Various perioperative vascular complications of anterior lumbar spine procedures have been described in orthopaedic literature. We report the unusual case of a perioperative bleeding from the right and left epigastric inferior artery occurring when using a stand-alone ALIF device (Synfix, Synthes, Oberdorf, Switzerland) at the L5/S1 level through an anterior left retroperitoneal approach. The primary stability of the Synfix is achieved by four divergent screws which are inserted through the anteriorly located plate into the neighbouring vertebral endplates. For the screw insertion the surrounding structures have to be mobilized more extensively than during a "standard" anterior lumbar interbody fusion (ALIF) procedure. The epigastric inferior arteries were embolized by applying polyvinyl alcohol particles and metal coils. The retroperitoneal haematoma caused herniation of the external rectus sheath. Hence revision surgery with removal of the haematoma and resuturing of the rectus sheath were performed. Insertion of divergent screws of the Synfix device may cause severe distension and rupture of the epigastric vessels. This case shows that a lesion of the right epigastric artery may be a hazard even in left retroperitoneal approaches. To the author's knowledge this is the first case describing a lesion of the right epigastric artery during an ALIF procedure through a left retroperitoneal approach.

We report two unusual cases of stem penetration of long shaft femoral prosthesis into the knee joint after revision total hip arthroplasty. In both patients, the protruded tip of the stem interfered with the tibial plateau and averted the knee joint from full range of motion. To avoid further extensive surgery, the tips of the femoral stem were excised using a high speed-cutter. Both patients had immediate improvement in range of motion postoperatively, fast and uncomplicated rehabilitation, immediate pain relief, and good radiological results. If this rare complication occurs, we recommend for a primary intervention to cut the tip of the stem because replacement of the prosthesis would be a long lasting and very exhaustive surgery for affected patients.

The absence of uniformity, the use of different terminologies, and the diversity of methods used to translate numerical data into clinical outcomes have been described as potential problems when dealing with clinical knee scores for total knee arthroplasty (TKA). Gait analysis is believed to provide more objective parameters. The aim of the present study was to obtain information about the correlation between the outcome in terms of locomotion and the clinical knee score after TKA.Thirty consecutive patients awaiting TKA were involved in the study. One day prior to surgery and 3 months postoperatively, data pertaining to the Hospital for Special Surgery Score (HSS) and the Knee Society Score (KSS) (subgroups 'pain', 'knee', 'function' and 'total sum') were analyzed for correlations with kinematic and temporospatial parameters of gait analysis.At a significance-level of p <= 0.001 moderate correlations (0.4<r<0.6) were found preoperatively, particularly between 'max knee flexion swing' and the function-subscores of HSS and KSS and the 'KSS total'. High correlations (0.6<r<0.8) were ascertained for 'stride length' and 'gait velocity' with 'KSS function'. High correlations were also determined between 'stride length' and 'KSS total' and between 'gait velocity' and 'HSS function'. The only correlation found postoperatively was between 'max pelvic obliquity stance' and 'KSS knee' (r=0.770, p<0.001).We conclude that the 'function' subscores of KSS and HSS are highly suitable to assess the functional capacity of patients scheduled for TKA. However, because no adequate correlations between knee scores and gait parameter were found postoperatively, we cannot recommend the abandonment of gait analysis when monitoring the functional benefit of TKA. (C) 2008 Elsevier B.V. All rights reserved.

Introduction: Modern cementing technique demands high intramedullar cement pressure to create an optimum fixed cement support of the femoral stem. Pressure resistant, stable closure of the canal therefore is absolutely necessary. Biodegradable cement restrictors, if corresponding to above mentioned attributes, could be of immense advantage in case of potential revision surgery. Material and methods: A prospective, randomized trial was performed on a consecutive series of 130 patients who underwent primary cemented total hip arthroplasty due to hip arthrosis to compare a degradable cement restrictor and a non-degradable cement restrictor in their ability to resist distal migration during stem insertion. Results: The median cement plug length measured 27 mm (range -12 to 126 mm, 95% confidence interval (CI) 20-33 mm) in the biodegradable restrictor group and 15 mm (range 0-61 mm, 95% CI 12-18 mm) in the non-degradable restrictor group (P=0.003). A significant effect of the relationship between the difference of restrictor size and the diameter of the femoral canal on length of cement distal of the tip of the stem in between the two groups was evident (P=0.031). Conclusion: The results indicate insufficient intramedullary plug fixation of the degradable restrictor probably due to the elastic material properties which also may lead to inferior precision in restrictor size choice.

Study Design. A retrospective cohort study.Objective. To evaluate anterior strut grafts in spinal fusion for thoracic/thoracolumbar kyphosis.Summary and Background Data. Autologous strut grafts harvested from the fibula, iliac crest, and rib are frequently used for treating severe kyphosis and kyphoscoliosis. However, a majority of the studies have presented mixed patient populations kyphosis and/or scoliosis, treated either with anterior or anteroposterior fusion. Very few reports have presented an evaluation of autologous strut grafts for anterior fusion with posterior instrumentation for the treatment of kyphotic deformities.Methods. A total of 23 patients comprised the study. Diagnosis was granulomatous infection ( 9 patients), congenital ( 6), posttraumatic ( 4), neurofibromatosis ( 1), ankylosing spondylitis ( 1), Scheuermann disease ( 1), and plasmacytoma of the vertebral body with pathologic fracture ( 1). Average age at surgery was 41 years ( range 6-77). Indication for surgery was pain with or without progression in 15 patients and additional progressive neurologic deficit in the other 8. Anterior strut grafts consisted of the autologous fibula ( 9 patients), iliac ( 10), fibula and ribs ( 2), fibula and iliac ( 1), and fibula, iliac, and ribs ( 1). The fusion areas were thoracic ( 11 patients), thoracolumbar ( 11), and cervicothoracic ( 1). Anterior decompression was performed in 8 patients because of the presence of neurologic symptoms caused by cord compression. Dorsal fusion was performed in all patients with third-generation systems.Results. Average 4.2 vertebrae were fused anteriorly. Mean follow-up bracing time was 9.7 months. Average kyphosis measured 50.9 degrees before surgery and 32.5 at a mean follow-up of 4.5 years ( P < 0.0001). No graft breakages were noted at final follow-up. Solid fusion was achieved in all patients. No donor site complications were observed. Of the 8 patients presenting with neurologic deficits, 4 had full recovery, 3 had partial recoveries, and 1 had no improvement. Loss of postoperative correction > 5 degrees was observed in 3 patients. At final follow-up, 3 patients complained of occasional pain, and 1 complained of pain when lying on the back, particularly on hard surfaces.Conclusion. Adequate correction was maintained throughout an average follow-up of 4.5 years, and solid fusion was obtained in all patients. Anterior strut grafts, supplemented with posterior fusion with instrumentation provide a good treatment alternative for the treatment of kyphosis deformity of the spine as a result of various etiologies.

The Knee Society Total Knee Arthroplasty Radiographic Evaluation and Scoring System was introduced to encourage uniform reporting of radiographic outcome. However, the method for evaluation of radiolucent lines has been shown to be unreliable. Because it has been shown that reducing the complexity of classification systems increases reliability and reproducibility, we questioned whether a simplification of the Radiographic Evaluation and Scoring System would improve reliability and reproducibility. A new system for assessment of radiolucent lines was introduced, and the interobserver reliability and intraobserver reproducibility were studied in 100 patients with 120 total knee replacements. For the new system the mean kappa intraobserver reproducibility coefficient was 0.71 (range, 0.62-0.85) for the femoral component, 0.86 (range, 0.80-0.96) for the tibial component, and 0.58 (range, 0.46-0.75) for the patella prosthesis. The mean interobserver reliability coefficient among three observers was 0.61 (range, 0.45-0.72) for the femoral component, 0.82 (range, 0.73-0.88) for the tibial component, and 0.58 (range, 0.43-0.72) for the patella prosthesis. The new system for assessment of radiolucent lines increased reliability and reproducibility and should supplement the Knee Society's Radiographic Evaluation and Scoring System.Level of Evidence: Diagnostic study, Level II-1 (development of diagnostic criteria on basis of consecutive patients - with universally applied reference gold standard). See the Guidelines for Authors for a complete description of levels of evidence.

Background. The radius/length (R/L) ratio was developed to evaluate the convexity of the talar dome in idiopathic clubfoot. However, the index has not been tested for its reliability and reproducibility. Methods: The R/L ratio was determined by three independent observers on the radiographs of 21 adult patients with idiopathic clubfoot and 30 adult subjects with normal feet. The reproducibility and the reliability of the R/L ratio were calculated. Results: For the normal feet the reproducibility and the reliability of the R/L ratio was high (correlation coefficient > 0.87). For the patients with clubfoot, the reliability and reproducibility depended on the severity of talar flattening. For a radius of less than 45 mm the mean intraobserver correlation coefficient was 0.74 (range 0.54 to 0.83) and the mean interobserver correlation coefficient was 0.58 (range 0.49 to 0.75). For a radius of more than 45 mm no statistically significant intraobserver and interobserver correlations were found. Conclusion: The current results indicate that the R/L ratio of talar flattening is reliable and reproducible for mild talardeformity but not for severe flattening (radius of more than 45 mm).

The purpose of the study was to compare conventional versus minimally invasive extraperitoneal approach for anterior lumbar interbody fusion (ALIF). Fifty-six consecutive patients with spondylolisthesis, lumbar instability, or failed back syndrome were treated with ALIF between 1991 and 2001. The patients were retrospectively evaluated and divided in two groups: Group 1, consisting 33 patients, was treated with ALIF using the conventional retroperitoneal approach, and Group 2, consisting of 23 patients, was operated with the minimally invasive muscle-splitting approach for ALIF. The groups were comparable as regards age, indication of fusion, and diagnosis. All patients in both groups had fusion with autologous iliac crest grafts and posterior instrumentation with posterolateral fusion in the same sitting. Clinical evaluation was done by two questionnaires: the North American Spine Society (NASS) Lumbar Spine Outcome Assessment Instrument and the Nottingham Health Profile (NHP). Fusion rate was evaluated radiologically. Mean clinical follow-up was 5.5 years. There was no statistical difference in the occurrence of complications with both approaches nor with the fusion rates of 92% in group 1 and 84% in group 2 respectively. The minimally invasive extraperitoneal approach for ALIF was associated with significantly less intraoperative blood loss, operation time, and length of the skin incision. In addition, this approach showed significant improvement in postoperative back pain in comparison to the conventional approach for ALIF.

Infection is a serious complication of total hip replacement. It has been proposed that 6% of all infections after total hip arthroplasty may be of dental origin through hematogenous spread. However, no conclusive evidence that the mouth is a definitive source for infection of a total hip replacement has been reported. In the current case, Prevotella loeschii, a pigmented bacteroides species was identified in a total hip replacement. Prevotella loeschii is an organism which exclusively inhabits the dental region. Hematogenous spread of Prevotella loeschii may occur after penetration of the mucosal barrier in cases of endodontic or periodontic lesions, pericoronitis, or complications of tooth extraction. The involvement of Prevotella loescheii in an infection in a patient who had a total hip arthroplasty is strong evidence for the mechanism of a hematogenous infection from a dental source.

Scoring systems frequently are used to assess the outcome of total hip arthroplasty. The result may be presented as a numeric value, or in descriptive terms such as excellent, good, fair, and poor (category system). The current study was done to investigate the influence of descriptive and numeric outcomes for interobserver reliability and interscore correlation of five different hip scores. Sixty-four patients (83 hips) were included in the study. The average age of the patients at followup was 70 years (range, 48-88 years). The average followup was 6.2 years (range, 2-17 years). For the numeric outcome a higher interobserver reliability (correlation coefficient, 0.71-0.81) and interscore correlation (correlation coefficient, 0.81-0.92) were found compared with the category system (interobserver reliability[correlation coefficient, 0.57-0.72]; interscore correlation [correlation coefficient, 0.46-0.62]). Findings from the study suggest that categorization of the results of total hip arthroplasty reduces interobserver reliability and interscore correlation.

For assessment of total knee arthroplasty outcome, various scoring systems have been introduced. The current study assessed the interobserver correlation of four commonly used total knee arthroplasty outcome scores. One hundred eighteen total knee arthroplasties were investigated by two independent observers, using the Hungerford score, the Hospital for Special Surgery score, the Knee Society score, and the Bristol score. Each score consisted of three subscores: pain, knee, and function. For the highest interobserver correlation was computed for the Bristol score (interobserver correlation coefficient, 0.88). For knee range of motion, flexion contracture, and extension lag there was high interobserver correlation (interobserver correlation coefficient > 0.8 each). For walking distance and walking aids, there also was a high interobserver correlation (interobserver correlation coefficient > 0.7 each). For clinical assessment of total knee arthroplasty, pain should be measured on a four-step system, the knee should be assessed by measurement of range of motion, extension lag, and flexion contracture, and function should be measured on a separate score assessing walking distance and walking aids.

The abnormal bony feature found most consistently in clubfeet is talar distortion. The significance of the talar distortion for mobility of the tibiotalar joint was investigated. Twenty-seven congenital clubfeet in 19 patients were examined at a minimal followup of 20 years. In all patients Turco's posteromedial release was done because of idiopathic clubfoot. Radiographic assessment of the feet included measurement of the talocalcaneal angle and index, and the tibiocalcaneal angle. The degree of talar flattening was estimated by the ratio of the curvature of the talar dome to the length of the talar bone (radius to length ratio). Three-dimensional gait analysis was done to assess the dynamic range of ankle motion. The static range of motion was measured with a goniometer. The degree of talar flattening correlated significantly with the dynamic range of ankle motion but not with the static mobility. For assessment of idiopathic clubfoot, evaluation of talar flattening should be done because of its significance for dynamic ankle mobility.

The records of 35 patients with total knee arthroplasty infection were reviewed to investigate the significance of delayed aspiration and the success of treatment. In 13 patients, aspiration was performed within 3 months after the onset of symptoms of infection. The median duration of treatment was 243 days, and infection was arrested in all patients. In 22 patients, aspiration was performed >3 months after the onset of symptoms. The duration of treatment was significantly longer in these patients (P<.001). Persistent infection was recorded in 8 patients, and amputation of the involved leg was done in 3 patients. Aspiration within 3 months after the onset of symptoms of infection significantly reduced the duration of treatment and increased the chances of successfully arresting infection.

STUDY DESIGN:The assignment of idiopathic scoliosis curves to the curve types,1-6 to the lumbar spine modifier (A, B, or C), and to the sagittal thoracic modifier (-, N, +), as recently described by Lenke et al, was evaluated by five observers on two occasions. OBJECTIVE:To determine the intraobserver and interobserver reliabilities of Lenke's new system for classifying idiopathic scoliosis. SUMMARY OF BACKGROUND DATA:Lenke et al recently introduced a new system for classifying idiopathic scoliosis. METHODS:Preoperative standing long cassette coronal and sagittal radiographs as well as side-bending radiographs of 51 consecutive patients who underwent surgery for idiopathic scoliosis were labeled with the Cobb angles for all the curves. The center sacral vertical line was marked as the bisection of the proximal sacrum perpendicular to the true horizontal line. Five observers independently assigned a curve type, a lumbar spine modifier, and a sagittal thoracic modifier to each curve following the guidelines as described by Lenke et al. Assignment of the curves was repeated 3 weeks later, with the curves presented in a different order. Kappa coefficients were used to determine the interobserver and intraobserver reliabilities. RESULTS:All five reviewers agreed on the overall classification in 21 (41%) of the 51 patients. A mean kappa value of 0.62 was determined for interobserver reliability, and a mean kappa of 0.73 for intraobserver reliability. Determination of an upper thoracic curve as structural or nonstructural and assignment of a lumbar spine modifier were the main reasons for disagreement. CONCLUSIONS:Lenke's new classification system is more reliable than the older King classification, but proper classification of high thoracic and lumbar curves seems to be difficult.

BACKGROUND:Severe total hip arthroplasty failure with central migration of prosthetic components is uncommon. If perforation of the medial acetabular wall occurs, injuries of intrapelvic structures may result. DATA SOURCES:A meta-analysis of the English literature was performed. A human pelvic cadaver was used to demonstrate the proximity of intrapelvic structures to a centrally dislocated cup. RESULTS:Fifty cases of intrapelvic injury were identified. Structures involved most frequently were the external iliac artery and the bladder. The most common types of complication included fistula formation, development of a false aneurysm, and hemorrhage. The human cadaver pelvis demonstrated the proximity of intrapelvic vessels, the bladder, the ureter, the vagina, the deferent duct, the sigmoid colon, the rectum, and the sciatic nerve to an intrapelvically intruded prosthesis. CONCLUSIONS:Failed total hip replacements should be considered to cause damage to pelvic viscera.

The Robodoc total hip replacement procedure requires a wider exposure of the proximal femur, especially of the greater trochanter, than the standard procedure. Moreover, the leg must be placed in a rigid leg-holder apparatus to obtain fixation in maximal hip adduction and external rotation. This may impair the hip abductors and reduce hip abduction in the mid- and terminal stance phase of the cycle. In this study we compared patients after Robodoc and conventional total hip arthroplasty with three-dimensional gait analysis (VICON System, Oxford Metrics, Oxford, U.K.) to assess the kinematics of the pelvis and hip. 25 patients underwent total hip replacement by means of the Robodoc total hip arthroplasty system, 25 patients were treated with conventional total hip replacement, and 40 healthy volunteers served as controls. None of the patients undergoing total hip replacement, robotic or conventional, obtained normal kinematic gait patterns 6 months after surgery. However, the reduction in hip abduction did not differ significantly in patients undergoing robotic or conventional total hip arthroplasty, which suggests that the robotic procedure did not impair hip abductor function more than the conventional method.

Sixty-five total knee arthroplasties were evaluated by the Knee Society Radiological Evaluation System which was developed to encourage uniform reporting of the results of total knee arthroplasty, All patients were examined by three independent experienced radiologists 8.9 years after surgery (range, 3-16 years) to analyze the interobserver variability. For measurement of angles, high interobserver correlation was calculated for the prosthetic component angles and the femorotibial shaft angle, The comparison of the means indicated no significant differences except for the femorotibial shaft angle. For measurement of radiolucent lines, interobserver correlation was low for all components. The differences of the means were significantly different for all components. The results of interobserver variability of the patellar evaluation revealed high interobserver correlation for the patellar angle and for patellar subluxation and dislocation evaluation. For assessment of patellar mediolateral and superoinferior displacement, a low interobserver correlation was found. For radiographic assessment of total knee arthroplasty, the measurement of angles, including alpha, beta, femorotibial shaft angle, sagittal femoral and tibial component angle, patellar angle, and patellar subluxation and dislocation evaluation are recommended. The method of assessing radiolucent lines should be reconsidered.

Circumscribed radiolucencies within the vertebral bones can be due to a variety of changes including benign and malignant tumours or tumour-like lesions. Radiolucencies due to degenerative intraosseous pneumatocyst are very uncommon but have to be taken into the differential diagnosis in well-circumscribed lytic lesions of the vertebral bodies. We describe the first case of multisegmental pneumatocysts in the lumbar spine mimicking osteolytic lesions. On computed tomography, the air-equivalent attenuation values of the lesions and the close vicinity to the degenerated vertebral endplates with vacuum phenomenon led to the correct diagnosis.

An 81-year-old man was referred to the authors for examination of the gastrointestinal tract. A proctoscopy revealed a draining sinus tract in the terminal rectum. Plain radiographs revealed a failed total hip arthroplasty that had migrated into the pelvis. Hip aspiration revealed an infection with bacteria commonly found in the gastrointestinal tract. A fistulogram confirmed a connection between the rectum and the hip replacement. The development of a fistula between the colon and the hip is extremely uncommon. A fistula between the hip and the rectum is a previously unreported complication of total hip arthroplasty.

Different imaging modalities are available for the diagnosis of cervical spine injuries. There is a controversial discussion about whether plain radiography (PR), conventional tomography (CTO) or computed tomography (CT) should primarily be used. PR and CTO are more often available and less costly than CT. Especially in second-care hospitals, CT is not always available. The diagnostic work-up in these centres has to rely on conventional techniques. The aim of this study was to define the role of PR supplemented by CTO in the diagnosis of cervical spine trauma in comparison to CT. Twenty-five patients were identified who underwent plain radiography (PR), conventional tomography (CTO) and computed tomography (CT) for the diagnosis of a cervical fracture. In 19 patients a fracture of the cervical spine was identified. All images were reviewed by two independent observers to estimate the interobserver variability. The highest detection rate was achieved by CT (18/18 fractures detected for observer 1/2), followed by CTO (16/16 fractures) and then PR (15/14 fractures). When the detection rates of PR and CTO are combined, 18 fractures were detected by each of the observers. The results were analysed for the dens and the rest of the cervical spine independently. For PR and CTO the detection rates were lower for fractures of the dens than for the rest of the cervical spine. We conclude that the combination of PR and CTO accurately detects fractures of the cervical spine compared with CT. If a fracture of the dens is suspected, the patients should be referred to CT due to its superior accuracy in this region.