Multidrug-resistant Gram-negative osteomyelitis: a 10-year study

AIM

Few series of osteomyelitis due to multi-drug (MDR) or extensively-drug resistant (XDR) gram-negative bacteria exist. A retrospective study of MDR and XDR gram-negative osteomyelitis cases was performed, aiming to investigate causative organisms, proper surgical and medical management, as well as outcome.

PATIENTS AND METHODS

All patients, treated at the University hospital of Crete between 2007 and 2016 for acute osteomyelitis, due to MDR or XDR gram-negative pathogens were evaluated.

RESULTS

A total of 14 patients (8 males) were identified with a mean age of 50.6 years. Five Acinetobacter baumanii cases, 3 XDR and 2 MDR, were found. Furthermore, 3 MDR Klebsiella pneumoniae and 3 MDR Enterobacter cloacae isolates were identified. Additionally, 2 MDR Escherichia coli, as well as 2 Pseudomonas aeruginosa, 1 XDR and 1 MDR, were isolated. One case of Roseomonas gilardii was also identified. In 5 cases the same pathogen was also isolated from blood. Five out of the 14 patients were smokers, 6 were suffering severe injury, 4 had diabetes-mellitus, 2 chronic renal disease and 2 were obese. Most causative organisms had hospital origin. All patients received first line empirical combination antimicrobial treatment, proven effective in 4. Thirteen patients were also subjected to surgical treatment. The study included mainly young individuals, most likely due to the high incidence of traffic accidents involving young adults in Crete.

CONCLUSIONS

Antimicrobial regimens are important supplements to surgical treatment of acute osteomyelitis. However, due to emergence of resistant microorganisms, compliance with strict rules of antimicrobial strategy is of utmost importance.

Experience of surgical treatment via posterior approaches for herniated thoracic disc

The incidence of symptomatic herniated thoracic disc (HTD) is very low. There are still no established priority in surgical approaches and guidelines for additional instrumentation with fusion. From 2007 through 2014, 38 patients (22 males and 16 females) were enrolled. The thoracolumbar region was a most common site for HTD (75.6%). The clinical characteristics of HTD based on size, location, and calcification; the factors for applying instrumentation with fusion were analyzed retrospectively. All patients were undergone surgical treatment via various posterior approaches. The additional instrumentation with fusion was performed in 14 patients (36.8%). The larger amount of facet joint resection (more than 50%) was only statistical significant factor for instrumentation (p=0.023). There were four surgical complications (10.5%). Surgical treatment via posterior approach was a reliable modality for HTD. The significant factor for applying additional instrumentation with fusion was the amount of facet joint resection.

Short-term effects of minimally invasive dynamic neutralization system for the treatment of lumbar spinal stenosis: An observational study

The aim of the study was to evaluate the safety and short-term effects of dynamic stabilization via minimally invasive system for degenerative lumbar spinal stenosis. Patients with degenerative lumbar spinal stenosis and treated with Transforaminal Lumbar Interbody Fusion via minimally invasive minimally system (mis-TLIF) were served as the control group.From April 2011 to March 2015, 47 patients (29 male, 18 female; mean age 47.6 [range, 26-52] years) with lumbar spinal stenosis were treated with decompression and excision of herniated disk via the minimally invasive system combined with the dynamic fixation technique, and 42 patients as control group with mis-TLIF. Minimally invasive surgeries were performed via the posterior incision approach. The clinical outcomes were evaluated by comparing the Visual Analog Scale (VAS) score, Oswestry Disability Index (ODI) scores, and the ROMs of the adjacent segment before and after surgery. The postoperative complications related to the implants were identified.A total of 83 patients (43 of Dynesys group and 40 of mis-TLIF group) were followed for an average duration of >35 months. Dynesys stabilization resulted in significantly higher preservation of motion at the index level (P < .05), and significantly less hypermobility at the adjacent segments. VAS for the back and leg pain and ODI improved significantly (P < .05) in 2 groups; however, there is no significant difference between the groups. In Dynesys group, 3 cases suffered skin flay necrosis, 1 of them had a wound infection that was treated with washing and drainage combined with antibiotic therapy. Skin flay necrosis were also observed in 2 cases of mis-TLIF group. Reoperation was performed in one case of Dynesys group for rupture of the internal fixation. No rupture of internal fixation was observed in mis-TLIF group.The nonfusion fixation system Dynesys may be used to treat degenerative spinal stenosis without posterior element damage. This surgical technique is safe and effective. However, utilizing higher preservation of motion may lead to the failure of internal fixation.

A numeric approach for anatomic plate design

Osteosynthesis plate designs with high levels of anatomical compliance have been demonstrated to have numerous clinical benefits. The purpose of this paper is to introduce a systematic numeric approach for anatomic plate design on the example of the distal medial tibia. The advantage of using numeric approaches for plate design is to gain objective and complete anatomical input as opposed to cadaveric investigations with limited sample sizes. A recent development in this area is a proprietary technology called SOMA which is based on a large database of 3D bone models generated from thin-slice computer tomographic scans plus associated software tools. In this paper, one of these associated software tools is described which automatically assesses the anatomic fit of osteosynthesis plates based on a large database of bone models. As an example, this tool was applied to assess the mean plate to bone distance of distal medial tibia plates, when fitted onto 444 Caucasian and 310 Asian 3D bone models respectively. The analyses revealed differences in the anatomical compliance of plates from different generations and manufacturers. The anatomical compliance of SOMA designed plates was statistically significantly better compared to all other plates in all groups "Short", "Intermediate" and "Long" and for both ethnicities "Caucasian" and "Asian" (P<0.001). The study has shown that using an underlying database with accompanying computational tools such as SOMA can be a powerful and efficient approach towards the development and advancement of osteosynthesis plates in trauma surgery, ultimately resulting in plates with high levels of anatomical compliance and potential clinical benefits.

Staged insertion of growing rods in severe scoliosis

PURPOSE

The objective of this retrospective chart and radiographic review was to present the clinical outcomes and complication rate of a staged approach to modern dual growing-rod (GR) surgery when treating children with severe early onset scoliosis.

METHODS

Fifteen patients received a 6-mm dual GR system. During Stage 1, pairs of end vertebra were exposed in a subperiosteal fashion, instrumented, grafted, and fused. Stage 2 was performed, on average, 5 months later (range 8-35 weeks) and the fused foundations were connected with two growing rods under skull-femoral traction. Clinical and operative notes were reviewed and all complications were recorded. Radiographic measurements were assessed at pre-index, with intraoperative traction during Stage 1, post-Stage 2 and at most recent follow-up. Statistical analyses were performed to evaluate change in scoliosis and kyphosis.

RESULTS

At initial surgery, the average age was 8.17 ± 1.5 years. The mean Cobb angle was 88.1° ± 14.0°, corrected to 60.3° ± 8.7° (p < 0.001) with intraoperative traction in Stage 1, preserved after Stage 2 instrumentation (59.5° ± 9.6°, p = 0.69), and maintained with subsequent lengthenings (60.6° ± 12.8°, p = 0.73). Hyperkyphosis (11/15 patients) improved from 70.8° ± 15.7° to 46.6° ± 9.7° (p < 0.001). At minimum 2-year follow-up (range 24-80 months, mean 49.5), the complication rate was 14 (0.93 complications/patient), including 6 rod breakages, 6 superficial infections, and 2 deep infections. No anchor migration or pull-out was noted. Seven patients have undergone definitive posterior spinal fusion.

CONCLUSIONS

Staged insertion of dual GR systems permits strong distraction, with acceptable correction of severe deformities and minimal complications. These slides can be retrieved under Electronic Supplementary Material.

Biomechanics of unilateral and bilateral sacroiliac joint stabilization: laboratory investigation

OBJECTIVE Bilateral symptoms have been reported in 8%-35% of patients with sacroiliac (SI) joint dysfunction. Stabilization of a single SI joint may significantly alter the stresses on the contralateral SI joint. If the contralateral SI joint stresses are significantly increased, degeneration may occur; alternatively, if the stresses are significantly reduced, bilateral stabilization may be unnecessary for patients with bilateral symptoms. The biomechanical effects of 1) unilateral stabilization on the contralateral SI joint and 2) bilateral stabilization on both SI joints are currently unknown. The objectives of this study were to characterize bilateral SI joint range of motion (ROM) and evaluate and compare the biomechanical effects of unilateral and bilateral implant placement for SI joint fusion. METHODS A lumbopelvic model (L5-pelvis) was used to test the ROM of both SI joints in 8 cadavers. A single-leg stance setup was used to load the lumbar spine and measure the ROM of each SI joint in flexion-extension, lateral bending, and axial rotation. Both joints were tested 1) while intact, 2) after unilateral stabilization, and 3) after bilateral stabilization. Stabilization consisted of lateral transiliac placement of 3 triangular titanium plasma-sprayed (TPS) implants. RESULTS Intact testing showed that during single-leg stance the contralateral SI joint had less ROM in flexion-extension (27%), lateral bending (32%), and axial rotation (69%) than the loaded joint. Unilateral stabilization resulted in significant reduction of flexion-extension ROM (46%) on the treated side; no significant ROM changes were observed for the nontreated side. Bilateral stabilization resulted in significant reduction of flexion-extension ROM of the primary (45%) and secondary (75%) SI joints. CONCLUSIONS This study demonstrated that during single-leg loading the ROMs for the stance (loaded) and swing (unloaded) SI joints are significantly different. Unilateral stabilization for SI joint dysfunction significantly reduces the ROM of the treated side, but does not significantly reduce the ROM of the nontreated contralateral SI joint. Bilateral stabilization is necessary to significantly reduce the ROM for both SI joints.

Clinical application of the sinus tarsi approach in the treatment of intra-articular calcaneal fracture

To observe the clinical outcome of the sinus tarsi approach in the operative treatment of intra-articular calcaneal fractures.Forty-nine intra-articular calcaneal fractures in 45 patients were managed surgically with sinus tarsi approach. The anatomical plate and compression bolts were applied in 14 feet. The anatomical plate and screws were applied in 35 feet. Maryland foot score system was used to evaluate the function of the hindfoot at the followup.The reduction of the posterior facet was graded as nearly anatomical (less than 2 mm articular displacement) in 46 feet (93.9%). The width, height, and Böhler angle were significantly improved in all patients (P < .01). After a mean follow-up period of 18.7 months (14.5-29 months), the Maryland foot scores were: 34 feet scored 90-100 points (excellent), 6 feet scored 80-90 points (good), 6 feet scored 70-80 points (fair), and 3 feet scored 60-70 points (poor). Incision-edge necrosis occurred in 2 cases. One case suffered from incomplete medial plantar nerve injury. One case suffered from heel pad branch of the tibial nerve injury. Six cases suffered from sural nerve injury, and 4 cases sustained a lateral wound dehiscence due to a hematoma. No case suffered from lateral impingement syndrome. Up to now, no patient had to accept subtalar arthrodesis.Sinus tarsi approach provides good exposure to the subtalar joint. Open reduction and internal fixation of calcaneus fractures through a sinus tarsi approach allows adequate reduction with low risk of wound-healing complications.

Pigeon chest: comparative analysis of surgical techniques in minimal access repair of pectus carinatum (MARPC)

BACKGROUND

After minimally invasive repair for pectus excavatum (MIRPE), similar procedures for pectus carinatum were developed. This study aimed to analyse the various published techniques of minimal access repair for pectus carinatum (MARPC) and compare the outcomes.

DATA SOURCES

Literature was reviewed on PubMed with the terms "pectus carinatum", "minimal access repair", "thoracoscopy" and "children".

RESULTS

Twelve MARPC techniques that included 13 articles and 140 patients with mean age 15.46 years met the inclusion criteria. Success rate of corrections was n = 125, about 89% in cumulative reports, with seven articles reporting 100%. The complication rate was 39.28%. Since the pectus bar is placed over the sternum and has a large contact area, skin irritation was the most frequent morbidity (n = 20, 14.28%). However, within the complication group (n = 55), wire breakage (n = 21, 38.18%) and bar displacement (n = 10, 18.18%) were the most frequent complications. Twenty-two (15.71%) patients required a second procedure. Recurrences have been reported in four of twelve techniques. There were no lethal outcomes.

CONCLUSIONS

MARPC techniques are not standardized, as MIRPE are, so comparative analysis is difficult as the only common denominator is minimal access. Surgical morbidity is high in MARPC and affects > 2/3rd patients with about 15% requiring surgery for complication management.

A Comparative Biomechanical Study of Femoral Cortical Suspension Devices for Soft-Tissue Anterior Cruciate Ligament Reconstruction: Adjustable-Length Loop Versus Fixed-Length Loop

PURPOSE

To determine whether there are differences between adjustable-length loop and fixed-length loop devices in terms of the amount of displacement, temporal pattern of displacement, and ultimate failure load when tested using 4,500 cycles of sinusoidal loading with high loads (100-400 N).

METHODS

Two cortical suspension devices with a fixed- or adjustable-length loop were tested. For our comparisons, a 20-mm fixed-length loop device and a fixed-length loop device with the same loop length were used. Comparisons between the devices used both a device-only model (DOM) and a device-bone-soft-tissue graft construct model (CM).

RESULTS

In the DOM, the adjustable-length loop device showed weaker mechanical properties. Mean cumulative peak displacement was 1.91 mm for the adjustable-length loop device and 0.74 mm for the fixed-length loop device (P = .001). The displacement of the adjustable-length loop device increased between 1,000 and 4,500 cycles; in contrast, that of the fixed-length loop device reached a plateau. However, there was never displacement greater than 3 mm. In addition, the adjustable-length loop device showed a weaker ultimate failure load (925 N vs 1,410 N, P = .001). In the CM, the difference in cumulative peak displacement between the 2 groups decreased and did not reach statistical significance. The displacement of both devices showed a similar pattern. In addition, there was no difference in ultimate failure load between the 2 groups.

CONCLUSIONS

There was no significant difference in terms of total displacement, temporal pattern of displacement, and ultimate failure load between the 2 devices in the CM, which is the more clinically relevant model. Furthermore, even in the DOM, the difference in total displacement was small and did not reach a clinically meaningful level. Therefore, both devices can be used effectively during anterior cruciate ligament reconstruction with soft-tissue graft.

CLINICAL RELEVANCE

Both femoral cortical suspension devices with adjustable- and fixed-length loops can be used with similar mechanical properties during anterior cruciate ligament reconstruction.

Comparison of the clinical effects of zero-profile anchored spacer (ROI-C) and conventional cage-plate construct for the treatment of noncontiguous bilevel of cervical degenerative disc disease (CDDD): A minimum 2-year follow-up

Comparing the clinical and radiographic outcomes in anterior cervical discectomy and fusion (ACDF) using a zero-profile anchored spacer (ROI-C) or a conventional cage-plate construct (CPC) for treating noncontiguous bilevel of cervical degenerative disc disease (CDDD).Overall, 46 patients with 2 noncontiguous segments of CDDD, treated with ACDF from January 2011 to October 2015, were included in this study. ROI-C was used in 22 patients (group A) and CPC in 24 patients (group B). The clinical and radiographic outcomes and complications were compared pre- and postoperatively. All patients were followed up for at least 24 months after surgery.No significant difference was found in fusion rate, cervical curvature, height of fused segment (FSDH), intraoperative blood loss, and Japanese Orthopaedic Association (JOA), and Neck Disability Index (NDI) scores between the 2 groups. Group A had a shorter operation time and significantly lower incidence of dysphagia (3 and 24 months postoperatively) than group B (P < .001 and P < .05, respectively). Moreover, group A had a higher loss of FSDH than group B, but with no difference between the 2 groups (P > .05). Two cages developed subsidence in group A (4.5%) and 2 adjacent levels developed degeneration in group B (2,8%).ACDF with ROI-C device was superior to CPC for noncontiguous bilevel of CDDD because it avoided postoperative dysphagia and required a shorter operation time. Moreover, the clinical outcomes were comparable. Prospective trials with larger samples and longer follow-up are required to confirm the results.

Spinal Metastasis Resulting from Atypical Thymic Carcinoid: A Case Report

BACKGROUND

Thymic carcinoid with spinal metastasis is an extremely rare entity. Clinically, the tumor presents either by its endocrine manifestations or by mechanical compression of surrounding structures. However, no previously published case studies have reported neck pain and neurologic deficit in the initial presentation of an atypical thymic carcinoid.

CASE DESCRIPTION

A 56-year-old man, a nonsmoker, presented with a 12-month history of intermittent neck pain and a 1-month history of progressive numbness and weakness of the right upper limb. Cervical MRI showed multiple abnormal signals and C2 soft-tissue mass intruding into the vertebral canal. Cervical CT scan showed multiple bone lesions. The diagnosis of thymic carcinoid was obtained by preoperative lymph node biopsy. The patient underwent cervical laminectomy and occipitocervical fixation. Significant alleviation of pain and neurologic improvement were achieved. The postoperative pathological examination confirmed the diagnosis of thymic carcinoid.

CONCLUSIONS

Neck pain and neurologic deficit could be the first presentation of thymic carcinoid with spinal metastasis. Palliative surgery is an effective method to improve quality of life in patients with thymic carcinoid with spinal metastasis.

[Growth Guidance System in Treatment of Early Onset Scoliosis]

PURPOSE OF THE STUDY The Growth Guidance System (GGS) represent a relatively new alternative to the traditional growing systems used for the treatment of early onset scoliosis. Ranking among the main aims of this surgical treatment is a three-dimensional correction of the deformity, maintenance of spinal growth and postponement of the necessity of final treatment by spondylodesis. MATERIAL AND METHODS Our study retrospectively evaluates the results of surgical correction in a group of 35 patients treated by GGS technique. The group consisted of patients with idiopathic, neuromuscular and syndromic spine deformity with the average age of 8 years and 2 months at the time of the surgery. The time of the follow-up is 3 years and 5 months on average. We evaluated the correction of the curve itself, the growth of the spine measured in the thoracic and lumbar part separately, and the growth of the trunk as a whole in the mentioned range on X-ray pictures. RESULTS The average correction of the scoliotic curve was 67%, from 75 preoperative degrees to 20 postoperative degrees. After the first operation 11% elongation of the trunk (from 321 mm to 356 mm) was reached, the thoracic spine was elongated by 10% (from 196 to 217 mm) and the lumbar spine was elongated by 11% (from 125 to 139 mm). The elongation of the trunk by 16% (from 322 to 375 mm) was observed in the cohort of patients with two years postoperative follow-up (21 patients). The total protraction of the trunk by 21% (from 318 to 386 mm) was reached in patients treated by definitive fusion (7 patients). DISCUSSION There is a very low number of studies analysing the long-term clinical results with the use of GGS. The first pilot results indicate that it is a technique allowing to achieve at least comparable results in correction of frontal plane compared with the distraction type of instrumentations. A negative aspect of this method is the abrasion of metal followed by metallosis. The new types of fixation screws enable more effective sliding of rods, maintenance of continuity of body grow by the shifting of rods as well as lower abrasion of the instrumentation. CONCLUSIONS The main advantage of GGS is the limited continuous growth of the spine, partial three-dimensional correction of the deformity, minimisation of inevitable reoperations under general anaesthesia and the possibility to quit a brace. Key words: growth guided system, early onset scoliosis, distraction, spinal growth, spondylodesis.

Effect of Antibiotic Prophylaxis on Surgical Site Infections Following Removal of Orthopedic Implants Used for Treatment of Foot, Ankle, and Lower Leg Fractures: A Randomized Clinical Trial

IMPORTANCE

Following clean (class I, not contaminated) surgical procedures, the rate of surgical site infection (SSI) should be less than approximately 2%. However, an infection rate of 12.2% has been reported following removal of orthopedic implants used for treatment of fractures below the knee.

OBJECTIVE

To evaluate the effect of a single dose of preoperative antibiotic prophylaxis on the incidence of SSIs following removal of orthopedic implants used for treatment of fractures below the knee.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter, double-blind, randomized clinical trial including 500 patients aged 18 to 75 years with previous surgical treatment for fractures below the knee who were undergoing removal of orthopedic implants from 19 hospitals (17 teaching and 2 academic) in the Netherlands (November 2014-September 2016), with a follow-up of 6 months (final follow-up, March 28, 2017). Exclusion criteria were an active infection or fistula, antibiotic treatment, reimplantation of osteosynthesis material in the same session, allergy for cephalosporins, known kidney disease, immunosuppressant use, or pregnancy.

INTERVENTIONS

A single preoperative intravenous dose of 1000 mg of cefazolin (cefazolin group, n = 228) or sodium chloride (0.9%; saline group, n = 242).

MAIN OUTCOMES AND MEASURES

Primary outcome was SSI within 30 days as measured by the criteria from the US Centers for Disease Control and Prevention. Secondary outcome measures were functional outcome, health-related quality of life, and patient satisfaction.

RESULTS

Among 477 randomized patients (mean age, 44 years [SD, 15]; women, 274 [57%]; median time from orthopedic implant placement, 11 months [interquartile range, 7-16]), 470 patients completed the study. Sixty-six patients developed an SSI (14.0%): 30 patients (13.2%) in the cefazolin group vs 36 in the saline group (14.9%) (absolute risk difference, -1.7 [95% CI, -8.0 to 4.6], P = .60).

CONCLUSIONS AND RELEVANCE

Among patients undergoing surgery for removal of orthopedic implants used for treatment of fractures below the knee, a single preoperative dose of intravenous cefazolin compared with saline did not reduce the risk of surgical site infection within 30 days following implant removal.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02225821.

Wrapping grafting for congenital pseudarthrosis of the tibia: A preliminary report

OBJECTIVE

Treatment of congenital pseudarthrosis of the tibia (CPT) remains a challenge. The autogenic iliac bone graft is important consistent of treatment for CPT. The purpose of this study was to investigate the role of wrapping autogenic iliac bone graft in improvement of the curing opportunities of CPT.

METHODS

We combined Ilizarov fixator with intramedullary rodding of the tibia and wrapping autogenic iliac bone graft for treatment 51 cases of CPT between 2007 and 2010. The mean age is 3.2 years at index operation, of which 31 patients (61%) were below 3 years old. According to Crawford classification, 5 tibia had type-II morphology; 3, type-III; 43, type-IV.

RESULTS

In the postoperative follow-up of 3.5 months (range from 3 to 4.5 months), all cases were found that the bone graft sites of pseudarthrosis of the tibia showed a significant augmentation and spindle-shaped expansion as obvious change. All cases of this series have been followed-up, average followed-up time were 1.6 years (range from 7 to 3.1 years), of which 19 cases were more than 2 years. The average time of removed the Ilizarov ring fixator was 3.5 months (range from 3 to 4.5 months). According to Johnston Clinical evaluation system, 26 cases had grade I, 21 cases, grade II, 4 cases, grade III. Following the Ohnishi X-ray evaluation criteria, union of pseudarthrosis of the tibia were 42 cases, delayed union 5 cases, nonunion 4 cases.

CONCLUSION

Autogenic iliac bone graft is able to offer the activity of osteoblasts and osteogenesis induced by bone morphogenetic protein (BMP) and glycoprotein, meanwhile enclosing bone graft could help keep cancellous bone fragments in close contact around pseudarthrosis of the tibia, allowing the formation of high concentration of glycoprotein and BMP induced by chemical factors because of established the sealing environment in location, all of which could enhance the healing of pseudarthrosis of the tibia.

Bosworth and modified Phemister techniques revisited. A comparison of intraarticular vs extraarticular fixation methods in the treatment of acute Rockwood type III acromioclavicular dislocations

OBJECTIVE

The aim of this study was to compare the long-term clinical and radiological results of Acromioclavicular (AC) fixation with K-wires (the modified Phemister procedure) and Coracoclavicular (CC) fixation with the Bosworth screw in the surgical treatment of Type 3 AC joint dislocations.

METHODS

Thirty-two patients with complete set of medical records and who received surgical treatment between September 2005 and January 2009 due to acute Rockwood Type 3 AC joint dislocation and properly attended their follow-ups were retrospectively evaluated. Sixteen patients (13 males, 3 females; mean age: 38, range: 24-52 years) were treated with CC fixation with Bosworth screw (Group 1), and the other 16 (12 males, 4 females; mean age: 53.3, range: 38-64 years) with AC fixation using K-wires (Group 2).

RESULTS

The mean follow-up time was 96 months for Group 1 and 93 months for Group 2 patients (p > 0.05). The mean Constant-Murley score at the final follow-up was 84.7 in Group 1 and 87.3 in Group 2 (p = 0.069). Radiological evaluation of the patients revealed AC arthrosis in 2 and 3 patients in Group 1 and 2, respectively. In Group 2, one patient had a recurrent dislocation, three patients had AC arthrosis and two patients had ossification in the CC ligament (Fig. 2). There was no superficial or deep wound infection in Group 1, while two patients from Group 2 had a superficial wound infection.

CONCLUSIONS

Our results suggest that both techniques are reliable and provide adequate reduction and similar outcomes in terms of functionality and pain levels, following the reduction of Type 3 AC joint dislocations. With lower rates of wound site infection in the early and AC arthrosis in the late postoperative period, CC fixation method with the Bosworth screw may be a better surgical option than AC fixation method with K-wires.

LEVEL OF EVIDENCE

Level III, Therapeutic study.

Fat grafting for resurfacing an exposed implant in lower extremity: A case report

RATIONALE

Although numerous reconstruction protocols have been reported for lower leg trauma, those for distal leg trauma remain few. We present the case of a woman with an implant exposure wound, who was successfully treated through fat grafting, without major flap surgery.

PATIENT CONCERNS

An 83-year-old woman with an exposed implant in lower extremity received reconstruction surgery once and the surgery failed. She refused additional major surgery and negative pressure wound therapy.

DIAGNOSES

The diagnosis of a tibia and fibula shaft open fracture (type IIIA) complicated with an exposed implant was made.

INTERVENTIONS

The procedure was performed by deploying purified and emulsified fat with a Micro-Autologous Fat Transplantation gun. The required lipoaspirate amount was grossly estimated using a standard formula: 0.5 cc of a lipoaspirate per square centimeter of wound. We prepared the lipoaspirate simply through centrifugation followed by physical emulsification. The endpoint of fat grafting was when lipoaspirate began to flow out of the wound. The initial dressing after the procedure included the topical usage of biomycin ointment with AQUACEL Foam (ConvaTec Inc., NC, USA) coverage, which was later changed to INTRASITE gel (Smith & Nephew, London, UK) with a gauze dressing for 4 weeks. After 4 weeks, dressing components were changed to Mepilex (Mölnlycke Health Care, Gothenburg, Sweden) alone.

OUTCOMES

The wound healed completely without requiring major flap surgery by 18 weeks after surgery.

LESSONS

Fat grafting is one kind of cell therapy and potentially has regenerative effects during wound healing. Fat grafting is critical in the healing processes of complicated wounds and might be considered a step in reconstruction surgery.

Pipkin type III femoral head fracture-dislocation combined with complicated acetabular fracture: A rare case report and literature review

RATIONALE

Pipkin III fracture, which is characterized by high risk of avascular necrosis of the femoral head, is extremely rare. It is more difficult to treat and has a worse prognosis when accompanied with severe acetabular fractures. Few studies show that both Pipkin type III femoral head fracture-dislocation and complicated acetabular fracture presented in one patient.

PATIENT CONCERNS

A 34-year-old male suffered a terrible traffic accident with a serious damage to the left side when he was sitting in the car's cockpit. Pelvic radiograph and 3-dimensional reconstruction of computed tomography revealed characteristics of fractures before the emergency operation.

DIAGNOSIS

Pipkin III fractures combined with complicated acetabular fracture.

INTERVENTIONS

Firstly, we used combined anterior and posterior approach for treatment to fix the femoral head fractures. Then, we completed anatomical reduction of fractures with countersunk head screw, hollow screw, and reconstruction plate.

OUTCOMES

At the 12-months follow-up, the patient could walk freely and perform activities of daily living without necrosis of femoral head and heterotopic ossification.

LESSONS

Although there are serious complications in Pipkin III fractures combined with complicated acetabular fracture, early surgical treatment with appropriate approach and fixation could get satisfactory results.

Pectus Excavatum: A Review of Diagnosis and Current Treatment Options

Osteopathic medicine places a special emphasis on the musculoskeletal system, and understanding how chest wall structure may influence function is critical. Pectus excavatum is a common congenital chest wall defect in which the sternum is depressed posteriorly. Patients may present with complaints of chest wall discomfort, exercise intolerance, and tachycardia. The medical implications, diagnosis, and treatment options for patients with pectus excavatum are reviewed.

A cost-utility analysis of Dynesys dynamic stabilization versus instrumented fusion for the treatment of degenerative lumbar spine diseases

BACKGROUND

Symptomatic chronic low back and leg pain resulting from lumbar spine degenerative disorders is highly prevalent in China, and for some patients, surgery is the final option for improvement. Several techniques for spinal non-fusion have been introduced to reduce the side-effects of fusion methods and hasten postoperative recovery. In this study, the authors have evaluated the cost-effectiveness of Dynesys posterior dynamic stabilization system (DY) compared with lumbar fusion techniques in the treatment of single-level degenerative lumbar spinal conditions.

METHODS

A total of 221 patients undergoing single-level elective primary surgery for degenerative lumbar pathology were included. 2-Year postoperative health outcomes of Visual Analogue Scale (VAS) for back and leg pain, Oswestry Disability Index (ODI), 36-Item Short Form Health Survey (SF-36) and EuroQol-5 Dimensions (EQ-5D) questionnaires were recorded. 2-Year back-related medical resource use, missed work, and health-state values (Quality-adjusted life-year [QALY]) were assessed. Cost-effectiveness was determined by the incremental cost per QALY gained.

RESULTS

At each follow-up point, both cohorts were associated with significant improvements in VAS scores, ODI, SF-36 scores and EQ-5D QALY scores, which persisted at the 2-year evaluation. The 2-year total mean cost per patient were significantly lower for Dynesys system ($20,150) compared to fusion techniques ($25,581, $27,862 and $27,314, respectively) (P < 0.001). Using EQ-5D, the mean cumulative 2-year QALYs gained were statistically equivalent between the four groups (0.28, 0.27, 0.30 and 0.30 units, respectively) (P = 0.74). Results indicate that patients implanted with the DY system derive lower total costs and more utility, on average, than those treated with fusion.

CONCLUSIONS

The Dynesys dynamic stabilization system is cost effective compared to instrumented lumbar fusion for treatment of single-level degenerative lumbar disorders. It is not possible to state whether DY or lumbar fusion is more cost-effective after 2 years.

Metastable Zr-Nb alloys for spinal fixation rods with tunable Young's modulus and low magnetic resonance susceptibility

Good ductility, low magnetic susceptibility, and tunable Young's modulus are highly desirable properties for materials usage as spinal fixation rods. In this study, the effects of niobium content on the microstructure, magnetic susceptibility, and mechanical properties of Zr-xNb (13≤x≤23wt%) alloys were investigated. For the Zr-15Nb and Zr-17Nb alloys, a remarkable increase in Young's modulus was achieved due to the occurrence of deformation-induced ω phase transformation. This was the result of the competition of two factors associated with the Nb content: an increase of the stability of β phase and a decrease of the amount of athermal ω phase with increasing Nb content. When the Nb content was 15% or 17%, the amount of deformation-induced ω phase was maximum. Moreover, the magnetic susceptibility decreased with the deformation-induced β→ω phase transformation, and the Zr-17Nb alloy with apparent kink bands exhibited a smaller amount of springback than the Zr-15Nb alloy with {332} 〈113〉 mechanical twins. Furthermore, the ions released from the Zr-xNb alloys in accelerated immersion tests were at a very low level. The combination of low initial Young's modulus, and its remarkable variation induced by deformation, low magnetic susceptibility, good ductility, and smaller springback make the Zr-17Nb alloy a potential candidate for spinal fixation rods.

STATEMENT OF SIGNIFICANCE

For the rods of spinal fixation devices, it is important but difficult to lower the springback for bending formativeness while keeping the low initial Young's modulus for biocompatibility and lower the magnetic susceptibility for postoperative examination simultaneously. In this study, Zr-17Nb alloy was successfully developed via deformation-induced ω phase transformation during loading, simultaneously meeting the abovementioned properties for spinal fixation rods.

Resorbable versus titanium plates for orthognathic surgery

BACKGROUND

Recognition of some of the limitations of titanium plates and screws used for the fixation of bones has led to the development of plates manufactured from bioresorbable materials. Whilst resorbable plates appear to offer clinical advantages over metal plates in orthognathic surgery, concerns remain about the stability of fixation and the length of time required for their degradation and the possibility of foreign body reactions. This review compares the use of titanium versus bioresorbable plates in orthognathic surgery and is an update of the Cochrane Review first published in 2007.

OBJECTIVES

To compare the effects of bioresorbable fixation systems with titanium systems used during orthognathic surgery.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 20 January 2017); the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 11) in the Cochrane Library (searched 20 January 2017); MEDLINE Ovid (1946 to 20 January 2017); and Embase Ovid (1980 to 20 January 2017). We searched the US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov (clinicaltrials.gov; searched 20 January 2017), and the World Health Organization International Clinical Trials Registry Platform (searched 20 January 2017) for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

Randomised controlled trials comparing bioresorbable versus titanium fixation systems used for orthognathic surgery in adults.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the results of the electronic searches, extracted data and assessed the risk of bias of the included studies. We resolved disagreement by discussion. Clinical heterogeneity between the included trials precluded pooling of data, and only a descriptive summary is presented.

MAIN RESULTS

This review included two trials, involving 103 participants, one comparing titanium with resorbable plates and screws and the other titanium with resorbable screws. Both studies were at high risk of bias and provided very limited data for the primary outcomes of this review. All participants in one trial suffered mild to moderate postoperative discomfort with no statistically significant difference between the two plating groups at different follow-up times. Mean scores of patient satisfaction were 7.43 to 8.63 (range 0 to 10) with no statistically significant difference between the two groups throughout follow-up. Adverse effects reported in one study were two plate exposures in each group occurring between the third and ninth months. Plate exposures occurred mainly in the posterior maxillary region, except for one titanium plate exposure in the mandibular premolar region. Known causes of infection were associated with loosened screws and wound dehiscence with no statistically significant difference in the infection rate between titanium (3/196), and resorbable (3/165) plates.

AUTHORS' CONCLUSIONS

We do not have sufficient evidence to determine if titanium plates or resorbable plates are superior for fixation of bones after orthognathic surgery. This review provides insufficient evidence to show any difference in postoperative pain and discomfort, level of patient satisfaction, plate exposure or infection for plate and screw fixation using either titanium or resorbable materials.

Usefulness of titanium mesh cage for posterior C1-C2 fixation in patients with atlantoaxial instability

The aim of this study was to investigate the usefulness of titanium mesh cage as an interlaminar spacer combined with nitinol shape memory loop fixation in patients with atlantoaxial instability.From April 2009 to March 2017, among the patients with atlantoaxial instability, a total of 30 patients were treated by nitinol shape memory loop fixation combined with titanium mesh cage as a spacer. We retrospectively reviewed 30 enrolled patients. Successful fusion was determined as improvement of symptoms and radiologic findings of bone fusion. We also reviewed surgical complications, instrumentation failure, bony fusion rate, and posterior atlantodental interval (PADI).After surgery, the symptoms of all patients significantly improved. Successful fusion was documented throughout the follow-up period. Evidence of solid bridging bone was found, and no instability was seen on flexion-extension radiographs and callus formation on 3D cervical spine computed tomography (CT) 6 months postoperatively in all cases. No surgical complications were observed. No cases of instrumentation failure were observed. The mean PADI also improved significantly to 22.45 ± 1.11 mm 6 months postoperatively compared with the preoperative value of 18.37 ± 1.16 mm (P < .05).We obtained a good fusion rate by using titanium mesh cage spacer with nitinol shape memory alloy loop in patients with atlantoaxial instability. This technique can help surgeons in avoiding vertebral artery injury and reducing bleeding and operation time. Therefore, we suggest that titanium mesh cage spacer combined with nitinol shape memory alloy loop can be a good substitute of autograft for C1-C2 fusion in treating atlantoaxial instabilities.

Reduction of intradiscal pressure by the use of polycarbonate-urethane rods as compared to titanium rods in posterior thoracolumbar spinal fixation

Loss of sagittal alignment and balance in adult spinal deformity can cause severe pain, disability and progressive neurological deficit. When conservative treatment has failed, spinal fusion using rigid instrumentation is currently the salvage treatment to stop further curve progression. However, fusion surgery is associated with high revision rates due to instrumentation failure and proximal junctional failure, especially if patients also suffer from osteoporosis. To address these drawbacks, a less rigid rod construct is proposed, which is hypothesized to provide a more gradual transition of force and load distribution over spinal segments in comparison to stiff titanium rods. In this study, the effect of variation in rod stiffness on the intradiscal pressure (IDP) of fixed spinal segments during flexion-compression loading was assessed. An ex vivo multisegment (porcine) flexion-compression spine test comparing rigid titanium rods with more flexible polycarbonate-urethane (PCU) rods was used. An increase in peak IDP was found for both the titanium and PCU instrumentation groups as compared to the uninstrumented controls. The peak IDP for the spines instrumented with the PCU rods was significantly lower in comparison to the titanium instrumentation group. These results demonstrated the differences in mechanical load transfer characteristics between PCU and titanium rod constructs when subjected to flexion-compression loading. The concept of stabilization with a less rigid rod may be an alternative to fusion with rigid instrumentation, with the aim of decreasing mechanical stress on the instrumented segments and the possible benefit of a decrease in the incidence of screw pullout.

Morphological analysis of interbody fusion following posterior lumbar interbody fusion with cages using computed tomography

Posterior lumbar interbody fusion (PLIF) using cages in conjunction with pedicle screw fixation is considered the gold standard for surgical treatment of degenerative lumbar spine disorders due to its biomechanical stability and high fusion rate. However, research regarding patterns of fusion in the interbody space during the early postoperative period is lacking.Sixty consecutive patients were recruited from May 2013 to June 2015. All patients underwent PLIF using 2 titanium cages filled with local bone chips from decompressed lamina and facet bone in conjunction with pedicle screw fixation. Computed tomography scans were obtained 3 to 6 months following surgery in order to evaluate the partial fusion state. Computed tomography (CT) classification of fusion morphology was divided into 8 groups and then into compartments according to fusion space, and the rate of fusion for each was calculated. Further follow-up was conducted to confirm fusion state and assess outcomes.The most frequent pattern of interbody fusion was bilateral intra-cage fusion with unilateral lateral bridging of extra-cage areas (N = 36, 43.4%); the least frequent was interspace bridging of the 2 cages alone (N = 0, 0%). The fusion rate for the intra-cage area (Compartment 1) reached 100%. However, the fusion in the lateral space outside of cages (Compartment 2) was not satisfactory, though reasonable (72.3%). All patients were confirmed as achieving adequate fusion at the final follow-up, with improved clinical outcomes.Widening of the contact area between the vertebral body and cages is recommended to promote increased interbody fusion during the early postoperative period.