Is the anterior approach still superior to posterior correction in AIS regarding correction, fusion levels and kyphosis when modern posterior systems are used?

PURPOSE

The aim of our study is to compare anterior and posterior corrections of thoracic (Lenke I) and lumbar (Lenke V) curves when modern posterior pedicle screw systems with vertebral derotation techniques are used. Curves that could not be corrected with both systems were excluded.

METHODS

A thoracic group (N = 56) of Lenke I AIS patients (18 anterior and 38 posterior) and a lumbar group (N = 42) of Lenke V patients (14 anterior and 28 posterior) with similar curves < 65° were identified.

RESULTS

Thoracic group The mean postoperative correction (POC) was 68 ± 13.4% in the anterior and 72 ± 10.5% in the posterior group. The postoperative change in thoracic kyphosis was +4° and +5° respectively. The median length of fusion was eight segments in the posterior and seven segments in the anterior groups. In 89% the LIV was EV or shorter in the anterior, and in 71% of the posterior corrections. Lumbar group The mean POC was 75 ± 18.3% (anterior) and 72 ± 8.5% (posterior). The postoperative gain in lumbar lordosis was 0.8° (anterior) and 4° (posterior). The median length of fusion was five segments in both groups and there was no difference in relation of the LIV to the EV.

CONCLUSION

With modern implants and derotation techniques, the posterior approach can achieve similar coronal correction, apical derotation and thoracic kyphosis with similar length of fusion and better lumbar lordosis restoration.

Partial glass-ceramic posterior restorations with margins beyond or above the cemento-enamel junction: An observational retrospective clinical study

PURPOSE

This observational retrospective clinical study aimed to investigate the survival and success rates of partial indirect lithium disilicate restorations with margins extending above or beyond the cementoenamel junction (CEJ).

METHODS

The study included patients who underwent partial indirect lithium disilicate restorations with immediate dentin sealing (IDS) between January 2008 and October 2018. All the restorations were placed in a single general dental practice following a standardized protocol. The impact of various predictive variables on the survival rates was assessed. Moreover, modified United States Public Health Service (USPHS) criteria were used to evaluate the survival quality.

RESULTS

Totally 1146 partial indirect lithium disilicate restorations in 260 patients were evaluated over an average period of 7.5 years. The cumulative survival and success rates were 97.3% and 95.3%, respectively. Margins extending beyond the cemento-enamel junction did not increase the risk of success or survival failure (P > 0.05). Patients with a high risk of caries, male sex, or non-vital teeth had a significantly higher risk of restoration failure (P < 0.05). Restorations with longer clinical service times exhibited marginally lower clinical quality (P < 0.001).

CONCLUSIONS

Partial indirect glass-ceramic restorations demonstrated survival and success rates of 97.3% and 95.3%, respectively, over an extended period. However, a higher risk of restoration failure existed in patients with a high caries risk for (pre)molars that had undergone endodontic treatment and in males. In terms of the risk of success or survival failure, comparable results were obtained for the positions of the restoration margin in relation to the cemento-enamel junction.

Prospective Investigation of the Posterior Longitudinal Ligament and Disc Complex after Posterior Stabilization and Decompression Surgery in Patients With Non-OPLL (Ossification of the Posterior Longitudinal Ligament) Cervical Spondylotic Myelopathy

BACKGROUND

Cervical spondylotic myelopathy (CSM) is a prevalent cause of spinal cord dysfunction in adults, primarily from degenerative changes. The efficacy of treatment strategies, especially surgical approaches, remains debated.

OBJECTIVE

This study aimed to assess the long-term impact of posterior fusion laminectomy on the posterior longitudinal ligament (PLL) thickness, disc complex, and myelomalacia signal changes in CSM patients.

METHODS

A single-centre, prospective study from January 2020 to December 2021 included CSM patients without ossified posterior longitudinal ligament (OPLL). Magnetic resonance imaging (MRI) data from baseline, 6, and 12 months postoperatively were collected. Measurements on the MRI were performed using the Osirix MD software, focusing on the PLL width, myelopathic foci dimensions, and canal diameter.

RESULTS

Out of the 82 initially enrolled patients, 64 were considered for analysis. Postoperatively, a significant reduction in PLL width and myelopathic foci dimensions was observed, alongside a considerable increase in the canal diameter. Clinical outcomes based on the Modified Japanese Orthopaedic Association (mJOA) scale also showcased marked improvements post-surgery.

CONCLUSIONS

Posterior fusion laminectomy effectively reduces anterior pressure in CSM patients. This treatment may represent an optimal surgical approach for selected CSM cases. Furthermore, more extensive studies with extended follow-up are advocated.

Evaluation of the Anatomical Reference Point in Posterior Minimally Invasive Atlantoaxial Spine Surgery: A Cadaveric Anatomical Study

OBJECTIVE

Minimally invasive atlantoaxial surgery offers the benefits of reduced trauma and quicker recovery. Previous studies have focused on feasibility and technical aspects, but the lack of comprehensive safety information has limited its availability and widespread use. This study proposes to define the feasibility and range of surgical safety using the intersection of the greater occipital nerve and the inferior border of the inferior cephalic oblique as a reference point.

METHODS

Dissection was performed on 10 fresh cadavers to define the anatomical reference point as the intersection of the greater occipital nerve and the inferior border of the inferior cephalic oblique muscle. The study aimed to analyze the safety range of minimally invasive atlantoaxial fusion surgery by measuring the distance between the anatomical reference point and the transverse foramen of the axis, the distance between the anatomical reference point and the superior border of the posterior arch of the atlas, and the distance between the anatomical reference point and the spinal canal. Measurements were compared using Student's t test.

RESULTS

The point where the occipital greater nerve intersects with the inferior border of the inferior cephalic oblique muscle was defined as the anatomical marker for minimally invasive posterior atlantoaxial surgery. The distance between this anatomical marker and the transverse foramen of the axis was measured to be 9.32 ± 2.04 mm. Additionally, the distance to the superior border of the posterior arch of the atlas was found to be 21.29 ± 1.93 mm, and the distance to the spinal canal was measured to be 11.53 ± 2.18 mm. These measurement results can aid surgeons in protecting the vertebral artery and dura mater during minimally invasive posterior atlantoaxial surgery.

CONCLUSIONS

The intersection of the greater occipital nerve with the inferior border of the inferior cephalic oblique muscle is a safe and reliable anatomical landmark in minimally invasive posterior atlantoaxial surgery.

Body morphometry did not affect the accuracy of a second-generation, miniature imageless navigation system for total hip arthroplasty (THA) using a posterior approach

Introduction

Some modern imageless navigation platforms for total hip arthroplasty (THA) rely on virtual frontal and sagittal planes determined with the patient in the lateral decubitus position. Body morphometry that changes with gender, body mass index, and other demographic factors may affect accuracy in patient positioning and consequently, navigation accuracy. The objective of this study was to analyze the influence of patient factors on the intraoperative accuracy of a second-generation imageless computer-assisted surgery platform.

Methods

325 consecutive patients undergoing posterior approach, navigated THA arthroplasty for primary osteoarthritis by a single surgeon were retrospectively reviewed. An optic-based imageless navigation system referenced off a generic sagittal and coronal plane was used to determine acetabular inclination and anteversion. Acetabular accuracy was determined by assessing differences between intraoperative values and those obtained from measuring standardized 6-week follow-up radiographs. The effect of age, gender, BMI, race, ethnicity, and laterality on acetabular accuracy was assessed via t-tests, Pearson correlation and ANOVA.

Results

Gender had a significant impact on raw inclination accuracy (females and males had an average error of 1.41° and -1.03°, respectively - p < 0.001). There was a weak correlation between acetabular accuracy and patient age and BMI as a continuous variable (both absolute γ < 0.2). No difference was found between acetabular accuracy and BMI groups.

Conclusion

This second-generation imageless computer assisted device provided accurate cup positioning regardless of patient's BMI. Gender was the only factor impacting inclination accuracy.

Clinical performance of bonded partial lithium disilicate restorations: The influence of preparation characteristics on survival and success

OBJECTIVES

The aim of this study was to investigate the influence of preparation characteristics on the survival, success, and clinical performance of partial indirect lithium disilicate restorations with immediate dentin sealing.

METHODS

This retrospective clinical study evaluated partial indirect lithium disilicate restorations placed in conjunction with Immediate Dentin Sealing (IDS) in (pre)molar teeth between March 2018 and May 2021. The restorations were luted using pre-heated composite. The study focused on survival, success, and clinical performance, which was evaluated using the modified United States Public Health Service (USPHS) criteria. Results were analyzed using the Kaplan-Meier estimates, log-rank tests, and Fisher exact tests.

RESULTS

Partial indirect lithium disilicate restorations (N = 454) were evaluated in 214 patients. The mean evaluation time was 37 months, with a cumulative survival rate of 99.2 % and a cumulative success rate of 97.6 %. Fourteen failures occurred, with endodontic pathology as the predominant failure mode, followed by secondary caries, debonding, and tooth fracture. No statistically significant influence of the preparation variables on survival and success was observed (p > .05). The short-term clinical performance was clinically acceptable in > 90 % of the evaluations.

CONCLUSIONS

This retrospective study on partial indirect lithium disilicate restorations in conjunction with IDS demonstrates survival and success rates of 99.2 and 96.7 % over a mean evaluation period of 37 months. A marked influence of the studied preparation characteristics on the survival, success and clinical performance of lithium disilicate partial restorations could not be demonstrated. Partial lithium disilicate restorations exhibit good clinical performance in >90 % of the cases.

CLINICAL SIGNIFICANCE

The results of this study suggest that preparation characteristics had no significant impact on the survival, success, and clinical performance of partial lithium disilicate restorations in conjunction with IDS. Results show good clinical performance and high survival and success rates, regardless of preparation characteristics.

Direct osteosynthesis in the treatment of atlas burst fractures: a systematic review

PURPOSE

The treatment of unstable atlas fractures remains a controversial topic. The study aims at assessing the prognosis and efficacy of osteosynthesis for unstable atlas fractures through a review of the current literature and additionally aims to compare outcomes between the transoral and posterior approaches.

METHODS

A systematic review of databases including PubMed, EMBASE, Cochrane, Web of Science, CNKI, and Wanfang was conducted. Titles and abstracts were screened by two reviewers to identify studies meeting pre-defined inclusion criteria for comprehensive analysis.

RESULTS

The systematic review included 28 articles, 19 employing the posterior approach and 9 utilizing the transoral approach. It covered osteosynthesis in 297 patients with unstable atlas fractures, comprising 169 treated via the posterior approach and 128 via the transoral approach. Analysis revealed high healing rates and clinical improvement in both approaches, evidenced by improvements in the visual analog scale, range of motion, atlantodens interval, and lateral displacement distance post-surgery.

CONCLUSION

Osteosynthesis offers effective treatment for unstable atlas fractures. Both transoral and posterior approaches can achieve good clinical outcomes for fracture, and biomechanical studies have confirmed that osteosynthesis can maintain the stability of the occipitocervical region, preserve the motor function of the atlantoaxial and occipito-atlantoaxial joints, and greatly improve the quality of life of patients. However, variations exist in the indications and surgical risks associated with each method, necessitating their selection based on a thorough clinical evaluation of the patient's condition.

The prone posteromedial approach to the knee revisited: a safe and effective strategy for posterior tibial plateau fractures

PURPOSE

To compare outcomes of patients with posterior tibial plateau fractures who underwent repair indirectly with an anterior approach to those who underwent direct repair with a prone "Lobenhoffer" operative approach.

METHODS

A total of 44 patients with a posterior column tibial plateau fracture that underwent repair were identified. Twenty-two patients with 22 tibial plateau fractures were fixed using a prone Lobenhoffer approach. They were compared to 22 patients treated with an indirect reduction using a supine approach for similar fracture patterns. Data collection at minimum 1 year included: patient-reported outcome scores (SMFA), patient-reported pain, knee range of motion, complications and need for reoperation. Radiographs were reviewed for knee alignment, residual depression and fracture healing.

RESULTS

All demographics were similar between the groups except BMI, which was lower in the prone group (P < 0.05). Fracture type according to age, Schatzker and three-column classification was matched between cohorts. There was no difference in outcomes including: pain, radiographic knee alignment, residual articular depression, functional outcome (SMFA), complications and need for reoperations. Knee flexion at 1 year was greater in the prone group (127.8 vs. 115.8; P = 0.018). In addition, surgical time was less in the prone group (mean 73.7 min vs. 82.3 min; P = 0.015).

CONCLUSION

The Lobenhoffer approach with direct reduction of posterior fracture fragments for complex tibial plateau fractures is an excellent option for these injuries. It allowed for faster surgery with improved ultimate knee range of motion in posterior column tibial plateau fractures.

Arthroscopic posterior capsulolabral repair grants adequate outcomes in shoulders with posterior instability without glenoid cartilage lesions

INTRODUCTION

Posterior capsulolabral repair (posterior Bankart) is effective to restore shoulder stability and relieve pain, though a recent meta-analysis reported recurrent instability in 9.5% of patients, and that only 62.7% were able to resume sports. The purpose of this study was to assess the outcomes of arthroscopic posterior capsulolabral repair in a population of unselected patients, in terms of recurrence of instability, clinical scores, and return to sports.

METHODS

The authors retrospectively studied a consecutive series of 22 patients that underwent posterior capsulolabral repair between 2009 and 2019. Patients were assessed before posterior capsulolabral repair and at a minimum follow-up of 24 months, in terms of subjective shoulder value (SSV), Western Ontario Shoulder Instability Index (WOSI), as well as level of sport. Following surgery, all complications, reoperations or episodes of instability were noted.

RESULTS

The cohort comprised 21 men (95%) and 1 woman (5%), aged 38.8 ± 12.5 years (range 17-61) at index surgery. Of the 20 patients that performed sports, only 2 (10%) stopped sports after surgery, while 18 resumed their main sport (90%). At a follow-up of 65.4 ± 34.8 months (range 25-146), the SSV was 85.1 ± 14.7, pain on VAS was 1.9 ± 2.1, and the Constant-Murley score was 71.6 ± 17.9. Five patients had subjective instability without dislocation (23%). Nine patients (41%) had no pain (0 points), 6 patients (27%) had mild pain (1-2 points), 4 patients (18%) had moderate pain (3 points), while 3 patients (14%) had severe pain (5-8 points).

CONCLUSION

Arthroscopic posterior capsulolabral repair prevented recurrent dislocation in patients with posterior shoulder instability at a minimum follow-up of 2 years, despite persistent pain in 32%, and subjective instability in 23%. These complications were mainly observed in patients with work-related accidents and glenoid cartilage lesions.

LEVEL OF EVIDENCE

III, case series.

Traumatic posterior sternoclavicular joint dislocation - Current aspects of management

The posterior sternoclavicular joint dislocation is a rare and potentially life-threatening injury, as massive haemorrhage can occur at the time of trauma, during reduction manoeuvres and drilling. These injuries are rare and a collective experience of managing them is of paramount importance. We present our multidisciplinary experience of managing several of these injuries in our centre, with learning points we have identified. Assessment should include Computerised Tomography Angiography (CTA) to assess the anatomy of the joint including the proximity to the underlying innominate vein and to identify any bleeding. Both closed reduction and open reconstruction have the potential for massive haemorrhage which can be controlled successfully with direct access to the underlying vessel. We recommend that all reductions should be performed in the presence of a cardiothoracic surgeon who can gain vascular control in the head, neck, and thorax. In specific high-risk cases, pre-emptive venous catheterisation can also be considered. We recommend that a discussion and rehearsal for intra-operative bleeding should be undertaken with the whole theatre team, with roles assigned pre-emptively and to allow identification of any deficiencies in staff expertise or equipment. Of the five recent cases managed in our centre one patient had a closed reduction and four had open reductions. Success of closed reductions within 48 h is high and these can be attempted up to 10 days after injury. Our patient undergoing closed reduction had a favourable outcome and returned to professional rugby at five months. Open reduction was performed in a physeal fracture as there was a delay to surgery and callus had begun to form and had the potential to adhere to the underlying vessel. In this case we performed open reduction and stabilised with tunnelled suture fixation. Our preferred method of reconstruction uses a palmaris graft with internal figure of eight bracing. One patient had a subsequent fracture of the medial clavicle around the drill holes that healed without further intervention. Despite good reduction and stability achieved following palmaris reconstructions, two patients are experiencing ongoing symptoms of globus and one with voice change without any objective underlying cause.

Stroke with large vessel occlusion in the posterior circulation: IV thrombolysis plus thrombectomy versus IV thrombolysis alone

Efficacy and safety of mechanical thrombectomy (MT) for stroke with posterior circulation large vessel occlusion (LVO) is still under debate. We aimed to compare the outcomes of stroke patients with posterior circulation LVO treated with intravenous thrombolysis (IVT) (< 4.5 h after symptom onset) plus MT < 6 h after symptom onset with those treated with IVT alone (< 4.5 h after symptom onset). Patients enrolled in the Italian Registry of Endovascular Treatment in Acute Stroke (IRETAS) and in the Italian centers included in the SITS-ISTR were analysed. We identified 409 IRETAS patients treated with IVT plus MT and 384 SITS-ISTR patients treated with IVT alone. IVT plus MT was significantly associated with higher rate of sICH (ECASS II) compared with IVT alone (3.1 vs 1.9%; OR 3.984, 95% CI 1.014-15.815), while the two treatments did not differ significantly in 3-month mRS score ≤ 3 (64.3 vs 74.1%; OR 0.829, 95% CI 0.524-1.311). In 389 patients with isolated basilar artery (BA) occlusion, IVT plus MT was significantly associated with higher rate of any ICH compared with IVT alone (9.4 vs 7.4%; OR 4.131, 95% CI 1.215-14.040), while two treatments did not differ significantly in 3-month mRS score ≤ 3 and sICH per ECASS II definition. IVT plus MT was significantly associated with higher rate mRS score ≤ 2 (69.1 vs 52.1%; OR 2.692, 95% CI 1.064-6.811) and lower rate of death (13.8 vs 27.1%; OR 0.299, 95% CI 0.095-0.942) in patients with distal-segment BA occlusion, while two treatments did not differ significantly in 3-month mRS score ≤ 3 and sICH per ECASS II definition. IVT plus MT was significantly associated with lower rate of mRS score ≤ 3 (37.1 vs 53.3%; OR 0.137, 0.009-0.987), mRS score ≤ 1 (22.9 vs 53.3%; OR 0.066, 95% CI 0.006-0.764), mRS score ≤ 2 (34.3 vs 53.3%; OR 0.102, 95% CI 0.011-0.935), and higher rate of death (51.4 vs 40%; OR 16.244, 1.395-89.209) in patients with proximal-segment BA occlusion. Compared with IVT alone, IVT plus MT was significantly associated with higher rate of sICH per ECASS II definition in patients with stroke and posterior circulation LVO, while two treatment groups did not differ significantly in 3-month mRS score ≤ 3. IVT plus MT was associated with lower rate of mRS score ≤ 3 compared with IVT alone in patients with proximal-segment BA occlusion, whereas no significant difference was found between the two treatments in primary endpoints in patients isolated BA occlusion and in the other subgroups based on site occlusion.

First-pass effect in posterior acute ischemic stroke undergoing endovascular thrombectomy: A systematic review and meta-analysis

OBJECTIVES

First-pass effect (FPE) has been shown to be a predictor of favorable clinical outcomes following endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) in the anterior circulation. Literature regarding FPE for posterior circulation AIS is sparse; we conducted a systematic review and meta-analysis to explore FPE in posterior circulation stroke undergoing EVT.

MATERIALS AND METHODS

We conducted a systematic review of the English literature in PubMed, Embase, Scopus, and Web of Science. FPE was defined as thrombolysis in cerebral infarction (TICI) 2c-3 and modified FPE (mFPE) was defined as TICI 2b-3 in one pass. Definitions of non-FPE and non-mFPE varied among studies. The primary outcome of interest was modified Rankin Scale (mRS) 0-2. Secondary outcomes of interest were mRS 0-3, symptomatic intracranial hemorrhage (sICH), and mortality. We calculated odds ratios (OR) and corresponding 95% confidence intervals (CI). Heterogeneity was assessed with Q statistic and I2 test.

RESULTS

Seven studies with 417 patients in the mFPE group, 942 in the non-mFPE group, 545 in the FPE group, and 1023 in the non-FPE group were included. Overall, FPE was associated with greater rates of 90-day mRS 0-2 (OR= 2.78, 95% CI= 2.11-3.65; P-value< 0.001) and mRS 0-3 (OR= 2.67, 95% CI= 1.98-3.60; P-value< 0.001); however, there was significant heterogeneity among studies for both mRS 0-2 (I2= 69%; P-value< 0.001) and mRS 0-3 (I2= 69%; P-value< 0.001). FPE and non-FPE were associated with similar rates of sICH (OR= 0.65, 95% CI= 0.40-1.07; P-value= 0.09), and no heterogeneity was observed (I2= 0%; P-value= 0.95). FPE was associated with lower rates of mortality (OR= 0.44, 95% CI= 0.33-0.58; P-value< 0.001), although heterogeneity was observed (I2= 58%; P-value= 0.01).

CONCLUSIONS

FPE is associated with favorable clinical outcomes in patients undergoing EVT for posterior circulation AIS. Future studies should work to further quantify the impact of FPE on outcomes in the posterior circulation.

Refractory post-surgical cystoid macular edema managed following suprachoroidal microcatheterization and delivery of triamcinolone

BACKGROUND

Post-surgical macular edema (ME) is a common cause of prolonged visual impairment. Here we report on the feasibility and clinical outcomes from the use of a novel suprachoroidal microcatheter to treat post-surgical chronic ME by the posterior suprachoroidal placement of a triamcinolone acetonide (TA) suspension.

METHODS

Two patients were catheterized with the Oxulumis suprachoroidal delivery system on two separate occasions starting 5 and 10 mm posterior to the limbus. The catheter only remains in the suprachoroidal space for the time of the drug administration. Visual acuity and spectral domain optical coherence tomography (SD-OCT) changes were followed over several weeks to months to determine the duration of ME resolution.

RESULTS

Suprachoroidal microcatheterization for posterior delivery of triamcinolone was possible in all attempts using the illuminated Oxulumis catheter. No reflux, scleral or choroidal trauma was observed. There was no intraocular pressure rise during the follow-up period. The triamcinolone deposit was visible on infrared imaging and on SD-OCT a choroidal elevation was visible. Both progressively disappeared over time. A rapid resolution of ME associated with improved vision was observed following each injection for 3 to 7 months with a TA dose of 2.4 mg or 4 mg.

CONCLUSIONS

In these patients with poorly responsive ME, posterior suprachoroidal TA led to a visible suprachoroidal drug deposit and prolonged visual improvement. The Oxulumis microcatheterization device performed as expected and was not associated with any complications.

Posterior Olecranon Fracture Dislocations in Adults: A Systematic Review

Posterior olecranon fracture dislocations (POFDs) were considered posterior Monteggia lesions, which were less described in the literature. The purpose of this study was to provide a systematic review of the diagnosis, treatment, prognosis, and complications of POFDs in adults. A systematic review was performed to identify all relevant studies on the POFDs in the PubMed, Web of Science, Embase, and MEDLINE databases. The methodological quality of the studies was scored using the Methodological Index for Non-Randomized Studies (MINORS). A total of 117 patients were identified in the nine studies selected. The high-energy injuries accounted for 42.7% of the included studies. The rates of concomitant coronoid process, radial head fractures, and lateral collateral ligament injury were 84.6% (99/117), 87.2% (102/117), and 5% (6/117), respectively. The procedure was performed with a dorsal mid longitudinal approach to reconstruct all injury components. The postoperative clinical scores included the Broberg/Morrey rating, with a mean rating of excellent or good at 66%, the mean DASH score was 20.6, and the mean ASES score was 83. The flexion and extension arc and forearm rotation arcs were 100° and 134°, respectively. Complications included arthrosis in 28.2% (33/117) of cases, fracture nonunion or delayed union in 9.4% (11/117) of cases, heterotopic ossification in 7% (8/117) of cases, and the re-operation rate was 16% (19/117). There was nearly no postoperative ulnohumeral instability. The main characteristics of POFDs were disruptions of the trochlear notch, including the olecranon and coronoid processes, and severe radial head fractures, while the lateral collateral ligament was spared. Although the POFDs had a low frequency of instability, the prognosis was relatively poor. The POFDs should be considered independently.

A piriformis-preserving posterior approach reduces dislocation rate of the hemiarthroplasty in patients with femoral neck fracture

INTRODUCTION

The posterior approach (PA) for hemiarthroplasty (HA) in patients with femoral neck fracture (FFN) has a high risk of dislocation; however, by preserving the piriformis muscle, the dislocation rate could be lowered considerably. The aim of this study was to compare the surgical complications of the piriformis-preserving posterior approach (PPPA) and the PA in patients with FNF treated with HA.

METHODS

On 1 January 2019, the PPPA was introduced at two hospitals as the new treatment standard. The sample size was calculated based on a 5 percentage point dislocation reduction and 25% censoring; a sample of 264 patients per group was determined. An approximately 2-year inclusion period with 1-year follow-up was estimated, including a historical cohort from 2 years before the PPPA introduction. Data were retrieved from health care records and X-ray images from the hospitals' administrative databases. Relative risk (RR) and 95% confidence intervals were calculated using Cox regression and adjusted for age, sex, comorbidity, smoking, surgeon experience and implant type.

RESULTS

There were 527 patients included in the study, of which 72% were women and 43% were above 85 years old. There were no baseline differences between the PPPA and PA groups in sex, age, comorbidity, body mass index, smoking, alcohol, mobility, length of surgery, blood loss or implant positioning, but there were differences in 30-day mortality, surgeon experience and implant type. The dislocation rate reduced from 11.6% in the PA group to 4.7% in the PPPA group (p = 0.004), with an RR of 2.5 (1.2; 5.1). The reoperation rate reduced from 6.8% with the PA to 3.3% with the PPPA (p = 0.022), with an RR of 2.1 (0.9; 5.2), and total surgery-related complications reduced from 14.7% with the PA to 6.9% with the PPPA (p = 0.003), with an RR of 2.4 (1.3; 4.4).

INTERPRETATION

Changing from PA to PPPA in patients with FNF treated with HA resulted in a more than 50% reduction in dislocation and reoperation rates. This approach was easily introduced and may enable further lowering of dislocation rates through the sparing of all short external rotators.

Epidemiology and specific features of shoulder injuries in patients affected by epileptic seizures

PURPOSE

Epileptic seizures can cause multiple shoulder injuries, the most common of which are dislocations, recurrent instability, fractures, and isolated lesions of the rotator cuff. Currently, only limited literature exists which describes the frequency and types of lesions in cohorts of epileptic patients and the corresponding treatment outcome. This study aims to document the occurrence of shoulder lesions in patients affected by seizures and to provide detailed information on trauma dynamics, specific lesion characteristics and treatment complications.

METHODS

All patients referring to a tertiary epilepsy center were screened for shoulder injuries and the clinical records of those sustaining them during a seizure were reviewed. Demographic information, lesions' characteristics and trauma dynamics were analysed, as wells as-when carried out-the type of surgical intervention and any postoperative complications.

RESULTS

The average age at the time of injury of 106 included patients was 39.7 ± 17.5 years and a male predominance was recorded (65%). Bilateral injuries occurred in 29 patients, simultaneously in 17 cases. A younger age, bilateral shoulder injuries and shoulder dislocations were significantly associated with the occurrence of a shoulder injury solely by muscular activation (p = 0.0054, p = 0.011, p < 0.0001). The complication rate in 57 surgically treated patients with follow-up data was 38.7%, with recurring instability being the most frequently reported complication (62.5%).

CONCLUSIONS

Uncontrolled muscle activation during a seizure is a distinctive but not exclusive dynamic of injury in epileptic patients, accounting for more than the half of all shoulder lesions, especially in the younger. This can lead both to anterior and posterior dislocations or fracture-dislocations and is frequently cause of bilateral lesions and of instability recurrence after surgery. The high complication rates after surgical treatment in this selected subgroup of patients require that appropriate preventative measures are taken to increase the probability of treatment success.

LEVEL OF EVIDENCE

Cohort study, level III.

Anterior versus posterior radical antegrade modular pancreatosplenectomy for pancreatic body and tail cancer: an inverse probability of treatment weighting with survival analysis

PURPOSE

Radical antegrade modular pancreatosplenectomy (RAMPS) is a standard procedure for patients with pancreatic body and tail cancer. There are two types of RAMPS: anterior and posterior, but their indications and surgical outcomes remain unclear. We compared the surgical outcomes, postoperative course, and prognosis between anterior and posterior RAMPS.

METHODS

Between 2007 and 2020, 105 consecutive patients who underwent RAMPS for pancreatic body and tail cancers were divided into an anterior RAMPS group (n = 30) and a posterior RAMPS group (n = 75). To adjust for differences in preoperative characteristics and intraoperative procedures, an inverse probability of treatment weighting (IPTW) analysis was done, using propensity scores.

RESULTS

After IPTW adjustment, the postoperative body temperature of the posterior RAMPS group and the amount of drain discharge in the anterior RAMPS group were significantly lower, from postoperative days (PODs) 1 to 3, but there were no differences in postoperative complications, recurrence patterns, or prognosis between the two groups. Regarding the diagnostic ability of multidetector-row computed tomography (MD-CT) for direct tumor involvement of the left adrenal gland, the sensitivity and specificity were 100% and 90.0%, respectively.

CONCLUSION

Pancreatic body and tail cancer without apparent preoperative direct tumor involvement of the left adrenal gland on MD-CT may be sufficient indication for anterior RAMPS.

Posterior Estimation Using Deep Learning: A Simulation Study of Compartmental Modeling in Dynamic PET

Background

In medical imaging, images are usually treated as deterministic, while their uncertainties are largely underexplored.

Purpose

This work aims at using deep learning to efficiently estimate posterior distributions of imaging parameters, which in turn can be used to derive the most probable parameters as well as their uncertainties.

Methods

Our deep learning-based approaches are based on a variational Bayesian inference framework, which is implemented using two different deep neural networks based on conditional variational auto-encoder (CVAE), CVAE-dual-encoder and CVAE-dual-decoder. The conventional CVAE framework, i.e., CVAE-vanilla, can be regarded as a simplified case of these two neural networks. We applied these approaches to a simulation study of dynamic brain PET imaging using a reference region-based kinetic model.

Results

In the simulation study, we estimated posterior distributions of PET kinetic parameters given a measurement of time-activity curve. Our proposed CVAE-dual-encoder and CVAE-dual-decoder yield results that are in good agreement with the asymptotically unbiased posterior distributions sampled by Markov Chain Monte Carlo (MCMC). The CVAE-vanilla can also be used for estimating posterior distributions, although it has an inferior performance to both CVAE-dual-encoder and CVAE-dual-decoder.

Conclusions

We have evaluated the performance of our deep learning approaches for estimating posterior distributions in dynamic brain PET. Our deep learning approaches yield posterior distributions, which are in good agreement with unbiased distributions estimated by MCMC. All these neural networks have different characteristics and can be chosen by the user for specific applications. The proposed methods are general and can be adapted to other problems.

Clinical evaluation of bulk-fill and universal nanocomposites in class II cavities: Five-year results of a randomized clinical split-mouth trial

AIM

Evaluating the clinical survival and quality parameters of class-II restorations using 3M™ Filtek^TM Bulk Fill Posterior Restorative compared to 3M™ Filtek^TM Supreme XTE Universal Restorative over a period of five years.

MATERIALS AND METHODS

A longitudinal, randomized, prospective split-mouth study with 60 patients (29 female, 31 male; mean age 44 y; range 20-77 y) and a total of 120 load-bearing class II restorations (TEST: n=60 Filtek Bulk Fill Posterior Restorative; CONTROL: n=60 Filtek Supreme XTE Universal Restorative) was conducted. Clinical evaluation was performed by blinded evaluators according to FDI criteria. Kaplan-Meier method was used for survival analysis and an intergroup comparison (Mann-Whitney-U-Test) was carried out. A basic significance level of 0.05 was corrected by the Bonferroni method to account for multiple testing (significance after correction: p<0.00067).

RESULTS

The mean overall survival of restorations was 92% after 56.98±1.51 months in the TEST group (95 CI= 54.02;59.94) and 92% after 57.25±1.46 months (95 CI= 54.39; 60.12) in the CONTROL group (log-rank p=0.995). In total, four failures occurred in both TEST and CONTROL group during the observation period (mean annual failure rate: 1.6%). The most common reasons for failure were chipping-fractures, debonding, cracked-tooth-syndrome and recurrent decay. With regard to the FDI criteria, no significant differences between TEST and CONTROL material occurred for any of the evaluated variables. In the TEST group two restorations had to be repaired and two had to be replaced, in the CONTROL group four restorations had to be replaced.

CONCLUSION

Both materials showed acceptable clinical performance and survival during the 5-year observation period.

CLINICAL SIGNIFICANCE

The use of a nanofilled bulk-fill composite proved to be an aesthetically, functionally and biologically satisfactory alternative in posterior dentition.

A Great Heist: Subclavian Steal Syndrome Causing Posterior Transient Ischemic Attack and Stroke

Introduction Subclavian steal syndrome is a phenomenon of arterial flow reversal secondary to occlusive disease in proximal subclavian arteries, occasionally resulting in neurologic sequelae. Case Presentation The authors present the case of a 67-year-old man with stroke risk factors and a history of receiving head and neck radiation therapy who developed subclavian steal physiology leading to a transient ischemic attack and posterior circulation stroke. He was medically optimized without substantial progression or recurrence of disease. Conclusion This case illustrates a case of vertebrobasilar transient ischemic attack and posterior circulation stroke from subclavian steal syndrome in the setting of prior radiation therapy manifesting as extremity weakness and discoordination. Further research on therapeutic radiation dosages and subsequent incidence of arterial disease which could contribute to subclavian steal syndrome is necessary.

Comparison between single anterior and single posterior approaches of debridement interbody fusion and fixation for the treatment of mono-segment lumbar spine tuberculosis

PURPOSE

To compare the efficacy of single anterior and single posterior approach of debridement, interbody fusion, and fixation for the treatment of mono-segment lumbar spine tuberculosis (TB) patients.

METHODS

Eighty-seven patients with mono-segment lumbar TB who underwent debridement, interbody fusion, and fixation through either single anterior (Group A) or single posterior approach (Group B) from January 2007 to January 2017 were enrolled in this study. The duration of the operation, blood loss, complication rate, visual analog scale (VAS), Oswestry disability index (ODI), Frankel scale, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), kyphosis angle, correction rate, correction loss, and time taken for bone graft fusion were compared between the groups.

RESULTS

The average period of follow-up was 34.3 ± 9.5 months (24-56 months). No significant differences were observed between patients in Group A and patients in Group B in terms of gender, age, body mass index (BMI), duration of illness and preoperative evaluative indices (P > 0.05). The mean operation time and blood loss was significantly higher in Group A (P = 0.000), along with a slightly higher rate of complications compared with Group B (P = 0.848). The VAS, ODI and Frankel scale scores showed significant improvement in both groups (P = 0.000), along with the ESR, CRP and kyphosis indices (P = 0.000), which were similar in both groups at the final follow-up.

CONCLUSION

Both single anterior and single posterior approaches of debridement, interbody fusion and fixation are effective for mono-segment lumbar TB patients, although the single posterior approach is of a shorter duration and results in less blood loss.

A preliminary study of the surgical approach for posterior tibial plateau fractures: Based on posterior fragment segment classification

PURPOSE

The optimal surgical approach for the posterior tibial plateau fractures (PTPFs) remains controversial. This study aims to establish a method for posterior fragment segment classification to guide the choice of surgical approach and to reveal the outcome of their early reduction and health status.

METHODS

The medical records of 42 PTPFs patients treated with the strategy were collected retrospectively from December 2017 to December 2021. The posterior cortex of the tibial plateau was classified into postero-medial (PM), postero-central (PC), and postero-lateral (PL) segments. A posteromedial inverted L-shaped approach was adopted when the fractures involved the PM segment in the presence or absence of PC. The Frosch approach was performed when the PL segment was concerned. Fractures containing both PM and PL segments were treated by combined approaches. Four factors were measured to evaluate the reduction effect, including medial proximal tibial angle (MPTA), lateral posterior slope angle (LPSA), medial posterior slope angle (MPSA), and articular step-off. The Short Form 36 (SF-36) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores were completed at the last follow-up to assess health status and the degree of osteoarthritis.

RESULTS

A posteromedial inverted L-shaped approach was adopted in 16 PTPFs patients, a Frosch approach was adopted in 14 PTPFs patients, and a combined approach was adopted in 12 PTPFs patients. Immediate radiographic results indicated a promising fixation performance with this treatment strategy. The results of SF-36 and WOMAC scores reported good health status in all patients with a mean follow-up time of 34.50 (23-50) months. Two patients developed superficial wound infections, and one patient had liquefaction necrosis in adipose tissue. Although skin numbness occurred in 4 patients, they recovered within 6 months.

CONCLUSION

PTPFs patients treated under the guidance of posterior fragment segment classification achieved encouraging levels of immediate fixation and health status.

Posterior urethral stenosis: a comparative review of the guidelines

PURPOSE

We aimed to provide a thorough comparative review of the available guidelines on the diagnosis, management, and follow-up for patients with posterior urethral stenosis by the American Urologic Association (2016), Société Internationale d'Urologie (2010), and European Urologic Association (2022).

METHODS

The AUA, SIU, and EAU guidelines were evaluated for recommendations on the diagnosis, evaluation, and treatment of posterior urethral stenosis. We also included the EAU and AUA urologic trauma guidelines for the trauma-related stenosis. The level or strength of recommendations is included in case of disparity between the guidelines.

RESULTS

The three guidelines align considerably in recommendations provided for the diagnosis, management, and follow-up of patients with posterior urethral stenosis. SIU and EAU emphasize the role of repeat endoscopic treatment in guidelines compared to AUA.

CONCLUSION

The preferred method to repair bulbo-membranous stricture/stenosis following radiation therapy remains an area of active interest, focusing on continence preservation. Additionally, there may be a role for advanced endoscopic treatments with or without adjunct therapies to manage even obliterated stenoses.

Trans-nasal Endoscopic Sphenopalatine Artery Ligation in Epistaxis: Coblation Versus Electrocauterization

Epistaxis is one of the most common emergencies encountered by otorhinolaryngologist. Although anterior epistaxis is easy to manage but posterior epistaxis is usually refractory. Transnasal endoscopic sphenopalatine artery ligation (TESPAL) is now a well established surgical technique for the management of refractory epistaxis. Electrocauterization and clipping are the most common methods used for ligation. Coblation is an upcoming tool with promising results in endoscopic skull base surgeries and tonsillectomies but has not been explored much in TESPAL. It was a randomised observational study.50 patients of refractory epistaxis were included in the study. The patients were divided into 2 groups. Group A underwent TESPAL using electrocauterization while Group B underwent TESPAL using coblation. The data was collected and analysed for various parameters like experience of the surgeon, time taken for surgery, episodes of rebleeding and postoperative crusting. Out of 50 cases in our study 27 were males and 23 were females. Most common age group was 60-70 years (68%). Most common cause was hypertension (86%). Surgeons were happy 21/25 times in coblation group compared to 9/25 times in electrocauterization group. There were 4/25 rebleeding episodes in electrocauterization group compared to none in coblation group. Post-operative crusting was also less in coblation group compared to electrocauterization. Though electrocauterization is a well established method for TESPAL our experience with coblation in TESPAL has been extremely satisfying. We suggest our colleagues to conduct more research studies on use of coblation in TESPAL to reach a consensus.

Open and arthroscopic posterior bone block with iliac crest autograft for posterior shoulder instability - systematic review of clinical and radiological outcomes

INTRODUCTION

Posterior shoulder instability (PSI) is a rare and challenging pathology to manage. The aim of this review was to assess and compare whether open and arthroscopic iliac crest bone graft (ICBG) bone block procedures succeeded in improving functional and clinical outcomes as well as radiological outcomes of union and graft resorption.

HYPOTHESIS

We hypothesised that there will be no difference in recurrence rate and functional outcome between open and arthroscopic procedures but there will be a higher complication rate with open bone block procedures.

METHODS

A systematic review was conducted in accordance with PRISMA guidelines using the online databases MEDLINE and Embase. The review was registered on the PROSPERO database. Studies of open or arthroscopic ICBG bone block procedures reporting patient reported outcome measures, recurrence, complications and progression to osteoarthritis and radiological outcomes of graft union and resorption were selected. Studies were appraised using the Methodical index for non-randomised studies (MINORS) tool.

RESULTS

14 studies satisfied the inclusion criteria; five studies were arthroscopic and nine used open techniques. A total of 183 patients and 201 shoulders were included, mean age was 25 years range (14-75 years). Recurrent instability ranged from 0% to 12.5% for arthroscopic and 0% to 36.4% for open studies. Arthroscopic studies had statistically significant increases in numerous functional outcome scores but there was no evidence for similar improvements in open studies. Osteoarthritis at follow-up ranged from 12.5% to 47% in arthroscopic and 0% to 81.8% for open studies. Arthroscopic complication rate ranged from 6.7% to 75% compared to 0% to 80% for open studies. Majority of complications were metalware related requiring surgical intervention. Partial graft resorption ranged from 7.7-100% after arthroscopic and 4.8-100% after open procedures. High union rates were seen with both open and arthroscopic techniques.

CONCLUSION

This study highlights a lack of high-level evidence for arthroscopic and open posterior bone block procedures using ICBG to manage PSI. Functional and instability outcome scores showed significant improvement with arthroscopic ICBG bone block procedures however limited evidence was available for open studies. Metalwork related complications requiring revision and radiographic progression to osteoarthritis was high in both arthroscopic and open studies.

LEVEL OF EVIDENCE

IV, systematic review.

Inactivation of the thalamic paraventricular nucleus promotes place preference and sucrose seeking in male rats

RATIONALE

The experience of reward entails both positive affect and motivation. While the brain regions responsible for these distinct aspects of reward are dissociable from each other, the paraventricular nucleus of the thalamus (PVT) may play a role in both.

OBJECTIVES

To investigate the role of the PVT in both affect and motivation, and to identify neuropeptides that might mediate these effects.

METHODS

Male rats were tested for conditioned place preference following temporary inactivation of the anterior or posterior PVT with local injections of the GABA_B and GABA_A agonists, baclofen + muscimol. They were tested for sucrose seeking under a fixed ratio 3 (FR3) schedule of reinforcement and after extinction, following injection into the posterior PVT of baclofen + muscimol or saline vehicle. Finally, quantitative real-time PCR was used to examine local neuropeptide gene expression following injection into the posterior PVT of baclofen + muscimol or saline vehicle.

RESULTS

Conditioned place preference was induced by temporary inactivation of the posterior but not anterior PVT. While sucrose seeking under an FR3 schedule of reinforcement was unaffected by inactivation of the posterior PVT, reinstatement of sucrose seeking was promoted by posterior PVT inactivation. Local gene expression of pituitary adenylate cyclase-activating polypeptide (PACAP), but not enkephalin or neurotensin, was reduced following inactivation of the posterior PVT.

CONCLUSIONS

Temporary inactivation of the posterior PVT affects both affect and motivation as well as local gene expression of PACAP. These results suggest that the posterior PVT is one brain region that may participate in both major aspects of reward.

Complete resection of dual ependymoma spinal metastasis using a fixed tubular retractor-a pediatric case report

There are no specific guidelines regarding best treatment for focal, distant metastasis in ependymoma in the context of a well-controlled primary site. A combination using maximal safe resection and adjuvant radiotherapy is usually advised. As wound healing might be hindered by repeated radiotherapy, and delay future radiation treatment if needed, there is a growing interest in less invasive surgeries to reduce post-operative pain and wound healing complications. Those approaches have been extensively used and studied in adult but never in the pediatric population. Here, we present a pediatric case of a 12-year-old boy known for a posterior fossa ependymoma completely resected 18 months earlier who presented with a dual lumbosacral intradural ependymoma metastasis. A single-stage complete resection was achieved using a fixed tubular retractor with no complication. Post-operative course was favorable with rapid healing and discharge, minimal post-operative pain, and a rapid return to normal activities. Re-irradiation could be performed 2 weeks later without any problem. To our knowledge, this is the first report of the use of minimally invasive techniques to achieve complete resection of dual intradural metastasis of an ependymoma in the pediatric population. We demonstrate its feasibility and safety as well as its advantages.

Cost analysis comparison between anterior and posterior cervical spine approaches

Background

The costs of cervical spine surgery have steadily increased. We performed a 5-year propensity scoring-matched analysis of 276 patients undergoing anterior versus posterior cervical surgery at one institution.

Methods

We performed propensity score matching on financial data from 276 patients undergoing 1-3 level anterior versus posterior cervical fusions for degenerative disease (2015-2019).

Results

We found no significant difference between anterior versus posterior approaches for hospital costs ($42,529.63 vs. $45,110.52), net revenue ($40,877.25 vs. $34,036.01), or contribution margins ($14,230.19 vs. $6,312.54). Multivariate regression analysis showed variables significantly associated with the lower contribution margins included age (β = -392.3) and length of stay (LOS; β = -1151). Removing age/LOS from the analysis, contribution margins were significantly higher for the anterior versus posterior approach ($17,824.16 vs. $6,312.54, P = 0.01).

Conclusion

Anterior cervical surgery produced higher contribution margins compared to posterior approaches, most likely because posterior surgery was typically performed in older patients requiring longer LOS.

Comparison of anterior or posterior approach in surgical treatment of thoracic and lumbar tuberculosis: a retrospective case-control study

BACKGROUND

With the widespread use of the posterior surgery, more and more surgeons chose posterior surgery to treat thoracic and lumbar tuberculosis. But others still believed that the anterior surgery is more conducive to eradicating the lesions, and easier to place larger bone pieces for bone graft fusion. We compared the clinical and radiological outcomes of anterior and posterior surgical approaches and presented our views.

METHODS

This study included 52 thoracic and lumbar tuberculosis patients at Sun Yat-sen Memorial Hospital from January 2010 to June 2018. All cases underwent radical debridement, nerve decompression, intervertebral bone graft fusion and internal fixation. Cases were divided into anterior group (24 cases) and posterior group (28 cases). Statistical analysis was used to compare the clinical effectiveness, radiological outcomes, complications and other related information.

RESULTS

Patients in the anterior group and the posterior group were followed up for an average of 27.4 and 22.3 months, respectively. There were no statistically significant differences between groups in the preoperative, postoperative and last follow-up VAS score, ASIA grade and Cobb angle of local kyphosis. Moreover, there were no statistically significant differences in the improvement of neurological function, loss of kyphotic correction, total incidence of complications, operative time, intraoperative blood loss and hospital stay between the two groups (P > 0.05). But there was greater correction of kyphosis, earlier bone fusion, lower incidence of poor wound healing, less interference with the normal spine and less internal fixation consumables and medical cost in the anterior group (P < 0.05).

CONCLUSIONS

Both anterior and posterior approaches are feasible for thoracic and lumbar tuberculosis. While for thoracic and lumbar tuberculosis patients with a single lesion limited in the anterior and middle columns of the spine without severe kyphosis, the anterior approach surgery may have greater advantages in kyphosis correction, bone fusion, wound healing, protection of the normal spine, and medical consumables and cost.

Posterior approach to the elbow for insertion of the internal joint stabilizer

Management of unstable injuries was revolutionized by the Internal Joint Stabilizer (IJS). When compared to long-term immobilization, transarticular pinning, and hinge external fixation, the IJS results in decreased complications and improved clinical outcomes. Historically, the IJS was applied via a lateral approach; however, this limited intraoperative visualization and, in some cases, resulted in increased operative times. This technical report describes a posterior approach, for IJS application. The posterior approach involves an 8- to 10-cm incision over the posterior elbow through the deep fascia before identifying the olecranon and lateral capitellum, then proceeding with IJS application through manufacturer instructions. The ulnar and radial nerves must be identified as they could be damaged in this approach. Using the posterior approach at our institution, we have noticed a possible decrease in operative times and an increase in intraoperative visualization of the elbow without a subsequent increase in complications.

Comparison of novel machine vision spinal image guidance system with existing 3D fluoroscopy-based navigation system: a randomized prospective study

BACKGROUND CONTEXT

The use of spinal image guidance systems (IGS) has increased patient safety, accuracy, operative efficiency, and reduced revision rates in pedicle screw placement procedures. Traditional intraoperative 3D fluoroscopy or CT imaging produces potentially harmful ionizing radiation and increases operative time to register the patient. An IGS, FLASH Navigation, uses machine vision through high resolution stereoscopic cameras and structured visible light to build a 3D topographical map of the patient's bony surface anatomy enabling navigation use without ionizing radiation.

PURPOSE

We aimed to compare FLASH navigation system to a widely used 3D fluoroscopic navigation (3D) platform by comparing radiation exposure and pedicle screw accuracy.

DESIGN

A randomized prospective comparative cohort study of consecutive patients undergoing open posterior lumbar instrumented fusion.

PATIENT SAMPLE

Adults diagnosed with spinal pathology requiring surgical treatment and planning for open posterior lumbar fusion with pedicle screws implanted into 1-4 vertebral levels.

OUTCOME MEASURES

Outcome measures included mean intraoperative fluoroscopy time and dose, mean CT dose length product (DLP) for preoperative and day 2 CT, pedicle screw accuracy by CT, estimated blood loss and revision surgery rate.

METHODS

Consecutive patients were randomized 1:1 to FLASH or 3D and underwent posterior lumbar instrumented fusion. Radiation doses were recorded from pre- and postoperative CT and intraoperative 3D fluoroscopy. 2 independent blinded radiologists reviewed pedicle screw accuracy on CT.

RESULTS

A total of 429 (n=210 FLASH, n=219 3D) pedicle screws were placed in 90 patients (n=45 FLASH, n=45 3D) over the 18-month study period. Mean age and indication for surgery were similar between both groups, with a non-significantly higher ratio of males in the 3D group. Mean intraoperative fluoroscopy time and doses were significantly reduced in FLASH compared to 3D (4.51±3.71s vs 79.6±23.0s, p<.001 and 80.9±68.1cGycm² vs 3704.1±3442.4 cGycm², p<.001, respectively). This represented a relative reduction of 94.3% in the total intraoperative radiation time and a 97.8% reduction in the total intraoperative radiation dose. Mean preoperative CT DLP and mean day 2 postoperative CT DLP were significantly reduced in FLASH compared to 3D (662.0±440.4mGy-cm vs 1008.9±616.3 mGy-cm, p<.001 and 577.9±294.3 mGy-cm vs 980.7±441.6 mGy-cm, p<.001, respectively). This represented relative reductions of 34.4% and 41.0% in the preoperative CT dose and postoperative total DLP, respectively. The FLASH group required an average of 1.2 registrations in each case with an average of 2447 (±961.3) data points registered with a mean registration time of 106s (±52.1). A rapid re-registration mechanism was utilized in 22% (n=10/45) of cases and took 22.7s (±11.3). Re-registration was used in 7% (n=3/45) in the 3D group. Pedicle screw accuracy was high in FLASH (98.1%) and 3D (97.3%) groups with no pedicle breach >2mm in either group (p<.001). EBL was not statistically different between the groups (p=.38). No neurovascular injuries occurred, and no patients required return to theatre for screw repositioning.

CONCLUSIONS

FLASH and 3D IGS demonstrate high accuracy for pedicle screw placement. FLASH showed significant reduction in intraoperative radiation time and dose with lower but non-significant blood loss. FLASH showed significant reduction in preoperative and postoperative radiation, but this may be associated to the lower number of males/females preponderance in this group. FLASH provides similar accuracy to contemporary IGS without requiring 3D-fluoroscopy or radiolucent operating tables. Reducing registration time and specialized equipment may reduce costs.

The computed tomographic evaluation of bony bridge of C1 as bleeding risk factor at the screw placement

PURPOSE

To investigate the prevalence and morphological characteristics of ponticulus posticus (PP) and ponticulus lateralis (PL) using computed tomography (CT) images on a large study sample of the Anatolian population. The presence of the PP and PL bridges can limit gap available for placement procedure through the bony elements of C1. Routine screw techniques are contraindicated because of high risk of fatal bleeding of vertebral artery (VA).

METHODS

The CT images of 1000 subjects (500 males, 500 females) were examined for the morphological characteristics and presence of PP and PL. The anteroposterior diameter, superoposterior (transverse) diameter, surface area, and central thickness of the bony bridge of the PP, PL, and transverse foramina (TF).

RESULTS

The prevalence of PP was 14.8%, and bilateral complete PP was the most common PP type at 6.8%. The prevalence of PL was 4.1% and left-side complete PL was the most common PL type at 1.2%. The prevalence of both PP and PL was more common in males and bilateral complete PP were more predominant in males (p = 0.004, p = 0.038, and p = 0.010, respectively). The surface area of PP and PL were determined to be smaller than the surface area of the ipsilateral TF (p < 0.001 and p = 0.042, respectively).

CONCLUSION

PP is not an uncommon anatomic anomaly and PL is even less frequently encountered. The prevalence of PP and PL was more common in males and bilateral complete PP was more predominant in males. Detailed information about the prevalence and morphometry of the PP and PL obtained in the present study could guide the clinicians dealing with neurosurgery, physical medicine and rehabilitation, and radiology in their practice.

The Outcomes of Soft-Tissue Repair for Posterior Shoulder Instability Surgery

BACKGROUND

This study aimed to assess the results after soft-tissue posterior instability surgery and address possible challenges during these operations.

METHODS

The databases of two tertiary hospitals were reviewed to identify patients treated for posterior shoulder instability between 2000 and 2015. Out of 198 treated patients, 19 cases underwent surgery with a mean follow-up of 35 months. Chart review was performed to obtain recurrence rates, revision rates, return to sport, persistent pain, subjective instability, subjective feeling of being better, complications, and range of motion after operative treatment of posterior shoulder instability. These outcomes were compared using the Fisher's exact and Mann-Whitney U tests.

RESULTS

After surgery, 6 (32%) patients had a recurrent subluxation, and 11 (58%) cases had persistent pain; moreover, 5 (26%) patients had a persistent feeling of instability, and 10 (53%) cases did not feel improvement after the operation. Furthermore, 10 (53%) patients required a revision, and there were 7 (37%) cases with a complication. Postoperatively, 75% of the patients had a full forward flexion, and 93% of the cases had full internal rotation; however, 64% of them had restrictions in external rotation.

CONCLUSION

There is a high rate of recurrent instability, need for revision, and complications after soft-tissue posterior instability surgery. Postoperative external rotation was impaired in most patients. Patients should be informed about these unsatisfactory results.

Use of a smartphone leveling application to optimize cervical thoracic alignment prior to posterior instrumentation

OBJECTIVE

Posterior cervical decompression and instrumentation (PCDI) is often associated with increase in sagittal balance and loss of lordosis. Here we propose a simple method of surgical positioning utilizing a readily available smartphone application to optimize cervical thoracic alignment in PCDI. The intent of this optimization is to minimize losses in lordosis and increases in sagittal balance.

METHODS

For patients since 2019, the position of the head was adjusted so that the occiput to thoracic spine was aligned and the chin brow angle was parallel to the rails of the surgical table utilizing a leveling smart application (RIDGID Level). Patients before 2019 who were not optimized were compared.

RESULTS

There were 13 patients in the nonoptimized cohort (NOC) and 20 in the optimized cohort (OC). In the NOC, the change in lordosis was -7° (p=0.016) and change in C2-SVA was 7 mm (p<0.001) from preoperative to postoperative values. In the OC, the change in lordosis was 2° (p=0.104) and change in C2-SVA was 2 mm (p=0.592) from preoperative to postoperative values. Between the NOC and OC cohorts, the changes in lordosis and sagittal balance between cohorts were significant (p=0.002 and p=0.001 respectively). There was no significant difference in clinical outcomes as measured by JOA or complication rates.

CONCLUSION

Positioning of the patient in preparation for PCDI can influence post-operative lordosis and sagittal balance. Using the leveling application on the smart phone (RIDGID Level), is a rapid and free alternative for the maintenance of lordosis and sagittal balance during instrumentation in the operating room.

Estimating COVID-19 R t in Real-time: An Indonesia health policy perspective

COVID-19 (SARS COV2 n-corona virus) is the newfangled virus of the coronavirus family. COVID-19 can cause serious illness with symptoms of fever, cold, cough, and respiratory blockage. COVID-19 is a contagious virus, which originated in Wuhan, China. After one month, WHO declared it as a Pandemic due to its rapid spreading. Presently, Indonesia is also facing a hard time controlling the spread. Hence, it is essential to understand the spread rate in Indonesia and to analyze the strategies to minimize the virus spread. The proposed study can be used to assess variations in virus spread both nationally, and sub-nationally. This allows public health officials and policy-makers to track the progress of the outbreak in near real-time using an epidemiologically valid measure.

Pilot MRI-based strategies to improve the detection of stroke in patients with dizziness/vertigo

Posterior strokes are frequently misdiagnosed as they present with non-specific complaints such as dizziness/vertigo. Emergency department (ED) practice often relies on CT/CTA to "exclude" infarct in such patients, providing false reassurance due to lower sensitivity of CT (42%) for stroke in the posterior circulation. We describe a pilot at our institution using a specialized MRI protocol with 95% sensitivity for posterior stroke, which may be used in place of CT/CTA or conventional MRI for stroke evaluation. Further development of this approach may help reduce the high rate of missed posterior stroke in patients presenting with dizziness.

Anterior Selective Lumbar Fusion Saving More Distal Fusion Segments Compared with Posterior Approach in the Treatment of Adolescent Idiopathic Scoliosis with Lenke Type 5: A Cohort Study with More Than 8-Year Follow-up

Objective

To investigate whether anterior selective fusion (ASF) could save more distal fusion segments compared with posterior approach in the treatment of Lenke type 5 adolescent idiopathic scoliosis with long term follow‐up.

Methods

A retrospective cohort study. From 2008 to 2011, 22 AIS girls with Lenke type 5 who underwent ASF or posterior selective fusion (PSF) with more than 8‐year follow‐up, were extracted from the database. 13 girls in the ASF group had an average age of 14.3 ± 1.3 years and Risser sign of 3.3 ± 1.1; 9 PSF girls had an average age of 16.2 ± 3.6 years and Risser sign of 3.8 ± 1.5. The radiographic outcome was compared between groups preoperatively, 6‐month postoperatively, 8‐year postoperatively and at last follow‐up (>8 years).

Results

The average follow‐up duration was 8.7 ± 0.4 (ASF) and 8.8 ± 0.5 (PSF) years, respectively. There was no significant difference at baseline in age, Risser sign and preoperative curve pattern in the coronal and sagittal plane between the groups (P > 0.05). The ASF group had significantly shorter fusion segments (5.1 ± 0.6 vs. 7.0 ± 1.3) and decreased upper instrumented vertebra (UIV) (T₁₁ ± 0.8 vs. T₁₀ ± 0.8) than the PSF (P < 0.05); while no significant difference was found in the lower instrumented vertebra (LIV) and distal reserved segments (P > 0.05), which suggested that ASF could shorten the fusion segments by lowering UIV. The distal compensatory curve in the ASF group (9.0° ± 3.9°) was significantly larger than in the PSF group (3.3° ± 2.4°, P = 0.003), despite of no significant difference in the incidence of coronal imbalance (P > 0.05), indicating that both two approaches could obtain satisfactory correction in the coronal plane. In the sagittal plane, PSF patients had significantly larger lumbar lordosis (LL, 59.1° ± 10.5°), thoracic kyphosis (TK, 37.2° ± 13.3°) and proximal junctional angle (PJA, 13.3° ± 6.1°) at the last follow‐up than the ASF (LL: 43.4° ± 9.4°; TK: 20.7° ± 8.4°; PJA: 4.7° ± 3.4°; P < 0.05), but without significant difference in proximal junctional kyphosis (PJK) and sagittal vertical axis (SVA) (P > 0.05). After controlling for age, Risser sign, and radiographic parameters related to the primary curve pattern, shorter fusion segments and more distal reserved segments still remained significant in the ASF group with greater Risser sign (P < 0.05). No major intra‐ or post‐operative complications occurred.

Conclusions

Both ASF and PSF could obtain satisfactory coronal and sagittal correction for Lenke 5 AIS; compared with PSF, ASF could shorten the fusion segments by lowering UIV, and save more distal fusion segments only in patients with greater skeletal maturity.

Minimally Invasive Posterior Cervical Diskectomy: Operative Video

Cervical disk protrusion is a common pathology. Anterior diskectomy and fusion is considered the gold standard of treatment, although anterior arthroplasty has gained some acceptance in the past decade as an alternative. Posterior cervical minimally invasive diskectomy is a rarely used technique, and there is less literature discussing this procedure. We have found this technique to be useful in lateral, soft disk herniations not ventral to the cord or mineralized. This avoids an anterior approach with risk to the cervical viscera, the dysphagia associated with an anterior approach, the need for expensive implanted instrumentation, and the need for prolonged activity restrictions after an anterior approach. We include a Video 1 documenting the technique of minimally invasive posterior cervical diskectomy (anatomic landmarks of interest are labeled at several points during the video). This is achieved prone on an OSI Jackson table (Mizuho OSI, Union City, California, USA) without skeletal fixation. A stepwise technique is used to advance an 18-mm tube retractor into contact with the facet and lateral lamina. A 5-mm smooth diamond drill is used to perform a foraminotomy. To avoid nerve root or spinal cord manipulation, it is often necessary to remove some of the rostral aspect of the inferior pedicle to gain access to the axilla and disk protrusion. The procedure is rapid, well tolerated, and performed as outpatient, and it results in a rapid return to normal activity.

Case report-Vascular injury in association with posteriorly displaced medial clavicle fracture

The primary stabiliser of the diarthrodial sterno-clavicular (SC) joint is the costo-clavicular ligament, this holds the clavicle to the first costal cartilage and the end of the first rib. The costo-clavicular and surrounding ligaments help maintain the stability and strength of the SC joint. As a result, SC joint dislocations are far less common than fractures to the clavicle due to the relatively larger forces required to disrupt these ligaments. Medial physeal injuries occur when there is a fracture through the physis of a clavicle which is yet to complete the ossification process, this can often be mistaken for sterno-clavicular joint dislocation. This report looks at a case of a posteriorly displaced medial physeal fracture in an adolescent male sustained while playing rugby. We hope this case provides the reader an insight into the potentially life threatening consequences that should be considered in such presentations and highlight the importance of prompt and appropriate imaging and specialist intervention.

Surgical Options in Treating Ossification of the Posterior Longitudinal Ligament: Single-Center Experience

BACKGROUND

Ossified posterior longitudinal ligament (OPLL) of the cervical spine can lead to spinal stenosis and become clinically symptomatic. The optimal approach in addressing OPLL is a debated topic and dependent on factors such as preoperative lordosis and levels affected.

METHODS

In this study, we retrospectively identified patients undergoing operative management for OPLL. Demographics, operative details, radiographic parameters, outcome measurements, and complications were compared between the different approaches for OPLL treatment.

RESULTS

We identified a total of 44 patients with 16 undergoing laminoplasty (Plasty), 18 anterior corpectomy and diskectomy (Ant), and 10 laminectomy and instrumentation (Linst). Ant had least OPLL levels with median (range) 3 (2-5), compared with Plasty 4 (2-7) and Linst 4 (3-6). Plasty was associated with the shortest operative time and hospital stay. Ant showed significant correction in kyphosis from 0.5° (-13 to 16°) to 9.5° (-7 to 20°). There was loss in lordosis in Plasty and Linst. Sagittal balance significantly increased irrespective of surgical approach with the least increase in the Ant group. Complications were least in the Plasty group with similar overall improvement in outcome measurements.

CONCLUSIONS

All 3 approaches in the management of OPLL were associated with clinical improvement without 1 approach surpassing the others. Laminoplasty had the advantage of addressing more levels of stenosis than the anterior approach and was associated with a shorter operating time. Laminoplasty patients had a shorter hospital stay than those undergoing laminectomy and instrumentation and appeared to have fewer complications than the other approaches. Laminoplasty is the preferred approach in patients with preserved motion and lordosis, with the anterior approach effective in the correction of kyphosis.

Vertebral growth modulation by posterior dynamic deformity correction device in skeletally immature patients with moderate adolescent idiopathic scoliosis

STUDY DESIGN

Retrospective, comparative, multicenter.

INTRODUCTION

Growth modulating spinal implants are used in the management of scoliosis such as anterior vertebral body tethering. A motion-sparing posterior device (PDDC) was recently approved for the treatment of moderate AIS. The purpose of this study was to determine if the PDDC can modulate growth in skeletally immature patients with AIS.

METHODS

From a database of patients treated with the PDDC over 4 years, we identified those who had a minimum of 2 years follow-up. Pre-operative and post-operative Cobb angles and coronal plane wedging of the apical vertebra were evaluated on standing full length radiographs. Independent sample t test and one-way ANOVA with post-hoc Tukey HSD analysis was used to compare three groups in varying skeletal maturity: Risser 0-1, Risser 2-3, and Risser 4-5.

RESULTS

45 patients (14.2-years old, 11-17) were evaluated with a mean pre-op curve of 46° (35°-66°). The average preoperative major curve magnitude, of either Lenke 1 or 5 curve type, was similar among the three groups 47.6°, 46° and 41.5°. Deformity correction was similar in the three groups, with reduction to 26.4°, 20.4° and 26.2°, respectively, at final follow-up [p < 0.05]. Pre-op wedging 7.4° (3.8°-15°) was reduced after surgery to 5.7° (1°-15°) (p < 0.05). Of those patients, Risser 0-1 (n = 16) had preoperative wedging of 9.5° (6°-14.5°) that was reduced to 5.4° (1°-8°) postoperatively (p < 0.05); Risser 2-3 (n = 15) had pre-op 7.7° (4°-15°) vs. post-op 7.0° (3°-15°); Risser 4-5 (n = 14) had pre-op 4.8° (3.8°-6.5°) vs. post-op 4.7° (3.7°-6.5°). Delta Wedging in Risser 0-1 stage was significantly different than for Risser 2-3 and for Risser 4-5.

CONCLUSION

The posterior dynamic deformity correction device was able to modulate vertebral body wedging in skeletally immature patients with AIS. This was most evident in patients who were Risser 0-1. In contrast, curve correction was similar among the three groups. This finding lends support to the device's ability to modulate growth.

Imaging findings of lesions in the middle and posterior mediastinum

Lesions in the middle and posterior mediastinum are relatively rare, but there are some useful radiological clues that can be used to diagnose them precisely. It is useful to determine the affected mediastinal compartment and the locations of the main thoracic nerves on medical images for diagnosing such mediastinal lesions. Neurogenic tumors can occur in the middle mediastinum, although they generally arise as posterior mediastinal tumors. Based on the above considerations, we review various characteristic imaging findings of middle and posterior mediastinal lesions, and their differential diagnoses.

Risk factors for adjacent segment degeneration after posterior lumbar fusion surgery in treatment for degenerative lumbar disorders: a meta-analysis

STUDY DESIGN

A meta-analysis.

OBJECTIVE

We performed a meta-analysis to explore the incidence and risk factors of adjacent segment degeneration (ASD) after posterior lumbar fusion surgery.

METHODS

An extensive search of the literature was performed in English database of PubMed, Embase, and Cochrane Library, and Chinese database of CNKI and WANFANG (up to May 2020). We collected factors including demographic data, surgical factor, and sagittal parameters. Data analysis was conducted with RevMan 5.3 and STATA 12.0.

RESULTS

Finally, 19 studies were included in the final analysis. In our study, the rate of ASD after posterior lumbar fusion surgery was 18.6% (540 of 2896). Our data also showed that mean age, body mass index (BMI), the history of smoking and hypertension, preoperative adjacent disc degeneration, long-segment fusion, preoperative superior facet violation, high lumbosacral joint angle, pre- and post-operative L1-S1 sagittal vertical axis (SVA), post-operative lumbar lordosis (LL), and preoperative pelvic incidence (PI) were associated with the development of ASD. However, gender, history of diabetes, bone mineral density (BMD), preoperative Oswestry Disability Index (ODI) and Japanese Orthopedic Association (JOA), the type of fusion (PLIF vs TLIF), type of bone graft (auto- vs allograft), fusion to S1(vs non-fusion to S1), diagnose (lumbar disc herniation, lumbar spinal stenosis, lumbar spondylolisthesis), preoperative pelvic tilt (PT), LL and sacral slope (SS), post-operative SS, PT and PI were not associated with the development of ASD.

CONCLUSIONS

In our study, many factors were correlated with the risk of ASD after posterior lumbar fusion surgery. We hope this article can provide a reference for spinal surgeons in treatment for lumbar degenerative diseases.

Treatment of unusual locked posterior fracture-dislocation of the shoulder: a case series

Background

Locked posterior fracture-dislocation of the shoulder (LPFDS) is a very rare injury that occurs predominantly in young patients following high-energy trauma. The long-term outcome of the treatment of this injury is often poor. This study sought to present the characteristics of injury, discuss the pathological anatomy, and to report the treatment outcomes of our case series.

Methods

Between January 2012 and May 2018, a total of 234 patients who underwent surgical treatment for proximal humerus fractures were reviewed. Among them, six patients (mean age, 54.7 years; range, 35-76 years) with LPFDS were included in this study. Four patients were treated with open reduction and internal fixation (ORIF) with locking plates, one with hemiarthroplasty, and one with reverse total shoulder arthroplasty. Clinical results were evaluated by Constant, American Shoulder and Elbow Surgeons (ASES), and visual analog scale (VAS) scores and radiologic evaluation was conducted using follow-up radiographs.

Results

The mean length of follow-up was 26.2 months (range, 12-54). The mean Constant, ASES, and VAS scores were 66.7, 65.5, and 2.2, respectively. Four patients who underwent ORIF achieved bony union, but avascular necrosis (AVN) of the humeral head was observed in two patients. No complications were observed in the patients who underwent arthroplasty surgery until final follow-up.

Conclusions

In the treatment of LPFDS, replacement arthroplasty can produce predictable results. The approach of ORIF may be considered as a first choice of treatment in young patients but is sometimes correlated with postoperative complications such as AVN and the functional outcomes may be unpredictable. Therefore, patients should undergo careful diagnosis and treatment of this type of injury.

Surgical outcomes of posterior occipito-cervical decompression and fusion for basilar invagination: A prospective study

STUDY DESIGN

A Prospective Study.

OBJECTIVE

To assess results of posterior occipito-cervical decompression and fusion operated with intra-operative traction/manipulation and instrumented reduction in cases of Basilar Invagination(BI).

METHODS

Total 22 patients of 8-65 years with diagnosed BI were operated for posterior occipito-cervical fusion by intra-operative traction/manipulation and instrumented reduction. Fusion was done using autologous bone graft taken from iliac crest. Immediate post-operative, first month and then every 3 months' follow-up examination were done for minimum period of 2 years.

RESULTS

22 patients (10 males,12 females) with mean age of 23.9 years having BI were included. 11 patients had C1 occipitalization, 4 had platybasia and 9 had atlanto-axial dislocation (AAD). 1 patient with os odontoideum with kyphotic deformity expired on 4th postoperative day due to respiratory insufficiency (mortality rate 4.54%). Neurological improvement by at least by one grade according to RANAWAT's and/or NURICK'S scale was observed in 17/21 patients (80.95%). 3 patients remained static and 1 had neuro-worsening. Mean mJOA score of 13.14 improved to 16.24. All had reduction of dens below foramen magnum according to McRae, chamberlain line and Ranawat index. Bone graft fused in all patients as confirmed with CT scan and dynamic X-rays. 1 wound dehiscence and 1 asymptomatic implant loosening were seen on follow-up.

CONCLUSION

Surgical treatment of BI with intra-operative traction/manipulation, instrumented reduction and posterior occipito-cervical fusion can achieve good correction of radiology, functional performance and clinical neurology as well as excellent fusion rates without adverse effects of trans-oral surgery.

Diagnosis and treatment of the short-arm type posterior semicircular canal BPPV

Introduction

The Epley maneuver is useful for the otoconia to return from the long arm of the posterior semicircular canal into the utricle. To move otoconia out of the posterior semicircular canal short arm and into the utricle, we need different maneuvers.

Objective

To diagnose the short-arm type BPPV of the posterior semicircular canal and treat them with bow-and-yaw maneuver.

Methods

171 cases were diagnosed as BPPV of the posterior semicircular canal based on a positive Dix–Hallpike maneuver. We first attempted to treat patients with the bow-and-yaw maneuver and then performed the Dix–Hallpike maneuver again. If the repeated Dix–Hallpike maneuver gave negative results, we diagnosed the patient with the short-arm type of BPPV of the posterior semicircular canal and considered the patient to have been cured by the bow-and-yaw maneuver; otherwise, probably the long-arm type BPPV of the posterior semicircular canal existed and we treated the patient with the Epley maneuver.

Results

Approximately 40% of the cases were cured by the bow-and-yaw maneuver, giving negative results on repeated Dix–Hallpike maneuvers, and were diagnosed with short-arm lithiasis.

Conclusion

The short-arm type posterior semicircular canal BPPV can be diagnosed and treated in a convenient and comfortable manner.