Revision for Cage Migration After Transforaminal/Posterior Lumbar Interbody Fusion; How to Perform Revision Surgery?

BackgroundSymptomatic pseudarthrosis and cage migration/protrusion are difficult complications of transforaminal or posterior lumbar interbody fusion (TLIF/PLIF). If the patient experiences severe radicular symptoms due to cage protrusion, removal of the migrated cage is necessary. However, this procedure is sometimes very challenging because epidural adhesions and fibrous union can be present between the cage and vertebrae. We describe a novel classification and technique utilizing a navigated osteotome and the oblique lumbar interbody fusion at L5/S1 (OLIF51) technique to address this problem.MethodsThis retrospective study investigated consecutive patients with degenerative lumbar diseases who underwent TLIF/PLIF. Symptomatic cage migration was evaluated by direct examination, radiography, and/or computed tomography (CT) at 1, 3, 6, 12, and 24 months of follow-up. Cage migration/protrusion was defined as symptomatic cage protrusion >5 mm from the posterior border of the over and underlying vertebral body compared with initial CT. We evaluated patient characteristics including body mass index, smoking history, fusion level, and cage type. A total of 113 patients underwent PLIF/TLIF (PLIF n=30, TLIF n=83), with a mean age of 71.1 years (range, 28–87 years). Mean duration of follow-up was 25 months (range, 12-47 months). ResultsCage migration was identified in 5 of 113 patients (4.4%). All cases of symptomatic cage migration involved the L5/S1 level and the TLIF procedure. Risk factors for cage protrusion were age (younger), sex (male), and level (L5/S1). The mean duration to onset of cage protrusion was 3.2 months (range, 2–6 months). We applied a new classification for cage protrusion: type 1, only low back pain without new radicular symptoms; type 2, low back pain with minor radicular symptoms; or type 3, cauda equina syndrome and/or severe radicular symptoms. According to our classification, one patient was in type 1, three patients were in type 2, and one patient was in type 3. For all cases of cage migration, revision surgery was performed using a navigated high-speed burr and osteotome, and the patient in group 1 underwent additional PLIF without removal of the protruding cage. Three revision surgeries (group 2) involved removal of the protruding cage and PLIF, and one revision surgery (group 3) involved anterior removal of the cage and OLIF51 fusion.ConclusionsThe navigated high-speed burr, navigated osteotome, and OLIF51 technique appear very useful for removing a cage with fibrous union from the disc in patients with pseudarthrosis. This new technique makes revision surgery after cage migration much safer, and more effective. This technique also reduces the need for fluoroscopy.

Salvaging the Digit in Invasive Subungual Malignancies Using a Triple Technique under Awake Local Anesthesia

Introduction. Amputation for subungual malignancy (SUM) was thought to be the gold standard in preventing recurrence and metastasis. The rationale behind this aggressive treatment was never based on scientific evidence. Even though multiple recent studies supported more conservative management by illustrating successful results of the digit salvage technique, especially for “in situ” SUM, this salvage approach is not well supported for the more aggressive type of the “invasive” SUM; herein, we salvaged two cases of “invasive” SUM. Case Presentation. We present two cases of invasive SUM without radiographic evidence of intraosseous involvement, where we avoided digit amputation for both invasive subungual squamous cell carcinoma of the thumb and invasive subungual melanoma of the ring finger. Both were salvaged by using a triple technique under awake local anesthesia which included (I) radical excision of the nail bed unit including both eponychium and periosteum, (II) dorsal cortical bone shaving using a high-speed burr for the distal phalanx, and (III) flap coverage. Brunelli flap was used for the thumb in the first case, and V-Y plasty combined with proximal nail fold advancement flap was used for the ring finger in the second case. There was no evidence of local or distant recurrence, with a good functional outcome after 2.5 years in the first case and 2 years in the second. Conclusion. Ensuring complete resection with negative margins while preserving the functionality of the affected digit is considered to be the optimal challenge in treating “invasive” subungual malignancies. These two case reports contribute by reporting a successful digit salvage. The safety of this procedure could be confirmed by larger series and longer follow-up periods.

Low-Grade Chondrosarcomas: Diagnosis and Treatment

Background: Multiple parameters are needed to distinguish between enchondroma and low-grade chondrosarcoma (LGCS). This study aimed to investigate the diagnosis, surgery type according to bone type, recurrence rates, and complications of LGCS in the appendicular and axial skeletons. Methods: A total of 52 surgically treated patients with LGCS, between March 2007 and May 2019, were retrospectively examined. Following diagnosis, the patients were operated on with intralesional curettage for long bones or wide local excision (WLE) for axial bones. The retrieved data included demographics, tumor location, surgical treatment type, local adjuvants, complications, and Musculoskeletal Tumor Society scores.Results: The final cohort included 52 patients (52 tumors; 35 female and 17 male). The male:female ratio was 1:2. The mean age was 44 ± 17 years. Forty of the tumors were treated with intralesional procedures (all with a high-speed burr and phenol), 6 with autograft, 8 with allograft, and 28 with cement augmentation, while 7 were treated with WLE.Conclusions: The use of phenol as an adjuvant may reduce recurrence rates. Using a putty graft alone may result in nonunion. Applying a thin layer of putty on the cementum can create callus tissue on the cementum. Even in the upper limb, plate and screw fixation should be used to prevent fractures in metaphyseal–diaphyseal curettages.

A Simple Technique for Removal of Interlocking Screw from an Intramedullary Nail: A Case Report

Introduction: Difficulties encountered during removal of implants present a common technical challenge in orthopedic surgery, for which a number of factors have been implicated. A variety of techniques and instruments have been used to overcome this. However, some of these may prove to be time consuming, expensive, and inaccessible to many surgical setups. We describe a technique used for the removal of a jammed interlocking screw from an intramedullary nail that allows for minimal damage to the hardware, bone, and surrounding soft tissue, with the added advantage of being relatively quick and technically uncomplicated with the use of simple instruments. Case Report: We describe the case of an 81-year-old female with a history of surgical fixation for a left femur intertrochanteric fracture, who presented with groin pain 13 months post-fixation. Radiographs were suggestive of avascular necrosis of the femoral head with resultant cut-in of the blade, and the patient was eventually taken up for the removal of implants and total hip replacement. Intraoperatively, difficulties were encountered in the removal of the distal interlocking screw, with failure of conventional techniques initially. A high-speed burr was then employed to shape the screw head so as to achieve better grip with extraction devices, which facilitated smooth removal. Conclusion: We describe a simple method for difficult screw removal involving the use of a high-speed burr and vise grip pliers. This technique provides a quick and inexpensive option with commonly available surgical tools and may be considered when encountering difficulties with screw extraction. Keywords: Trauma, revision surgery, interlocking screw, screw removal.

Adjuvant Therapy by High-Speed Burr May Cause Intraoperative Bone Tumor Seeding: an animal study

Background Bone tumors are often treated with intralesional curettage. High-speed burring, an adjuvant therapy, was performed to maximize the tumor cell killing; however, tumor recurrence might still occur, which may be caused by residual tumor or local tumor spread during surgery. Methods A porcine cadaver (femur) was utilized to determine whether the use of a high-speed burr causes bone cement spray. To mimic residual tumor after curettage, luminescent cement was smeared on two locations of the bone cavity, the wall and the bottom. The cavity in the femoral bone was then placed in the middle of a sheet of drawing paper featuring 10 cm, 20 cm, and 30 cm concentric circles. The luminescent cement was then burred totally with a high-speed burr. Results The intensity of the area in the wall in circle I was 72.6% ± 5.8%; within circle II, it was 22.1% ± 4.2%; and within circle III, it was 5.4% ± 1.5%. The intensity of the area within the bottom of the femoral bone within circle I was 66.5% ± 6.1%, within circle II was 28.1 ± 4.8%, and within circle III, it was 5.4% ± 1.4%. The amount of luminescent cement seeding decreased with distance, but there was no difference while burring at different locations of the bone cavity. Under the handpiece cover, a greater amount of cement spray was retained in circle I during burring of the cement in the bottom of the cavity and less was sprayed out in circle III. Conclusions High-speed burring may cause explosive bone cement spray, which could extend to 20 cm. The intensities of spray did not decrease, even when the handpiece cover was used. The wide range of bone cement spray caused by high-speed burr was inspected in this pilot study, which may lead to tumor seeding.

Is precise open excision a more suitable surgical method for osteoid osteoma?

Background The aim of this retrospective study was to evaluate the efficacy of precise open excision surgery to treat osteoid osteoma with C-arm assisted precise localization during the operation. Methods From June 2010 to June 2017, patients with osteoid osteoma of the extremities who had undergone treatment by high speed burr grinding, full scratching with curette, and C-arm assisted lesion localization during the operation were analyzed retrospectively. The preoperative and postoperative pain was assessed by the visual analogue scale (VAS) scoring. The patients were followed up regularly, and the advantages, effects, and complications of the therapeutic technique were analyzed. Results The study consisted of 94 patients (59 males, 35 females; mean age, 17.6 ± 8.5 years) and they were followed up for a mean of 38.9 months (range, 24–72 months). All patients were diagnosed with osteoid osteoma by postoperative pathological examination. Follow-up consisted of imaging reexamination and clinical evaluation. If the patients did not take non-steroidal anti-inflammatory drugs (NSAIDs) before the operation, the mean pre-operative VAS score was 6.7, and the mean VAS score of all patients was 0 one month after operation. The mean time for all patients to resume normal daily activities was 14.3 days (range, 10–21 days). There was no recurrence of pain, infection, vascular or nerve injury, and fracture complications during the follow-up. In only one case of distal femur osteoid osteoma (OO), review X-ray found a suspected recurrence 50 months after the primary surgery and subsequently, the patient underwent a second surgery. Till date, the patient has reported no discomfort following the second surgery. Conclusions For treatment of osteoid osteoma, open incision and minimal resection with C-arm assisted tumor localization is still a suitable method, especially for osteoid osteoma located on the surface of the cortical bone.

Adjuvant Therapy by High-Speed Burr May Cause Intraoperative Bone Tumor Seeding: An Animal Study

BackgroundBone tumors are often treated with intralesional curettage. High-speed burring, an adjuvant therapy, was performed to maximize the tumor cell killing; however, tumor recurrence might still occur, which may be caused by residual tumor or local tumor spread during surgery.MethodsA porcine cadaver (femur) was utilized to determine whether the use of a high-speed burr causes bone cement spray. To mimic residual tumor after curettage, luminescent cement was smeared on two locations of the bone cavity, the wall and the bottom. The cavity in the femoral bone was then placed in the middle of a sheet of drawing paper featuring 10 cm, 20 cm, and 30 cm concentric circles. The luminescent cement was then burred totally with a high-speed burr.ResultsThe intensity of the area in the wall in circle I was 72.6% ± 5.8%; within circle II, it was 22.1% ± 4.2%; and within circle III, it was 5.4% ± 1.5%. The intensity of the area within the bottom of the femoral bone within circle I was 66.5% ± 6.1%, within circle II was 28.1 ± 4.8%, and within circle III, it was 5.4% ± 1.4%. The amount of luminescent cement seeding decreased with distance, but there was no difference while burring at different locations of the bone cavity. Under the handpiece cover, a greater amount of cement spray was retained in circle I during burring of the cement in the bottom of the cavity and less was sprayed out in circle III.ConclusionsHigh-speed burring may cause tumor seeding, which could extend to 20 cm. The intensities of spray did not decrease, even when the handpiece cover was used. The correlation between high-speed burring and tumor seeding was highly suspect in this pilot study.