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      A comparative study between the Universal Spinal System ® (USS) and the CD Horizon ® Legacy™ (CDH) in the management of thoracolumbar fractures

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          Abstract

          Introduction: For the treatment of unstable non-osteoporotic thoracolumbar fractures, the clinical and radiological outcome of short-segment fixation with the USS™ – Universal Spine System (DePuy Orthopedics, Inc., Warsaw, IN, USA) and the CD HORIZON ® LEGACY™ 5.5 Spinal System, (Medtronic Sofamor Danek USA, Inc., Memphis, TN, USA) were compared.

          Methods: From March 2015 to January 2016, 40 consecutive patients with unstable traumatic thoracolumbar fractures who met our inclusion criteria were treated with either the USS system or CDH Legacy system. Segmental kyphosis angle (SKA) and anterior body height (ABH) of fractured vertebrae, and ASIA Impairment Scale (AIS) were evaluated. Radiological fusion was confirmed with plain X-rays and when indicated with computerized tomography (CT).

          Results: The mean immediate kyphotic angle correction was 16.6° for the Schanz and 6.4 for the Legacy system, and the immediate mean anterior vertebral body height correction was 0.92 cm for the Schanz and 0.51 cm for the Legacy system. Our study shows a significant statistical difference between Schanz and Legacy systems regarding post-operative segmental kyphosis and height correction immediately postoperatively, at 6 months and at one-year follow-up ( p-value < 0.005). The degree of pain reduction and neurological improvement was not influenced by the screw system.

          Conclusion: Usage of USS in thoracolumbar fracture as a short-segment fixation led to a near anatomical reduction when compared to the Legacy system. However, there was no advantage regarding pain reduction and neurological outcome.

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          Most cited references25

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          The load sharing classification of spine fractures.

          A 3 to 4 year follow-up was performed on a consecutive series of 28 patients who had three-column spinal fractures surgically stabilized by short-segment instrumentation with first generation VSP (Steffee) screws and plates and autograft fusion. The follow-up revealed 10 patients with broken screws. Retrospective examination of preoperative radiographs and computed tomographic axial and sagittal reconstruction images clearly demonstrated that the screw fractures all occurred in patients with a disproportionately greater amount of injury to the vertebral body. A point system (the load sharing classification) was developed that grades: 1) the amount of damaged vertebral body, 2) the spread of the fragments in the fracture site, and 3) the amount of corrected traumatic kyphosis. This point system can be used preoperatively to: 1) predict screw breakage when short segment, posteriorly placed pedicle screw implants are being used, 2) describe any spinal injury for retrospective studies, or 3) select spinal fractures for anterior reconstruction with strut graft, short-segment-type reconstruction.
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            Short-segment fixation of lumbar burst fractures using pedicle fixation at the level of the fracture.

            Cadaveric biomechanical study and retrospective chart review. Biomechanical comparison of segmental versus nonsegmental fixation of lumbar burst fractures and clinical analysis of short-term radiographic outcomes. Traditional short nonsegmental posterior fixation of thoracolumbar burst fractures suffers from high rates of failure. Construct stability may be improved by inserting additional screws at the fracture level. Six intact human spines (L1-L3) were biomechanically tested in flexion-extension, lateral bending, and axial torsion. The inferior half of the L2 vertebral bodies and L2-L3 discs were resected to mimic an unstable L2 burst fracture with loss of anterior column support. Pedicle screws were inserted in L1 and L3 for the control group (nonsegmental fixation). Screws were inserted at all levels for the experimental group (segmental fixation). Construct stiffness and L1-L2 disc pressure were analyzed. Twelve patients with thoracolumbar burst fractures treated with this type of segmental fixation were reviewed. Construct stiffness during axial torsion was significantly higher for segmental constructs compared with nonsegmental constructs (P < 0.02) with no differences between flexion-extension and lateral bending. Disc pressure fluctuations during flexion-extension were significantly higher for segmental compared with nonsegmental constructs (P < 0.02), with no differences in lateral bending and torsion. Mean preoperative kyphotic deformity was 9 degrees and improved by 15 degrees after surgery. Follow-up films on 9 patients showed 5 degrees of kyphosis correction loss. Mean anterior vertebral body height was 58% of normal before surgery. After surgery height was 89% of normal and at final follow-up, 78%. Segmental fixation of burst fractures with screws at the level of the fracture offers improved biomechanical stability. Theoretically, segmental fixation provides for additional fixation points that may aid in fracture reduction and kyphosis correction. This specific parameter is not evaluated in this study but will be an important outcome measure for a planned randomized controlled trial.
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              Successful short-segment instrumentation and fusion for thoracolumbar spine fractures: a consecutive 41/2-year series.

              A retrospective review of all the surgically managed spinal fractures at the University of Missouri Medical Center during the 41/2-year period from January 1989 to July 1993 was performed. Of the 51 surgically managed patients, 46 were instrumented by short-segment technique (attachment of one level above the fracture to one level below the fracture). The other 5 patients in this consecutive series had multiple trauma. These patients were included in the review because this was a consecutive series. However, they were grouped separately because they were instrumented by long-segment technique because of their multiple organ system injuries. The choice of the anterior or posterior approach for short-segment instrumentation was based on the Load-Sharing Classification published in a 1994 issue of Spine. The purpose of this review was to demonstrate that grading comminution by use of the Load-Sharing Classification for approach selection and the choice of patients with isolated fractures who are cooperative with spinal bracing for 4 months provide the keys to successful short-segment treatment of isolated spinal fractures. The current literature implies that the use of pedicle screws for short-segment instrumentation of spinal fracture is dangerous and inappropriate because of the high screw fracture rate. Charts, operative notes, preoperative and postoperative radiographs, computed tomography scans, and follow-up records of all patients were reviewed carefully from the time of surgery until final follow-up assessment. The Load-Sharing Classification had been used prospectively for all patients before their surgery to determine the approach for short-segment instrumentation. Denis' Pain Scale and Work Scales were obtained during follow-up evaluation for all patients. All patients were observed over 40 months except for 1 patient who died of unrelated causes after 35 months. The mean follow-up period was 66 months (51/2 years). No patient was lost to follow-up evaluation. Prospective application of the Load-Sharing Classification to the patients' injury and restriction of the short-segment approach to cooperative patients with isolated spinal fractures (excluding multisystem trauma patients) allowed 45 of 46 patients instrumented by the short-segment technique to proceed to successful healing in virtual anatomic alignment. The Load-Sharing Classification is a straightforward way to describe the amount of bony comminution in a spinal fracture. When applied to patients with isolated spine fractures who are cooperative with 3 to 4 months of spinal bracing, it can help the surgeon select short-segment pedicle-screw-based fixation using the posterior approach for less comminuted injuries and the anterior approach for those more comminuted. The choice of which fracture-dislocations should be strut grafted anteriorly and which need only posterior short-segment pedicle-screw-based instrumentation also can be made using the Load-Sharing Classification.
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                Author and article information

                Journal
                SICOT J
                SICOT J
                sicotj
                SICOT-J
                EDP Sciences
                2426-8887
                2019
                29 November 2019
                : 5
                : ( publisher-idID: sicotj/2019/01 )
                : 42
                Affiliations
                [1 ] Orthopedics and Traumatology Department, Faculty of Medicine, Cairo University Kasr Al Ainy Street Cairo 11562 Egypt
                [2 ] Orthopedic Department, Spine Surgery Unit, Al-Razi Hospital, Block 1 Jamal Abdul Nasser Street Kuwait City State of Kuwait
                Author notes
                [* ]Corresponding author: ahmedsamir222222@ 123456live.com
                Author information
                http://orcid.org/0000-0002-6778-2364
                Article
                sicotj190047 10.1051/sicotj/2019039
                10.1051/sicotj/2019039
                6884022
                31782725
                b60c3bae-71bb-409e-8363-6b7822f0be6d
                © The Authors, published by EDP Sciences, 2019

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 09 May 2019
                : 08 November 2019
                Page count
                Figures: 3, Tables: 1, Equations: 0, References: 23, Pages: 7
                Categories
                Spine
                Original Article

                short-segment fixation,pedicle screw,polyaxial,thoracolumbar burst fractures,uss universal spine system,cdh legacy

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