients who underwent hip surgery during this period. In 24 (35%) procedures the surgeon was alerted to a possible lesion to the sciatic and/or femoral nerve. Alerts were observed most frequently during peri-acetabular osteotomy. The surgeon adapted his approach based on interpretation of the neurophysiological changes. From 69 monitored surgical procedures, there was only one true positive case of post-operative nerve injury. There were no false positives or false negatives, and the remaining 68 cases were all true negative. The sensitivity for predicting post-operative nerve injury was 100% and the specificity 100%. We conclude that it is possible and appropriate to use this method during complex hip surgery and it is effective for alerting the surgeon to the possibility of nerve injury

We present the case of a 15-year-old boy with symptoms due to Klippel–Feil syndrome. Radiographs and CT scans demonstrated basilar impression, occipitalisation of C1 and fusion of C2/C3. MRI showed ventral compression of the medullocervical junction. Skull traction was undertaken pre-operatively to determine whether the basilar impression could be safely reduced. During traction, the C3/C4 junction migrated 12 mm caudally and spasticity resolved. Peri-operative skull-femoral traction enabled posterior occipitocervical fixation without decompression. Following surgery, cervical alignment was restored and spasticity remained absent. One year after surgery he was not limited in his activities. The surgical strategy for patients with basilar impression and congenital anomalies remains controversial. The anterior approach with decompression is often recommended for patients with ventral compression of the medullocervical region, but such procedures are technically demanding and carry a significant risk of complications. Our surgical strategy was an alternative solution. Prior to a posterior cervical fixation, without decompression, skull traction was used to confirm that the deformity was reducible and effective in resolving associated myelopathy.