A hip fracture nurse specialist has a positive outcome on the length of stay for patients with hip fractures

AIM

To determine if recruitment of a hip fracture nurse specialist has a reduction in length of stay for hip fracture patients.

METHOD

Primary data was extracted from the National Hip Fracture Database (NHFD). The length of stay of hip fracture patients from 2011-2014 was compared to the period 2014-17, following appointment of a hip fracture nurse specialist in 2014.

RESULTS

The average length of stay in the first group (2011-2014) was 19.94 days and in the second group (2014-2017) was 16.52 days. There was a reduction of 3.42 days (17.15%) and was statistically significant. There was also a reduction in the time to surgery (1.38 days versus 1.15 days) and the crude 30-day mortality (10% versus 6.06%) both of which were statistically significant. The two groups were well-matched with regards to age, female: male ratio and severity of co-morbidities (based on American Society of Anaesthesiologists physical status classification system).

CONCLUSION

The introduction of a dedicated hip fracture nurse specialist has a positive outcome on hip fracture patients by reducing length of stay, time to surgery and the crude 30-day mortality.

Clinical and radiological results comparison of allograft and polyetheretherketone cage for one to two-level anterior cervical discectomy and fusion: A CONSORT-compliant article

BACKGROUND

Recently, many kinds of cages for cervical fusion have been developed to avoid the related complications caused by tricortical iliac crest graft. The existing literature has reported the excellent clinical efficacy and superior fusion rate. However, various types of cages have their own disadvantages. Which bone graft material is the best choice for cage with the fewest complications? At present, there is still no conclusion.

METHODS

By reviewing patients with 1 to 2-level cervical degenerative disease in our hospital with a novel cage made of allograft or polyetheretherketone (PEEK), we evaluated the efficacy and reliability of the new cage in anterior cervical discectomy and fusion (ACDF). From 2015 to 2016, a prospective review of 58 and 49 consecutive cases with spondylotic radiculopathy or myelopathy undergoing ACDF using allograft (group A) and PEEK (group B) cage were performed. The follow-up ranged from 12 to 40 months. Intraoperative index, clinical outcome and complications were recorded. Radiographs evaluated segmental and overall cervical lordosis, the height of the intervertebral space, interbody height ratio (IHR), cage positioning, and fusion state.

RESULTS

A total of 134 cages were implanted. Compared to preoperatively, the visual analog scale (VAS) and neck disability index (NDI) were reduced postoperatively without any change during the subsequent follow-up in both groups. There was no migration or extrusion of the cages at the latest follow-up. There were 2 and 4 patients suffering dysphagia respectively. In both groups, the intervertebral height, IHR, segmental and overall cervical lordosis were significantly greater than pre-operation (P < .05) and were maintained at the last follow-up, but were not statistically significant (P > .05). The allograft group achieved a fusion rate of 100% (58/58) according to CT scans at 3 months post-operation, while PEEK group was 91.8% (45/49), which reached 95.9% (47/49) at 6 months and 100% at 12 months. In addition, the fusion state was maintained in all patients at the last follow-up.

CONCLUSION

Our data showed that the new allograft cage is superior to the PEEK cage in providing a high fusion rate and fewer complications after 1-level and 2-level ACDF procedures. It may represent an excellent alternative to other cages.

Stress analysis of the implants in transforaminal lumbar interbody fusion under static and vibration loadings: a comparison between pedicle screw fixation system with rigid and flexible rods

The use of a pedicle screw fixation system with rods made of more compliant materials has become increasingly popular for spine fusion surgery in recent years. The aim of this study was to compare stress responses of the implants in transforaminal lumbar interbody fusion (TLIF) when using flexible and conventional rigid posterior fixation systems. A previously validated intact L1-S1 finite element model was modified to simulate single-level (L4-L5) TLIF with bilateral pedicle screw fixation using two types of connecting rod (rigid and flexible rods). The von Mises stresses in the implants (including TLIF cage, pedicle screws and rods) for the rigid and flexible fixations were analyzed under static and vibration loadings. The results showed that compared with the rigid fixation, the use of flexible fixation decreased the maximum stress in the pedicle screws, but increased the maximum stress in the cage and the ratio of maximum stress in the rods to the yield stress. It was also found that with decreasing diameter of the flexible rod (i.e. increasing flexibility of the rod), the maximum stress was decreased in the pedicle screws but increased in the cage and the rods. The findings imply that compared with the rigid rod, application of the flexible rod in the pedicle screw fixation system for the TLIF might decrease the breakage risk of pedicle screws but increase the risk of cage subsidence and rod breakage. Moreover, flexibility of the rod in the flexible fixation system should be carefully determined.

Comparison and predictive factors analysis for efficacy and safety of Kirschner wire, anatomical plate fixation and cannulated screw in treating patients with open calcaneal fractures

This study aimed to compare the efficacy and safety among Kirschner wire, anatomical plate fixation and cannulated screw treatments in patients with open calcaneal fractures, and to explore the predictive factors for treatment response and complication occurrence.The 142 open calcaneal fracture patients were enrolled in this study, who received fixation procedures of Kirschner wire, anatomical plate fixation or cannulated screw on demand. Treatment efficacy was assessed by AOFAS score and occurrence of complications was recorded.No difference of AOFAS score was observed among Kirschner wire, anatomical plate fixation and cannulated screw groups (P = .792), and the numbers of patients with excellent, good, medium, and poor AOFAS score in Kirschner wire group were 16 (16.2%), 42 (42.4%), 32 (32.3%), and 9 (9.1%), which in anatomical plate fixation group were 4 (16.7%), 11 (45.8%), 7 (29.2%), and (8.3%), and in cannulated screw group were 1 (5.3%), 10 (52.6%), 6 (31.6%), and 2 (10.5%), respectively. No difference of total complication occurrence (P = .709) or specific complications including skin graft (P = .419), flap graft (P = .229), deep infection (P = .644) or amputation (P = .428) was discovered among 3 groups. Logistic regression analysis revealed that fixation options did not affect treatment response and complication occurrence (all P > .05), while higher Gustilo type correlates with decreased treatment response (P < .001) and elevated complication occurrence (P < .001) independently.Kirschner wire, anatomical plate fixation, and cannulated screw are equally efficient and tolerated in treating patients with open calcaneal fractures, and higher Gustilo type correlates with decreased treatment response and increased complication occurrence independently.

Unusual form of the distal bone defect of ulna with neurofibromatosis type 1: A case report

RATIONALE

Bone malformation occurs in 10% to 25% neurofibromatosis type 1 (NF-1) patients, and the manifestations are scoliosis, congenital arch and pseudo-joint formation, bone cyst, and pathologic fracture. However, a large segmental defect without obvious signs of bone destruction has rarely been reported.

PATIENT CONCERNS

A 4.5-year-old male presented with a 4-year history of shortening of the right upper limb and radial head dislocation. The X-ray indicated a lack of the distal part of the right ulna and radial head dislocation.

DIAGNOSIS

The X-ray showed obvious bone resorption at the right ulna distal, proximal stubble, and distal part of the epiphyseal residue, which was 4.3 mm shorter after 14 months. The patient was finally diagnosed with NF-1 according to the pathologic examination.

INTERVENTIONS

The treatment included tumor resection, ulnar osteotomy, and fixation by an Ilizarov frame.

OUTCOMES

The Ilizarov frame was removed after 2.7 months of surgery. The radial head was successfully repositioned, and the elbow joint function was significantly improved. No recurrence of the deformity was noted until now.

LESSONS

Osteolysis (defect without bone destruction) is an extremely rare symptom in patients with NF1. Therefore, it is essential to make the right diagnosis by comprehensive and careful physical examination.

The Effect of Expansion Thoracostomy on Spine Growth in Patients with Spinal Deformity and Fused Ribs Treated with Rib-Based Growing Constructs

STUDY DESIGN

Retrospective review of prospective registries.

OBJECTIVES

We hypothesized that patients with congenitally fused ribs who underwent thoracostomy upon implantation of rib-based distraction devices would achieve improved spine growth compared with those who did not undergo thoracostomy.

SUMMARY OF BACKGROUND DATA

Patients with fused ribs may develop thoracic insufficiency syndrome. Treatment for severe early-onset spinal deformity with rib fusions often includes the placement of rib-based expansion devices with surgical division of the fused ribs (thoracostomy). The effect of thoracostomy on spinal growth has not been fully examined.

METHODS

Two multicenter registries of primarily prospectively collected data were searched. Patients with fused ribs and implantation of a rib-based device were identified. A total of 151 patients with rib fusions treated with rib-based constructs and minimum two-year follow-up were included. Among those, 103 patients were treated with expansion thoracostomy at the time of implantation, whereas 48 patients received device implantation alone. We evaluated change in T1-T12 and T1-S1 height, coronal Cobb angle, kyphosis, and number of surgeries. Preoperative deformity was similar between the two groups. Only 19% of patient underwent final fusion, with similar numbers fused in each group.

RESULTS

At latest follow-up, the expansion thoracostomy group had a greater total improvement in T1-S1 height (7.2 cm vs. 4.8 cm, p = .004). There was no difference between the two groups for change in spinal height at each lengthening procedure. Interestingly, thoracostomy patients also underwent more total surgeries (11.5 vs. 9.6, p = .031) and more lengthening procedures (8.3 vs. 6.6, p = .017) than the comparison group despite similar length of follow-up.

CONCLUSIONS

Patients who underwent expansion thoracostomy at the time of rib expansion device implantation achieved greater improvement in T1-S1 height than those who underwent implantation of rib expansion device alone. Further work is needed to evaluate whether expansion thoracostomy impacts pulmonary function.

Management of Catastrophic Proximal Junctional Failure Following Spinal Deformity Correction in an Adult with Osteogenesis Imperfecta: Case Report and Technical Note

BACKGROUND

Proximal junctional failure (PJF) is a major and sometimes devastating problem following adult spinal deformity (ASD) correction surgery. Common consensus still lags on guidelines for preventing and managing these complications. Surgical treatment of scoliosis in the presence of osteogenesis imperfecta (OI) in the pediatric population is well described. The complication rates are unusually higher in this special subset of patients owing to poor quality of bone. There is a paucity of literature focusing on surgical techniques, strategies, and problems involved in the management of ASD associated with OI.

CASE DESCRIPTION

We report a 59-year-old female with type 1 OI and adult scoliosis who underwent T10-to-pelvis fusion for ASD according to the principles of adult deformity correction. At a 1-year follow-up, she presented with asymptomatic proximal junctional kyphosis of 45° and 2 weeks later had PJF along with spinal cord injury after a fall. On computed tomography scan, kyphosis was increased to 60° at T9-T10. She underwent decompression and revision deformity correction using quadruple rods, with extension of instrumentation to T2 with soft landing using rib bands. At a 4-year follow-up, she had a good functional outcome after revision surgery.

CONCLUSIONS

This is the first report of successful management of PJF following ASD correction in the presence of OI using this technique. Suboptimal hold of implants due to poor bone quality must be at the focus of any surgical planning for these patients. All possible strategies to prevent PJF must be considered when planning the deformity correction in adults with OI.

First-stage scapholunate fusion for the treatment of a chronic lunate dislocation: A case report

RATIONALE

Lunate dislocation is a rare injury to the wrist caused by high-energy trauma, and poor prognosis is often associated with missed initial diagnosis. To date, there is no consensus regarding an effective treatment plan for such cases.

PATIENT CONCERNS

Here, we describe the case of a 36-year-old man who presented with lunate dislocation following a delay in diagnosis of over 7 weeks, and further illuminate its diagnosis and treatment.

DIAGNOSIS

The diagnosis of chronic lunate dislocation was rendered.

INTERVENTIONS

The patient was treated using reduction via the dorsal approach brachial plexus anesthesia. After the reduction, a headless compression screw fixation was performed for first-stage scapholunate fusion, and Kirschner wire fixation of the lunate-triquetrum-hamate was used to stabilize the distal and proximal carpal rows.

OUTCOMES

The patient was followed up for 1 year and showed wrist function recovered well; radiographic examination showed no lunate dislocation and successful scapholunate bony fusion. A satisfactory outcome was achieved.

LESSONS

The case study presented here provide evidence that performing an effective first-stage scapholunate fusion is recommended to achieve better therapeutic outcomes for a chronic lunate dislocation. Furthermore, this approach led to a good long-term clinical outcome in our case.

First Biomimetic Fixation for Resurfacing Arthroplasty: Investigation in Swine of a Prototype Partial Knee Endoprosthesis

Resurfacing hip and knee endoprostheses are generally embedded in shallow, prepared areas in the bone and secured with cement. Massive cement penetration into periarticular bone, although it provides sufficient primary fixation, leads to the progressive weakening of peri-implant bone and results in failures. The aim of this paper was to investigate in an animal model the first biomimetic fixation of components of resurfacing arthroplasty endoprostheses by means of the innovative multispiked connecting scaffold (MSC-Scaffold). The partial resurfacing knee arthroplasty (RKA) endoprosthesis working prototype with the MSC-Scaffold was designed for biomimetic fixation investigations using reverse engineering methods and manufactured by selective laser melting. After Ca-P surface modification of bone contacting surfaces of the MSC-Scaffold, the working prototypes were implanted in 10 swines. Radiological, histopathological, and micro-CT examinations were performed on retrieved bone-implant specimens. Clinical examination confirmed very good stability (4 in 5-point Likert scale) of the operated knee joints. Radiological examinations showed good implant fixation (radiolucency less than 2 mm) without any signs of migration. Spaces between the MSC-Scaffold spikes were penetrated by bone tissue. The histological sections showed newly formed trabecular bone tissue between the spikes, and the trabeculae of periscaffold bone were seen in contact with the spikes. The micro-CT results showed the highest percentage of bone tissue ingrowths into the MSC-Scaffold at a distance of 2.5÷3.0 mm from the spikes bases. The first biomimetic fixation for resurfacing arthroplasty was successfully verified in 10 swines investigations using RKA endoprosthesis working prototypes. The performed research shows that the MSC-Scaffold allows for cementless and biomimetic fixation of resurfacing endoprosthesis components in periarticular cancellous bone.

Treatment of open chest rib fractures with the matrix rib internal fixation system: A case report

RATIONALE

Rib fractures are common among patients with blunt chest wall trauma and often represent life-altering injuries.

PATIENT CONCERNS

A 31-year-old woman presented with right chest trauma, with pain and bleeding as a result of a traffic accident 1 hour previously.

DIAGNOSES

Chest computed tomography showed open chest trauma, multiple rib fractures, flail chest, hemopneumothorax, and lung contusion on the right side.

INTERVENTIONS

We decided to perform debridement via emergency, thoracoscopic exploration to remove blood and contaminants from the chest cavity. Thereafter, the third to seventh fractured ribs were fixed and reconstructed using the matrix rib internal fixation system, followed by suturing of the incision according to the original anatomical level.

OUTCOMES

The patient was discharged 15 days after surgery, and recovered well with satisfactory results.

LESSONS

We believe that initial chest reconstruction with internal fixation in the first stage following thorough debridement may be suitable for treating flail chest, and could save the patient's life in the early stages. However, the decision to perform the first-stage operation for the open contaminated wound should be carefully considered.

Sport and physical activity after ankle arthrodesis with Ilizarov fixation and internal fixation

BACKGROUND

Severe osteoarthritis (OA) of the ankle joint constitutes an important social problem.

OBJECTIVES

We used (1) the GRIMBY scale, (2) the LOWER LIMB Activity scale, (3) the UCLA (University of California Los Angeles) activity scale, (4) the VAS (visual analogue scale) ACTIVITY scale, and (5) the FAAM (foot and ankle ability measure) SPORT scale to verify whether the type of ankle joint arthrodesis stabilization affected sports and physical activity levels.

MATERIAL AND METHODS

We carried out a prospective clinical study of 47 patients who had undergone ankle arthrodesis with Ilizarov external fixator stabilization (Group 1, n = 21) or internal stabilization with screws (Group 2, n = 26) at Orthopaedic Clinic at the Wroclaw Medical University, Poland, from 2007 to 2015. Sports and physical activity levels were measured by (1) the GRIMBY scale, (2) the LOWER LIMB Activity scale, (3) the UCLA activity scale, (4) the VAS ACTIVITY scale, and (5) the FAAM SPORT scale.

RESULTS

A comparison between the average results of Group 1 and Group 2 on the LOWER LIMB Activity scale and the GRIMBY scale before and after surgery revealed no significant differences. In Group 1, the mean scores on the VAS ACTIVITY scale and the UCLA activity scale after treatment were higher than in Group 2. In Group 1, the mean outcome in the SPORT FAAM scale after treatment was 40; in Group 2 it was 30.06.

CONCLUSIONS

Ilizarov fixation of ankle arthrodesis is associated with better scores on the FAAM SPORT, UCLA activity and VAS ACTIVITY scales after treatment than internal fixation. The scores on the GRIMBY scale and the UCLA activity scale were significantly higher after treatment than before treatment in both groups. In this study, ankle fusion with Ilizarov fixation and internal fixation was found to be effective in the treatment of ankle arthritis. The levels of sport and physical activity were satisfactory in both groups, but the outcomes after fixation with the Ilizarov apparatus were better than after internal stabilization.

A Novel Posterior Rod-Link-Reducer System Provides Safer, Easier, and Better Correction of Severe Scoliosis

STUDY DESIGN

Retrospective review.

OBJECTIVES

To compare the Cobb >75° scoliosis correction obtained using a novel Rod-Link-Reducer (RLR) system versus traditional corrective techniques (TCT) in patients with severe adolescent idiopathic scoliosis (AIS).

SUMMARY OF BACKGROUND DATA

Current implant strategies provide for good correction, especially for moderate curves; however, severe scoliosis continues to be challenging to obtain correction in a safe and effective manner.

METHODS

A novel correction device was developed so that two provisional rods are placed on the convex side of the scoliosis proximally and distally, which are then linked to an external reduction device termed the RLR. A retrospective analysis was performed to compare the RLR versus the TCT in patients with curve >75° with the diagnosis of AIS with respect to the radiographic outcomes, operative time, intraoperative blood loss, complications, and SRS-30 scores of a minimum 2-year follow-up.

RESULTS

A total of 36 patients were evaluated (RLR-18, TCT-18). The data sets were similar for age, gender, coronal Cobb, curve flexibility, and follow-up period. The mean preoperative Cobb for the RLR group was 91.7° (76°-113°) and 91.8° (78°-108°) for the TCT group. The mean coronal Cobb correction rate was significantly greater for the RLR group (73.1% vs. 56.6%, p < .0001). The mean operative time was 74.8 minutes shorter in the RLR group (316.6 minutes vs. 391.4 minutes, p = .03). There were 2 late-developing infections and 3 intraoperative neuro-monitoring changes during the correction maneuvers in the TCT group compared with none in the RLR group (p = .02).

CONCLUSION

In a matched cohort, the use of the RLR exhibited greater coronal Cobb correction, shorter operative time, and was less likely to have critical neuro-monitoring changes compared with the TCT group. The RLR provides safer and improved correction for severe curves without adding surgical risk.

LEVEL OF EVIDENCE

Level III.

Loosening of Transtibial Pullout Meniscal Root Repairs due to Simulated Rehabilitation Is Unrecoverable: A Biomechanical Study

PURPOSE

To determine whether meniscal root repairs recover from displacement due to rehabilitative loading.

METHODS

Transtibial pullout repairs of the posteromedial meniscal root were performed in 16 cadaveric ovine knees. Single- and double-tunnel repairs using the 2-simple suture technique were cyclically loaded in tension to 10,000 cycles, allowed to rest, and loaded in tension again. Paired differences in displacement with rest were recorded to evaluate recoverability. Displacement of repairs at cycles of interest was recorded, and the response of repairs to 10,000 cycles was assessed.

RESULTS

All outcomes were not significantly different between the single- and double-tunnel techniques; therefore, the results were pooled. The difference in displacement between the first cycle and the first cycle after rest was 1.59 ± 0.69 mm. Repair displacement did not reach an equilibrium within 10,000 cycles and instead resulted in a steady increase in displacement of 0.05 ± 0.02 mm per additional 1,000 cycles. Sutures macroscopically began to cut out of the meniscus in both single- and double-tunnel repairs.

CONCLUSIONS

This study showed that significant, unrecoverable loosening from rehabilitative loading occurred in single- and double-tunnel meniscal root repairs. Root repairs also gradually displaced with continued loading instead of reaching an equilibrium displacement after 10,000 cycles. This progressive, unrecoverable loosening needs to be studied further to better understand the resultant impact on knee mechanics. In addition, the quality and quantity of meniscal root repair healing at the time of rehabilitation should be studied to determine how susceptible patients are to repair loosening.

CLINICAL RELEVANCE

Rehabilitative loading caused unrecoverable and progressive loosening of root repairs, showing the importance of healing before loading. Investigations on the effects of loosening on mechanics and the quality of repair healing at weight bearing are necessary to better understand the clinical implications.

Comparison of efficacy and safety of different fixation devices for anterior cruciate ligament reconstruction: A Bayesian network meta-analysis protocol

BACKGROUND

Anterior cruciate ligament (ACL) injury is a common ligament injury to the knee joint, and often lead to limited function, osteoarthritis after knee trauma, secondary damage to meniscus and cartilage, and impaired quality of life. ACL reconstruction is the gold standard surgical treatment for ACL injury, and ligament fixation after reconstruction is the key factor of ACL reconstruction success. However, the optimal fixation device for ACL reconstruction remains unclear. This study aims to evaluate the efficacy and safety of different fixation devices and to find the best fixation device for ACL reconstruction.

METHODS

The PubMed, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and Chinese Biomedicine Literature will be searched to identify relevant studies from inception to December 2018. We will include randomized controlled trials (RCTs) comparing the effects of different fixation devices fixed on the femoral side in arthroscopically assisted ACL reconstruction. Risk of bias assessment of the included RCTs will be conducted according to the Cochrane Handbook 5.1.0. A Bayesian network meta-analysis (NMA) will be performed using R software.

RESULTS

The results of this NMA will be submitted to a peer-reviewed journal for publication.

CONCLUSION

This NMA will summarize the direct and indirect evidence to evaluate the effect of different fixation devices for ACL reconstruction.

Comparison of mid-term outcomes of posterior or postero-anterior approach using different bone grafting in children with lumbar tuberculosis

The anterior and middle columns instead of the posterior column of spine are usually destroyed by tuberculosis which could aggravate the kyphosis accompanying the growth imbalance of spine in children. The surgical method needs to be selected cautiously for effective treatment. To our knowledge, few studies have evaluated mid-term outcomes of 2 surgeries (posterior-only approach and combined posterior and anterior approaches) with allograft or shaped titanium mesh cages for the treatment of lumbar tuberculosis in children. The study aims to compare the surgical mid-term outcomes of the posterior-only approach and the combined approaches using different bone grafting for the treatment of pediatric lumbar tuberculosis.Between January 2007 and June 2013 at our spine center, 51 consecutive pediatric lumbar tuberculosis with an average age of 7.3 ± 3.93 years treated with combined posterior and anterior approaches (PA, 22 cases) or posterior-only approach (PO, 29 cases) were enrolled. Two types of interbody bone graft were applied in this study: fresh-frozen tricortical iliac-bone allograft (AG, 21 cases) and shaped titanium mesh cages (TM, 30 cases). All medical records and radiographs were retrospectively reviewed. The Japanese Orthopaedic Association (JOA) is applied to evaluate the neurological function. The average visual analogue (VAS) and Oswestry Disability Index (ODI) were used to evaluate the quality of life.The average follow-up was 6.7 ± 1.9 years. The mean operation time, average blood loss, complication rate, and lengths of hospital stay of PO were less than those of the PA. The postoperative VAS (1 day after surgery) of PA was significantly higher than that of PO. The ODI, VAS and JOA scores at the final follow-up had been improved significantly compared with preoperative scores. The ODI, VAS and JOA scores at the final follow-up were similar between PA and PO as well as between AG and TM. There was no statistically significant difference about the fusion times between PO and PA groups. The final follow-up kyphosis correction rate and the correction loss at the final follow-up between the PO and PA groups showed no statistically significant difference. However, the final follow-up correction rate of the AG group was lower than that of TM group. The correction loss of the AG group was higher than that of TM group.The posterior only approach in experienced hands provides satisfying treatment for the children lumbar tuberculosis with less invasive, much safer, and more effective compared with combined posterior and anterior approach. The shaped titanium mesh cages are noted to be a valuable tool in surgical decision making.

In vitro and in vivo analysis of the biodegradable behavior of a magnesium alloy for biomedical applications

The present study was designed to investigate the biodegradation behavior of Mg alloy plates in the maxillofacial region. For in vitro analysis, the plates were immersed in saline solution and simulated body fluid. For in vivo, the plates were implanted into the tibia, head, back, abdominal cavity, and femur and assessed at 1, 2, and 4 weeks after implantation. After implantation, the plate volumes and the formed insoluble salt were measured via micro-computed tomography. SEM/EDX analysis of the insoluble salt and histological analysis of the surrounding tissues were performed. The volume loss of plates in the in vitro groups was higher than that in the in vivo groups. The volume loss was fastest in the abdomen, followed by the head, back, tibia, and femur. There were no statistically significant differences in the insoluble salt volume of the all implanted sites. The corrosion of the Mg alloy will be affected to the surrounding tissue responses. The material for the plate should be selected based on the characteristic that Mg alloys are decomposed relatively easily in the maxillofacial region.

Where to stop distally in Lenke modifier C AIS with lumbar curve more than 60°: L3 or L4?

OBJECTIVE

Selecting lowest instrumented vertebra (LIV) in adolescent idiopathic scoliosis (AIS) with large lumbar curve can be difficult. Stopping the distal fusion at L3 could save more mobile lumbar segments but may increase the risk of decompensation. This study was designed to evaluate preoperative radiographic factors that were associated with the selection of either L3 or L4 as LIV in posteriorly treated AIS patients with large lumbar curve.

PATIENTS AND METHODS

A total of 84 AIS patients with lumbar curve >60° were analyzed with a minimum of 2-year follow-up after posterior instrumentation with lumbar curves included in fusion. Patients were grouped according to the selection of LIV, either L3 or L4 group. All radiograph parameters were measured pre- and post-operatively including Cobb angle, lumbar flexibility, L3 translation and rotation on posteroanterior (PA) and side-bending (SB) film, etc. The SRS-22 score was used to assess clinical outcomes. Radiographic and clinical parameters were compared between the two groups.

RESULTS

There were 24 patients in L3 group and 60 patients in L4 group. At last follow-up, no difference was found in the clinical and radiographic parameters between the two groups. Preoperatively, the L3 group had lower L3 translation on PA view, L3 translation on concave SB film, L3 rotation on convex SB film, more L3/4 disc opening on convex SB film and larger lumbar flexibility. Multivariate regression found L3 translation on concave SB film was the single most important predictor of LIV selection. Specifically, L3 translation on concave SB film <10 mm was a potential threshold for selecting L3 as LIV.

CONCLUSIONS

For AIS patients with large lumbar curve, instrumentation can be reliably stopped at L3 if L3 translation on preoperative concave SB film was less than 10 mm, with the same radiographic and clinical outcomes as fusing to L4.

Comparison of radiological outcomes and complications between single-level and multilevel anterior cervical discectomy and fusion (ACDF) by using a polyetheretherketone (PEEK) cage-plate fusion system

This study aimed to compare the differences in radiological outcomes and complications between single- and multilevel anterior cervical discectomy and fusion (ACDF) by using a polyetheretherketone (PEEK) cage-plate fusion system.Fifty-seven patients who underwent ACDF via the PEEK cage-plate fusion system were enrolled and subjected to ≥6 months of follow-up. The patients were divided into 4 groups according to different cage-plate implantation levels: 1-level group (n = 17), 2-level group (n = 24), 3-level group (n = 12), and 4-level group (n = 4). Fusion time, changes in segment and global lordotic angle, subsidence rate, and changes in disc and adjacent segmental disc height were subjected to radiological evaluation.The fusion period of multilevel ACDF was longer than that of single-level ACDF. The fusion period of the 3-level (4.09 ± 0.94, P = .004) and 4-level (5.25 ± 0.89, P = .004) group was also significantly longer than that of the 1-level group. The mean lordotic angle in all of the groups was changed in the immediate postoperative period and in the final follow-up. The cage subsidence rates were 11.76% (2/17) in the 1-level group, 20.83% (5/24) in the 2-level group, and 2/12 (16.67%) in the 3-level group. No subsidence occurred in the 4-level groups. Changes in the lower adjacent segmental disc height were significantly increased in multilevel ACDF compared with those in single-level ACDF.Despite the longer fusion time, the outcomes of the proposed system were even better with the greater number of treatment levels by using PEEK cage-plate fusion system. Changes in the lower adjacent segmental disc height should also prolong follow-up duration to investigate the symptomatic adjacent segment degeneration in multilevel ACDF.

Treatment of Traumatic Elbow Instability With an Internal Joint Stabilizer

PURPOSE

Current options for treating elbow instability include bony and/or ligamentous fixation with orthosis or cast immobilization, transarticular cross-pinning, temporary bridge plating, and hinged or rigid external fixation. Our purpose was to evaluate the recently developed internal joint stabilizer (IJS), which acts as an internal external fixator of the elbow. Our primary end point was to assess whether use of the device results in a stable and congruent reduction of the ulnohumeral and radiocapitellar joints in patients with acute or chronic elbow instability as a result of trauma. In our series, patients with elbow instability as a result of acute or chronic trauma were treated with an IJS.

METHODS

This retrospective study reviewed 20 patients who underwent placement of a U.S. Food and Drug Administration (FDA)-approved IJS for elbow instability. Serial physical examinations and radiographs were performed to verify stability. Patients were instructed that, if they are dissatisfied with their postoperative motion, a secondary contracture release operation will be offered to them. Patients were asked to complete outcome-scoring questionnaires including the Disabilities of the Arm, Shoulder, and hand (DASH) and Mayo Elbow Performance (MEP) score. Complications were monitored for all patients.

RESULTS

Twenty patients who underwent placement of an IJS for persistent elbow instability were reviewed. Patients with a flexion-extension arc of 70° or less at 12 weeks were offered a staged arthroscopic contracture release. The average MEP score improved from 12.2 ± 12.4 to 82.5 ± 14.3 and the average DASH score improved from 85.3 ± 23.0 to 37.26 ± 29.3. The average postoperative flexion-extension arc at most recent follow-up was 124.3° ± 14.9°, with a median follow-up of 17 months (8 weeks-25 months).

CONCLUSIONS

Use of an IJS allows for early, congruent, and stable ulnohumeral and radiocapitellar range of motion in instances of persistent elbow instability.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

A novel method using bone peg fixation for acute osteochondral fracture of the talus: a surgical technique

INTRODUCTION

The osteochondral fracture of the talus is an uncommon condition, therefore, there are controversies for the optimal treatment. We report a novel surgical technique of bone peg fixation for osteochondral fracture of the talus.

MATERIALS AND METHODS

We report two cases that underwent bone peg fixation for the acute osteochondral fractures of talus. Clinical and radiographic evaluations were performed at the last follow-up.

RESULTS

At the last follow-up, mean ROM of ankle joint was 50° (range 45°-55°). Additionally, mean VAS and AOFAS score were 0 and 100 at the last follow-up, respectively. All patients obtained bone union without complication at the last follow-up radiographs.

CONCLUSIONS

This case study shows good clinical and radiographic results with autologous bone peg fixation in patients with acute osteochondral fractures of the talus.

LEVEL OF EVIDENCE

V, expert opinion.

[InternalBrace ACL Repair - First Experiences and Outcomes]

PURPOSE OF THE STUDY In recent years attempts have been made again to repair anterior cruciate ligament (ACL) in order to maintain native kinematics and knee joint proprioception. The method of choice is the arthroscopic suture of the ligament using the InternalBrace ligament augmentation. This study presents the first experience gained with this surgical technique and the clinical outcomes. MATERIAL AND METHODS In the period from November 2016 to December 2018, a total of 46 patients with acute ACL rupture underwent the ACL repair using the InternalBrace ligament augmentation. This study includes only the patients followed up for a minimum period of 12 months postoperatively. For the evaluation of patients, the well-established clinical scores were used - the Tegner Activity Level Scale, the IKDC (International Knee Documentation Committee) subjective scale and the Tegner Lysholm Knee Scoring Scale. The measurements were taken preoperatively and at 6 and 12 months postoperatively. RESULTS The evaluations concerned 20 patients who had undergone surgery in the period from February 2017 to February 2018. In the aforementioned group of patients, there were 3 cases of reconstruction failure (15%), subsequently requiring the ACL reconstruction. The average preoperative Tegner Activity score was 8.2 (6-10; median 8.0). At six months postoperatively, the average value of this score was 7.35 (5-10; median 7), and at 12 months postoperatively it was 7.35 (4-10; median 7). The average preoperative Lysholm score was 66.4 (16-100; median 69). At six months postoperatively, the average value of this score improved to 90.70 (71-100; median 92) and at 12 months postoperatively to 91 (75-100; median 90). The average IKDC subjective score before the surgery was 49.8 (36-74; median 49). At six months postoperatively the average achieved score was 87.70 (71-99; median 90) and at 12 months postoperatively it was 88.9 (63-99; median 93). The differences between the preoperative values and the values at 6 months after the surgery were significant in all the followedup parameters. Conversely, the differences between the values at 6 and at 12 months were not significant. DISCUSSION The clinical outcomes of the patients after the ACL repair are valuable and comparable to the data published in literature. They were largely achieved within 6 months after the surgery. A fairly high percentage of failure of this method compared to literature (Jonkergouw 7.5%, McKay 1.5%) can partly be ascribed to the learning curve even though the surgeries were performed exclusively by experienced surgeons. A certain role could also be played by more challenging indication for this procedure or a faster return to postoperative load. CONCLUSIONS Anterior cruciate ligament suture with the InternalBrace ligament augmentation judging from the results achieved by our group of patients brings very good clinical outcomes already at 6 months postoperatively. This method allows the athletes to return to full load soon. It maintains the kinematics and knee joint proprioception, and thus can potentially contribute to the prevention of post-traumatic arthritis. Strict application of indication criteria is a precondition to success. A longer follow up and evaluation of a larger number of patients will, however, be necessary to definitely confirm the success of this surgical technique. Key words: arthroscopy, ACL rupture, ACL repair, InternalBrace, clinical evaluation.

Clinical and radiological outcomes of a cervical cage with integrated fixation

Cervical cages with integrated fixation have been increasingly used in anterior cervical discectomy and fusion (ACDF) to avoid complications associated with anterior cervical plates. The purpose of this paper is to provide 2-year follow-up results of a prospective study after implantation of a cervical cage with an integrated fixation system.This was a prospective multicenter outcome study of 90 patients who underwent ACDF with a cage with integrated fixation. Fusion was evaluated from computed tomography images (CT-images) by an independent laboratory at 2-year follow-up (FU). Clinical and radiological findings were recorded preoperatively and at FU visits and complications were reported.At 24 months, the fusion rate was 93.4%. All average clinical outcomes were significantly improved at 2 years FU compared to baseline: neck disability index (NDI) 18.9% vs 44.4%, visual analog scale (VAS) for arm pain 18.2 mm vs 61.9 mm, VAS for neck pain 23.9 mm vs 55.6 mm. Short form-36 (SF-36) scores were significantly improved. One case of dysphagia, which resolved within 12 months, and 1 reoperation for symptomatic pseudarthrosis were reported. Subsidence with no clinical consequence or reoperation was reported for 5/125 of the implanted cages (4%). There was also 1 case of per-operative vertebral body fracture that did not require additional surgery. Superior and inferior adjacent discs showed no significant change of motion at 2-year FU compared to baseline. Disc height index (DHI) and lordosis were enhanced and these improvements were maintained at 1 year.The ACDF using cages with an integrated fixation system demonstrated reliable clinical and radiological outcomes and a high interbody fusion rate. This rate is comparable to the rate reported in recent series using other implants with integrated fixation, but the present device had a lower complication rate.

DW. The Deformity TLIF: Bilateral Facetectomy and Osteotomy Closure with a Hinged Table

BACKGROUND

Increasing emphasis has been placed on segmental lordosis correction, even in short segment constructs. However, the majority of reports on TLIF indicate that lordosis correction is modest at best. TLIF with bilateral facetecomy has been described with better lordosis correction, but is usually performed with the spine in extension throughout the case. This report presents a new technique for lordosis correction during TLIF with the use of bilateral facetectomy and osteotomy closure using a mechanically hinged operative table.

METHODS

A 78-year-old male presented with claudicatory back and leg pain due to foraminal stenosis and spondylolisthesis at L4-5 and L5-S1, and was operated on with bilateral facetectomies and TLIF while positioned on a motorized-hinged table, which started in flexion for the decompression and was brought into extension at the end of the case for osteotomy closure.

RESULTS

Segmental lordosis from L4-S1 increased from 15° pre-operatively to 42° postoperatively.

CONCLUSIONS

A comparison of pre- and post-operative lateral radiographs showed 27° segmental lordosis correction, and intra-operative fluoroscopy showed correlation between extension of the table and segmental lordosis correction. Bilateral facetectomy and TLIF allows for segmental lordosis correction. Use of the hinged table allowed for ideal positioning during the decompression and controlled osteotomy closure with close correlation between table position and segmental alignment.Level of Evidence: V.

Midfoot Charcot Reconstruction

Midfoot Charcot joints are complex problems that are most commonly seen in patients with peripheral neuropathy secondary to diabetes. The goal of management is to prevent pedal collapse, which can lead to ulceration; infection; and in some cases, amputation. Principles of surgical management should be centered on respecting the soft tissue, obtaining correction, maintaining correction, and supplementing with orthobiologics to achieve healing. The authors present strategies, case examples, and tips and tricks to treat this complex condition with external and internal fixation.

Pedicle screw shift without loosening following instrumented posterior fusion: limitations of pedicle screw fixation

The disc angle at the fused segment is extended in operative prone position, but eventually returns to preoperative neutral position within 6 months to 1 year. This study aimed to assess pedicle screw (PS) shift without loosening to identify the mechanism of the change in disc angle after posterior fusion for degenerative lumbar spondylolisthesis (DLS). Sixty-three consecutive patients who underwent facet fusion for L4 single-level DLS were retrospectively reviewed using computed tomography (CT) immediately after surgery and 6 months postoperatively. Twenty-two patients (88 PSs) in whom the disc angle had decreased by more than 4° at 6-month postoperative radiographic follow-up were selected to more readily identify and quantify PS shift. Six patients with PS loosening and/or nonunion were excluded. We reconstructed a CT plane, vertical to the cranial endplate of the vertebrae and passing through the cannula used for percutaneous PSs. Angle α, which is formed by the cranial endplate and the cannula on this plane, was measured. A change in angle α of more than 2° between the immediate postoperative period and the 6-month follow-up was defined as a PS shift. Angle α did not change by more than 2° in any of the 44 PSs in the upper vertebrae of the fused segment. In the lower vertebrae, angle α changed by more than 2° in 22 of 44 PSs. The change in angle α in the lower vertebrae (average, 2.3°) was significantly greater than that in the upper vertebrae (average, 0.2°) (P < 0.0001). The change in the disc angle was not relevant to clinical outcomes assessed by the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire, the Roland-Morris Disability Questionnaire, and the visual analogue scale. The disc angle at the fused segment returned to preoperative neutral position due to PS shift without loosening, mainly in the lower vertebrae. PS shift is caused by bone remodeling in response to biomechanical load, similar to that in orthodontic tooth movement. As PS has limited ability to maintain a lordotic disc angle, even with the insertion of a cage, lumbar alignment will return to preoperative neutral position owing to cage subsidence or adjacent segment disease. These findings might indicate that it is not necessary to correct the spinal alignment for DLS.