Percutaneous fixation and balloon kyphoplasty for the treatment of A3 thoracolumbar fractures

BACKGROUND

Despite a long history of descriptive and clinical series, there is still no consensus in the treatment of traumatic thoracolumbar fractures. It is now widely accepted that percutaneous surgery in thoracolumbar spine trauma management can achieve the same results as conventional treatment but less morbidity but it is still not clear which are the best indications for these minimal invasive procedures.

METHODS

Thirty-two adult patients with single type A3 thoracolumbar burst fractures without neurologic deficits were included in this retrospective review of clinical and radiological outcomes after surgical management. All patients underwent combined percutaneous kyphoplasty and short fixation with screws in the vertebral pedicles above and below the fracture. Radiographic evaluation of segmental kyphosis and local kyphotic corrections were made preoperatively, 3 days postoperatively, 12 months post-operatively and at the last follow-up (the mean last follow-up was 41 months post-operatively). Clinical outcomes were determined by SF-36^® Health Survey and Oswestry Disability Index scores at 3-month and 12-month follow-ups.

RESULTS

Clinical assessments suggested good outcomes as early as the third postoperative month. The clinical outcomes were sustained at one year follow-up. At the last follow-up the segmental kyphosis correction and local kyphotic correction were maintained.

CONCLUSIONS

Our analysis demonstrates that minimally invasive kyphoplasty and percutaneous short fixation applied to thoracolumbar A3 burst fractures without neurological deficit may achieve results comparable to nonsurgical or open surgical treatment, but with less morbidity and complication, and should be considered as a valid treatment option.

Correction of adult spinal deformity with a minimally invasive fusionless bipolar construct: Preliminary results

INTRODUCTION

Fusion in adult spinal deformity has a high rate of complications. Fusionless constructs in children and percutaneous fixation in adults are now being used routinely. The aim of this study was to evaluate the preliminary results of a minimally invasive fusionless surgical technique used to correct adult spinal deformity.

MATERIALS AND METHODS

Thirty-eight patients with an average age of 45 years (15-76) with major spinal deformity requiring extensive arthrodesis from the upper thoracic region to the pelvis were operated consecutively and followed prospectively. Two hooks were implanted at the top and two iliosacral screws at the bottom. Two large rods connected by dominos to two small rods joined the upper hooks to the lower screws. The surgical data (operative time and bleeding), the radiological findings (Cobb angle, sagittal parameters, C7-plumbline AP and lateral), the complication rate and the morbidity were evaluated at the last follow-up visit.

RESULTS

The primary curvature was reduced by 40% from a mean of 58.5° (26-146) to 35.2° (3-109) (p<0.001). A clear decrease in operating time (270min) and blood loss (50cc/level) were observed. The length of hospitalization averaged 18 days (6-66), including an 8-15 day long preoperative traction period for 11 patients. We found 7 infectious complications, 11 early mechanical complications and one case of paraplegia due to severe kyphoscoliosis.

CONCLUSION

The corrections obtained are comparable to those reported in the literature for standard constructs. Most patients had an uneventful postoperative course. The early complications observed led us to very carefully select the indications. Long-term follow-up is essential.

Percutaneous Fixation by Internal Cemented Screws of the Sternum

PURPOSE

To evaluate the feasibility, efficacy and safety of sternal percutaneous fixation by internal cemented screw (FICS) using fluoroscopy and/or CT needle guidance.

MATERIALS AND METHODS

This retrospective single-center study analyzed 9 consecutive cancer patients managed with percutaneous FICS for sternal fracture fixation or osteolytic metastasis consolidation, from May 2014 to February 2019. Eastern Cooperative Oncology Group performance status, Numeric Pain Rating Scale (NPRS) and opioid use were studied preoperatively and postoperatively. Sternal images at last follow-up appointment were also collected.

RESULTS

Among the 9 patients, 7 had a sternal fracture with 5 being displaced. The technical feasibility was 100%. Both NPRS score significantly decreased from 5.6/10 ± 2.8 to 1.1/10 ± 1.6, and analgesic consumption was significantly improved (p = 0.03) after intervention. No post-procedural complications requiring surgical correction or screw displacement occurred after a mean imaging follow-up that exceeded 1 year (mean follow-up duration, 401.8 days ± 305.8).

CONCLUSION

Image-guided sternal percutaneous FICS is feasible and safe. It reduces pain and analgesic consumption related to pathologic fracture of the sternum.

Cannulated screw and Kirschner fixation for the treatment of medial and lateral malleolar epiphyseal fractures in children: a retrospective study of 36 cases

BACKGROUND

Percutaneous fixation with cannulated screws is an effective method for treating medial malleolar epiphyseal fractures, which comprise a portion of bimalleolar and trimalleolar fractures. Lateral malleolar fractures also need to be fixed to achieve anatomical reduction and absolute stable fixation of the ankle. However, there are no individual studies in the literature on this topic.

METHODS

Thirty-six children (22 boys and 14 girls) aged 8 to 15 years (average, 11.3 years) with medial and lateral epiphyseal fractures were treated by cannulated screw and Kirschner fixation after closed reduction from January 2010 to December 2015 in our hospital. The patients were examined each month postoperatively. Ankle function was assessed using the Baird-Jackson ankle score.

RESULTS

The 36 patients were followed up for 18 to 29 months (average, 25 months). No cases of fracture non-union or secondary displacement were observed, and the healing time was 2.8 ± 1.1 months (range, 2-4 months). At the last follow-up visit, the Baird-Jackson ankle score ranged from 83 to 100 (average, 94), including an "excellent" score in 13 cases, a "good" score in 19 cases, a "fair" score in 4 cases, and a "poor" score in 0 cases. The ankle recovered to the pre-injury level of function within 3.5 ± 1.6 months (range, 2-5 months). Dysfunction, pain, instability, and premature epiphyseal closure were not observed during the follow-up of the 36 patients.

CONCLUSIONS

Cannulated screw and Kirschner fixation after closed reduction is an effective and readily available method for the treatment of medial and lateral malleolar epiphyseal fractures in children.

Open reduction and internal fixation versus closed reduction and percutaneous fixation in the treatment of Bennett fractures: A systematic review

PURPOSE

Open reduction and internal fixation (ORIF) of Bennett fractures is increasingly preferred over closed reduction and percutaneous fixation (CRIF) in an attempt to prevent the development of post-traumatic arthrosis. The aim of this systematic review was to determine whether the preference for ORIF is justified based on the available literature regarding functional outcome and complications after surgery.

METHODS

A systematic review was performed in Medline, Embase, Cochrane CENTRAL, Web of science, and Google scholar. Duplicates were removed and title and abstract were screened after which full text articles were analysed. The reference lists of selected articles were screened for additional relevant studies. Study characteristics were recorded and methodological qualities were assessed after which data was extracted from the included articles. The Eaton-Littler score for post-traumatic arthrosis (primary outcome) on follow-up X-rays was used as primary outcome. Secondary outcomes were Grip strength, Pinch strength, persistent pain, fixation failure, functional impairment, infection and surgery time.

RESULTS

Ten studies were included; three retrospective comparative studies and seven retrospective case series. Of the 215 patients in these studies, 138 had been treated using an open technique and 77 by a closed percutaneous technique. The pooled rate of post-traumatic arthrosis was 57.5% (26.6-85.5) in the ORIF group versus 26.1% (3.9-59.0) in the CRIF group. Mean surgical operation time was 71.9 min for ORIF and 30.2 min for percutaneous patients. Fixation failure was significantly more often seen in the ORIF patients, 8.2% (0.7-22.8) vs. 2.9% (0.8-9.1), Risk Ratio 1.132 (0.01-176.745); p = 0.048. Infection was only seen in 5 CRIF patients. Persistent pain was seen in 32.9% (0.6-83.1) in ORIF patients versus 22.3% (8.1-41.1) in the CRIF patients. The pooled means Grip strength was 48.3 kg (95% CI; 39.7-56.9) versus 43.4 kg (95% CI; 22.9-63.8) for ORIF and CRPF, respectively. Functional impairment was similar between the two groups, 1.4% (0.1-4.4) vs 1.8% (0.1-5.7) respectively.

CONCLUSION

The analysed data do not confirm ORIF to prevent post-traumatic arthrosis, secondly more fixation failure and pain was seen in the ORIF group. The pooled data show percutaneous fixation to be preferable over ORIF in the surgical treatment of Bennett fractures.

Reduction and functional outcome of open reduction plate fixation versus minimally invasive reduction with percutaneous screw fixation for displaced calcaneus fracture: a retrospective study

Background

Minimally invasive surgery has become popular because of the lower incidence of wound complications. However, achieving an anatomic reduction that provides a satisfactory outcome is difficult using minimally invasive surgery. Our study aimed to evaluate the reduction and clinical outcomes of closed reduction and percutaneous fixation treatment using a closed reduction traction device for displaced intra-articular calcaneal fractures compared with traditional open reduction plate fixation using an extended lateral approach.

Methods

A total of 40 patients and 45 feet with calcaneus fractures from 2012 to 2016 were studied. The open reduction plate fixation group (24 feet) was compared to the closed reduction percutaneous fixation group (21 feet) with a traction device. The reduction assessments included length, width, height, Bohler’s angle, Gissane’s angle, and varus or valgus angle before and after surgery. The clinical outcomes included the American Orthopaedic Foot and Ankle Society hindfoot score and the visual analog score for pain, length of stay, and complication rate.

Results

The patients were followed up for an average of 16.53 ± 3.95 months. No significant differences in reduction were observed between the open and closed groups (P > 0.05). The American Orthopaedic Foot and Ankle Society scores of the two groups were 80.29 ± 6.15 and 83.62 ± 6.95 (open versus closed) (P = 0.0957). The visual analog scores of the open and closed groups were 1.50 ± 1.22 and 0.81 ± 0.87 (P = 0.0364). The lengths of stay in the open and closed groups were 9.63 ± 2.72 days and 6.71 ± 1.85 days (P = 0.0002). The complication rates of the open and closed groups were 20.8% (5/24) and 4.8% (1/21) (P < 0.0001).

Conclusions

The closed reduction percutaneous fixation with traction device method may provide equivalent reduction results and superior outcomes for the length of stay, VAS score, and complication rate for displaced intra-articular calcaneal fractures.

Midline Longitudinal Sacral Fracture in an Anterior-Posterior Compression Pelvic Injury -A Surgical Decision-making and Outcome

INTRODUCTION

Anterior-posterior compression pelvic injuries occur from high-energy blunt trauma and can result in devastating outcomes. Often, widening of the pubic symphysis occurs with subsequent disruption of posterior pelvic ligamentous structures. Associated sacral fractures may increase the likelihood of neurologic injury and pelvic ring instability. The most common sacral fracture in this injury is an avulsion fracture of the sacral ala. Midline longitudinal sacral fractures into the spinal canal are an extremely rare variant of sacral injuries in conjunction with pelvic trauma. In contrast to traditional anterior-posterior pelvic ring injuries, those associated with this unique fracture type carry a decreased risk of neurologic injury. Only a small number of these cases exist in English literature. Given its rarity, further, investigation of the fracture mechanism and treatment protocol is warranted.

CASE REPORT

A 67-year-old Caucasian male presented with an anterior-posterior compression pelvic ring injury after he was struck by an oncoming vehicle on his motorcycle. Radiographs revealed pubic symphyseal widening of 4.7 cm. A pelvic binder was placed as a temporary measure to minimize intrapelvic hemorrhage. Advanced imaging revealed a complete, midline sagittal sacral fracture through the posterior sacral elements. During his hospital admission, the patient required multiple procedures for sustained upper extremity fractures and subsequently underwent surgical fixation of his anterior and posterior pelvic ring injuries 2 days after admission. Our patient to date has achieved sacral fracture union, minimal residual pubic diastasis, and has no evidence of neurologic injury. He has some persistent impotence and is ambulating without assistance. Despite his significant injuries, his outcome to date has been quite impressive.

CONCLUSION

It is critical to always examine the posterior pelvis and sacrum when examining anterior-posterior compression injuries. While most cases have reported fixation of only the anterior pelvis, we explain the need for additional posterior pelvic fixation to address the inherent instability of these unique sacral fractures and ultimately decrease patient morbidity. The surgical fixation technique of this patient's pelvic injuries is described, as well as his post-operative course and outcome to date.

Interspinalis-longissimus mid-line approach for thoracic and thoracolumbar minimally invasive fixation: Technical note

The authors present a new minimally invasive posterior thoracic and upper lumbar spinal approach, using midline-staged incision with bilateral dissection via the natural muscular cleavage plane between the spinalis and longissimus muscles for pedicle fixation. The aim was to clarify anatomy and compare results between this technique and the conventional paraspinal approach. An anatomic MRI study determined the position of the superficial aponeurosis of the spinalis-longissimus intermuscular cleavage plane with respect to the midline. The surgical procedure is described. A radiological and clinical study evaluated 24 patients divided into two comparative groups, operated on via the medial intermuscular or the paraspinal approach, for isolated A3 and B2 Magerl fracture between T2 and L2, without neurologic involvement. Pain, postoperative complications, reduction quality and esthetic satisfaction were assessed. MRI located the cleavage plane, which was consistently 11.01±0.9mm (range, 9.4-12.3mm) from the midline. In the "medial approach" group, hospital stay was significantly shorter, by 3 days, at 4±1.9 (range, 2-8 days) (p: 0.005); pain on VAS was 2 points lower at postoperative day 1 (2.1±1.4; range,≤1-4; p:0.032), and lower at discharge (0.3±0.6; range, 0-1; p: 0.001). The scar was considered esthetically very satisfactory. This easily performed and reproducible medial intermuscular approach showed low iatrogenesis, significantly improving postoperative course.

The obturator oblique and iliac oblique/outlet views predict most accurately the adequate position of an anterior column acetabular screw

OBJECTIVE

Percutaneous fixation of the acetabulum is a treatment option for select acetabular fractures. Intra-operative fluoroscopy is required, and despite various described imaging strategies, it is debatable as to which combination of fluoroscopic views provides the most accurate and reliable assessment of screw position.

MATERIALS AND METHODS

Using five synthetic pelvic models, an experimental setup was created in which the anterior acetabular columns were instrumented with screws in five distinct trajectories. Five fluoroscopic images were obtained of each model (Pelvic Inlet, Obturator Oblique, Iliac Oblique, Obturator Oblique/Outlet, and Iliac Oblique/Outlet). The images were presented to 32 pelvic and acetabular orthopaedic surgeons, who were asked to draw two conclusions regarding screw position: (1) whether the screw was intra-articular and (2) whether the screw was intraosseous in its distal course through the bony corridor.

RESULTS

In the assessment of screw position relative to the hip joint, accuracy of surgeon's response ranged from 52% (iliac oblique/outlet) to 88% (obturator oblique), with surgeon confidence in the interpretation ranging from 60% (pelvic inlet) to 93% (obturator oblique) (P < 0.0001). In the assessment of intraosseous position of the screw, accuracy of surgeon's response ranged from 40% (obturator oblique/outlet) to 79% (iliac oblique/outlet), with surgeon confidence in the interpretation ranging from 66% (iliac oblique) to 88% (pelvic inlet) (P < 0.0001).

CONCLUSIONS

The obturator oblique and obturator oblique/outlet views afforded the most accurate and reliable assessment of penetration into the hip joint, and intraosseous position of the screw was most accurately assessed with pelvic inlet and iliac oblique/outlet views.

EVIDENCE

Clinical Question.

Percutaneous fixation of avulsion fracture at the plantar lateral base of the first metatarsal using ZipTight Fixation System: A case report

Isolated avulsion fracture of the peroneus longus tendon insertion at the base of the first metatarsal without injury of the tarsometatarsal joint is very rare. Similar to most avulsion fractures, this type of injury is caused by strong tension exerted by the peroneus longus tendon. The mechanism leading to this lesion and treatment options are not clearly defined. Several surgical techniques have been advocated for this fracture, including excision of an avulsion fragment and open reduction for internal fixation through the medial aspect of the foot or minimal plantar incision. We have described a method of percutaneous fixing of the avulsion fracture at the plantar lateral base of the first metatarsal using the ZipTight Fixation System (Zimmer Biomet Warsaw, Indiana, USA), which offers the advantage of allowing a rigid fixation and minimal invasive surgical technique for a small fragment.

A Prospective Study of Acute Undisplaced and Minimally Displaced Scaphoid Fractures Managed by Aggressive Conservative Approach

BACKGROUND

To identify acute un-displaced and minimally displaced scaphoid fractures which are unlikely to unite with non-operative treatment at six weeks with CT scan and stabilize them with percutaneous screw fixation with the aim of preventing non-union.

METHODS

A scaphoid series radiographs of wrist were obtained for patients with undisplaced or minimally displaced fractures and were immobilized in a thumb spica cast for six weeks. At six weeks, CT scan was done for patients showing doubtful signs of clinical and radiographic union. Patients with a gap less than 2 mm were continued on cast for an additional two to four weeks. Those with gap more than 2 mm underwent percutaneous screw fixation. In both cases the immobilisation was discontinued when the fracture was considered to be united and mobilization was initiated.

RESULTS

21 out of 39 patients managed initially with cast for six weeks showed clinical and radiological evidence of union. 18 patients showed persistent tenderness of which eight showed a clear gap in radiographs and 10 patients had doubtful union. Eight of these 10 patients on CT scan showed fracture gap of more than 2 mm while two patients showed fracture gap of less than 2 mm. Hence, 16 patients underwent percutaneous fixation. Repeat radiographs showed progression to union at an average of 3.8 weeks from surgery. Remaining two eventually united on continuing the cast. All patients showed confirmed union at one year on follow up.

CONCLUSIONS

An objective measurement of fracture gap by CT scan at six weeks is useful in predicting cases with tendency for delayed union. Early percutaneous fixation of fractures would not further jeopardize the blood supply of fracture site. This aggressive conservative management also avoids unnecessary surgery in all acute scaphoid fractures.

Percutaneous fixation of valgus displaced fracture of the proximal humerus using a single screw

Valgus-impacted proximal humerus fracture is a classic but rare entity in shoulder traumatology. Surgical treatment is controversial, with increasing use of minimally invasive techniques. Our technique uses a minimally invasive approach under fluoroscopic control. Raising the humeral head to reduce the valgus enables spontaneous and well-positioned reduction of the tuberosities and screw fixation between the greater tuberosity and the humeral shaft. Indications comprise valgus-impacted fracture without comminution of the medial epiphyseal-metaphyseal hinge or greater tuberosity; the rotator cuff contributes to reduction and must be intact. This type of fixation restores proximal humerus anatomy and achieves consolidation with low risk of secondary necrosis. Minimally invasive single-screw fixation is an alternative of choice for surgical treatment of valgus-impacted proximal humerus fracture.

A novel percutaneous achievement and maintenance of reduction and screw fixation for acute displaced scaphoid fractures: minimum two-year follow-up

PURPOSE

The purpose of this study was to introduce a novel method of percutaneous achievement and maintenance of reduction for acute displaced scaphoid fractures and evaluate the feasibility of this method in treating acute displaced scaphoid fractures as well as explore its indications.

METHODS

From February 2012 to March 2014, 15 patients with acute displaced scaphoid fractures were treated with our technique. Two Kirschner wires were used to achieve and maintain the reduction of the scaphoid fractures throughout the entire process of the traditional percutaneous screw fixation process. The following parameters including function scores according to modified Mayo wrist scoring system, range of motion (ROM) of the wrist, grip strength, pinch strength, healing time, time to return to work, and final outcomes were recorded.

RESULT

All patients were followed up with a mean period of 2.5 years (range, 2-3.5 years). All fractures healed with a mean of 9.3 weeks (range, 7-11.5 weeks). All patients returned to pre-injury level of activity within six weeks. The functional scores averaged 90.3 (range, 80-100). ROM of the wrist was equal to that of the contralateral side at three months postoperatively. Grip strength and pinch strength compared with contralateral were 98% and 92%, respectively. All were satisfied with the final outcomes.

CONCLUSIONS

Our technique is successfully performed in acute displaced scaphoid fractures resulting in shortened immobilization and prompt functional recovery. It broadens the indications of the percutaneous method, which means the advantages of the percutaneous method are maximally reserved whilst the drawbacks of open reduction were avoided.

Scaphoid Fractures treated with a volar percutaneous approach. Analysis and results in 92 cases

OBJECTIVE

Herbert type B1 and B2 scaphoid fractures can be treated by orthopaedic treatment or surgery. The aim of this study is to analyse results and complications of scaphoid waist fractures treated using the percutaneous volar approach.

MATERIAL AND METHOD

We present a retrospective study of 92 patients, treated in our institution from 2006 to 2016 using a volar percutaneous fixation. Mean Follow-up was 16 months (range 12-48). Injuries were classified using Hebert's classification, including B1 and B2 fracture types; the other fracture types following this classification system were excluded. Politrauma patients, dorsal approach, fractures associated with distal radius injuries, patients treated using another surgical technique and patients with non follow-up were also excluded. Functional results were evaluated using the DASH questionnaire. Consolidation was established as the presence of bony bridges crossing the fracture site on x-rays, associated with absence of pain.

RESULTS

The average time to fracture healing was 6.6 weeks (range 5-11). After 12 months of follow-up, the average wrist range of motion was 70° of extension (range 58-75) and 70° of flexion (range 62-80). Regarding functional evaluation, the average DASH questionnaire score was 42. The most frequent complication was non-union in 4 cases (4.44%). Average surgical time was 25min.

CONCLUSIONS

Volar percutaneous fixation is a simple and quick technique for a specialist surgeon, characterised by low morbidity and complication rates compared to ORIF and orthopaedic treatment, which accelerates the patient's functional recovery.

The Role of Percutaneous Reduction and Fixation of Lisfranc Injuries

To be able to perform percutaneous fixation of Lisfranc injuries, this article emphasizes that an anatomic reduction must be mandatory. When uncertainty remains as to whether closed reduction is anatomic, formal open reduction is recommended because accuracy of reduction is correlated with long-term outcome. Closed injuries with minimal displacement, bony avulsions, and skeletally immature individuals seem the most appropriate indications for percutaneous fixation. Not all injuries are ideal for this method of treatment, and this is an area that needs to be more clearly defined in the future.

Fracture reduction by postoperative mobilisation for the treatment of hyperextension injuries of the thoracolumbar spine in patients with ankylosing spinal disorders

INTRODUCTION

The aim of this study was to evaluate results of surgical stabilisation of hyperextension injuries of the thoracolumbar spine in patients with ankylosing spinal disorders using two different treatment strategies: the conventional open rigid posterior instrumentation and percutaneous less rigid posterior instrumentation. Surgical and non-surgical complications, the postoperative radiological course, and clinical outcome at final follow-up were comparatively assessed. Moreover, we sought to discuss important biomechanical and surgical aspects specific to posterior instrumentation of the ankylosed thoracolumbar spine as well as to elaborate on the advantages and limitations of the proposed new treatment strategy involving percutaneous less rigid stabilisation and fracture reduction by postoperative mobilisation.

MATERIALS AND METHODS

Between January 2006 and June 2012, a consecutive series of 20 patients were included in the study. Posterior instrumentation was performed either using an open approach with rigid 6.0 mm bars (open rigid (OR) group) or via a percutaneous approach using softer 5.5 mm bars (percutaneous less rigid (PLR) group). Complications as well as the radiological course were retrospectively assessed, and patient outcome was evaluated at final follow-up using validated outcome scores (VAS Spine Score, ODI, RMDQ, Parker Mobility Score, Barthel Score and WHOQOL-BREF).

RESULTS

Surgical complications occurred more frequently in the OR group requiring revision surgery in two patients, while there was no revision surgery in the PLR group. The rate of postoperative complications was lower in the PLR group as well (0.7 vs. 1.3 complications per patient, respectively). Fracture reduction and restoration of pre-injury sagittal alignment by postoperative mobilisation occurred within the first 3 weeks in the PLR group, and within 6 months in the OR group. The clinical outcome at final follow-up was very good in both groups with no relevant loss in VAS Spine Score (pain and function), Parker Mobility Score (mobility), and Barthel Index (social independency) compared to pre-operative values.

CONCLUSIONS

This study indicates that the proposed treatment concept involving percutaneous less rigid posterior instrumentation and fracture reduction by postoperative mobilisation is feasible, seems to facilitate adequate reduction and restoration of pre-injury sagittal alignment, and might have the potential to reduce the rate of complications in the management of hyperextension injuries of the ankylosed thoracolumbar spine.

Comparison of percutaneous cannulated screw fixation and calcium sulfate cement grafting versus minimally invasive sinus tarsi approach and plate fixation for displaced intra-articular calcaneal fractures: a prospective randomized controlled trial

BACKGROUND

The management of displaced intra-articular calcaneal fractures (DIACFs) remains challenging and controversial. A prospective randomized controlled trial was conducted to compare percutaneous reduction, cannulated screw fixation and calcium sulfate cement (PR+CSC) grafting with minimally invasive sinus tarsi approach and plate fixation (MISTA) for treatment of DIACFs.

METHODS

Ultimately, 80 patients with a DIACFs were randomly allocated to receive either PR+CSC (N = 42) or MISTA (N = 38). Functional outcomes were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scores. Radiological results were assessed using plain radiographs and computed tomography (CT) scans, and postoperative wound-related complications were also recorded.

RESULTS

The average time from initial injury to operation and the average operation time in the PR+CSC group were both significantly shorter than those in the MISTA group (p < 0.05). There were significantly fewer complications in the PR+CSC group than those in the MISTA group (7.1 % vs 28.9 %, p < 0.001). The calcaneal width immediate postoperatively and at the final follow-up in the MISTA group were obviously improved compared to those in the PR+CSC group (p < 0.001). The variables of sagittal motion and hindfoot motion of the AOFAS scoring system in the PR+CSC group were significantly higher than those in the MISTA group (p < 0.05). The good and excellent results in the two groups were comparable for Sanders Type-II calcaneal fractures, but the good to excellent rate in the MISTA group was significantly higher for Sanders Type-III fractures (p < 0.05).

CONCLUSION

The clinical outcomes are comparable between the two minimally invasive techniques in the treatment of Sanders Type-II DIACFs. The PR+CSC grafting is superior to the MISTA in terms of the average time between initial injury and operation, operation time, wound-related complications and subtalar joint activity. However, the MISTA has its own advantages in improving the calcaneal width, providing a more clear visualization and accurate reduction of the articular surface, especially for Sanders Type-III DIACFs.

TRIAL REGISTRATION

ChiCTRIOR16008512 . 21 May 2016.

A comparative study of two percutaneous pinning techniques (lateral vs medial-lateral) for Gartland type III pediatric supracondylar fracture of the humerus

BACKGROUND

The management of displaced supracondylar fracture of the humerus with closed reduction and percutaneous pin fixation is the most widely accepted method of treatment, but controversy continues regarding the pin fixation techniques. A prospective randomized controlled study was undertaken to compare the stability, functional outcome and iatrogenic ulnar nerve injury between lateral pin fixation and medial-lateral pin fixation.

MATERIAL AND METHOD

Sixty-two patients with Gartland type III supracondylar fracture of the humerus were randomized into two groups-lateral pin fixation (n = 31) and medial-lateral pin fixation (n = 31). Primary assessment was performed for major loss of reduction and iatrogenic ulnar nerve injury. Secondary assessment included clinical outcome, elbow range of motion, radiographic measurements, Flynn grade, and complications.

RESULTS

There were two (6.5 %) iatrogenic ulnar nerve injury cases in the medial-lateral entry group and two (6.5 %) cases with mild loss of reduction in the lateral entry group. No major loss of reduction was observed in either of the groups. There was no statistically significant difference in change of Baumann angle, metaphyseal-diaphyseal angle, Flynn grade, carrying angle, and the total elbow range of motion (P < 0.05) between the two groups.

CONCLUSIONS

Lateral pin fixation offers similar functional and radiological outcome and almost equal mechanical stability compared with medial-lateral pinning without the risk of iatrogenic ulnar nerve injury. LEVEL OF EVIDENCE [OCEBM 2011]: Level 2.

Biomechanical investigation of a minimally invasive posterior spine stabilization system in comparison to the Universal Spinal System (USS)

Background

Although minimally invasive posterior spine implant systems have been introduced, clinical studies reported on reduced quality of spinal column realignment due to correction loss. The aim of this study was to compare biomechanically two minimally invasive spine stabilization systems versus the Universal Spine Stabilization system (USS).

Methods

Three groups with 5 specimens each and 2 foam bars per specimen were instrumented with USS (Group 1) or a minimally invasive posterior spine stabilization system with either polyaxial (Group 2) or monoaxial (Group 3) screws.

Mechanical testing was performed under quasi-static ramp loading in axial compression and torsion, followed by destructive cyclic loading run under axial compression at constant amplitude and then with progressively increasing amplitude until construct failure.

Bending construct stiffness, torsional stiffness and cycles to failure were investigated.

Results

Initial bending stiffness was highest in Group 3, followed by Group 2 and Group 1, without any significant differences between the groups.

A significant increase in bending stiffness after 20’000 cycles was observed in Group 1 (p = 0.002) and Group 2 (p = 0.001), but not in Group 3, though the secondary bending stiffness showed no significant differences between the groups.

Initial and secondary torsional stiffness was highest in Group 1, followed by Group 3 and Group 2, with significant differences between all groups (p ≤ 0.047). A significant increase in initial torsional stiffness after 20’000 cycles was observed in Group 2 (p = 0.017) and 3 (p = 0.013), but not in Group 1.

The highest number of cycles to failure was detected in Group 1, followed by Group 3 and Group 2. This parameter was significantly different between Group 1 and Group 2 (p = 0.001), between Group 2 and Group 3 (p = 0.002), but not between Group 1 and Group 3.

Conclusions

These findings quantify the correction loss for minimally invasive spine implant systems and imply that unstable spine fractures might benefit from stabilization with conventional implants like the USS.

Percutaneous Sacroiliac Screw Fixation of the Posterior Pelvic Ring

Percutaneous sacroiliac (SI) screw fixation is indicated for unstable posterior pelvic ring injuries, sacral fractures, and SI joint dislocations. This article provides a review of indications and contraindications, preoperative planning, imaging techniques and relevant anatomy, surgical technique, complications and their management, and outcomes after SI screw insertion.

Degenerative facet joint changes in lumbar percutaneous pedicle screw fixation without fusion

BACKGROUND

Aim of the study was to evaluate degenerative lumbar facet-joints changes after percutaneous pedicle screw fixation (PPSF) in the treatment of lumbar fractures.

MATERIALS AND METHODS

Thirty patients underwent short PPSF without fusion. CT-scan was performed in the pre- and post-operative time at four, eight and 12 months. The six zygapophyseal joints adjacent the fracture's level were evaluated.

RESULTS

At four months patients showed no differences between pre- and post-operative joint radiographic aspect. At eight and 12 months, CT-scan demonstrated a progressive degeneration only in the middle joints respectively in 21.42% and in 76.92% of the cases. All 10 disrupted facet joints showed progressive degenerative changes at eight and 12 months.

CONCLUSION

Lumbar percutaneous fixation without fusion induces little degenerations essentially collocated in the middle joints close to fracture level at eight and 12 months. In the proximal and distal joints adjacent the screws degenerative changes can be seen only when associated to pedicle-screw encroachment.

Multiple noncontiguous spinal fractures and occipitocervical dislocation in a patient with ankylosing spondylitis treated with a hybrid open and percutaneous spinal fixation technique: a case report

BACKGROUND CONTEXT

Spinal fractures occur with a greater frequency in ankylosing spondylitis (AS) patients. Treatment of these fractures is complicated because of a higher incidence of medical comorbidities, higher rate of neurologic deficits, and higher risk of neurologic deterioration.

PURPOSE

To report a case report of a novel, combined open and percutaneous surgical techniques used for the treatment of multiple noncontiguous spinal fractures in a patient with AS.

STUDY DESIGN/SETTING

We describe the surgical treatment and the outcome of a patient with AS that sustained an occipitocervical dislocation and two noncontiguous three-column extension injuries using a hybrid technique with open occipital to T3 fusion and percutaneous T5-L1 instrumentation at a tertiary care facility.

PATIENT SAMPLE

A 77-year-old man with multiple comorbidities and newly diagnosed AS.

OUTCOME MEASURES

Two-year clinical and radiographic outcome of a patient treated surgically for multiple spine injuries in the setting of an ankylosed spine.

METHODS

The patient was treated with a hybrid approach using both open fusion and percutaneous instrumentation techniques.

RESULTS

At 2 years postoperatively, the patient had recovered ambulatory ability and had a good clinical outcome.

CONCLUSIONS

We describe a unique case of noncontiguous spinal trauma in a medically complex patient with AS treated with a hybrid open and percutaneous technique to minimize surgical insult and blood loss, with a good clinical and radiographic outcome 2 years postoperatively.

Open reduction and internal fixation versus percutaneous transverse Kirschner wire fixation for single, closed second to fifth metacarpal shaft fractures: a systematic review

Purpose

Open reduction and internal fixation (ORIF) of single, closed metacarpal shaft fractures is increasingly preferred over closed reduction and percutaneous fixation (K-wire). The aim of this systematic review is to determine whether the preference for ORIF can be substantiated based on the available literature regarding the functional outcome and complications after surgery.

Methods

A systematic review was performed using a computer-based search on MedLine and Embase, following the preferred reporting items for systematic and meta-analyses guidelines.

Results

Five non-comparative studies were found. Two studies reported on 36 ORIF-treated patients. Three studies reported on 65 K-wire-treated patients. Complications were reported in 8 ORIF-treated patients (22 %) and in 23 K-wire-treated patients (35 %). Functional outcome was generally reported as good for both techniques. Nonetheless functional impairment requiring reoperation was reported in 6 ORIF-treated patients (17 %) and in none of the K-wire-treated patients.

Conclusions

Although for both techniques good functional outcomes were reported, the significance of the functional impairment after ORIF requiring reoperation suggests ORIF to be a less favorable technique for single, closed metacarpal shaft fractures.

Good outcomes of percutaneous fixation of spinal fractures in ankylosing spinal disorders

INTRODUCTION

The ankylosed spine is prone to trauma even with after application of force at low energy levels. Multi-level vertebral bony fusions produce long lever arms, susceptible to fracture, with an increased risk of neurological injury. Additional problems result from delayed presentation and osteoporosis. These patients are also often at high risk of complications, making conventional open spinal surgery less appealing. We present the outcomes of percutaneous fixation and its advantages in this high risk group of patients.

METHODS

A retrospective review of a series of 10 patients with a diagnosis of either ankylosing spondylitis or diffuse idiopathic skeletal hyperostosis (DISH). All patients had sustained a spinal fracture between January 2009 and January 2013 and underwent percutaneous fixation using Medtronic longitude system (Minneapolis, USA) with Polyaxial screws. All were followed up with outcomes, complications and functional scores (Oswestry Disability Index (ODI) and Pain Visual Analogue scores (VAS).

RESULTS

The mean patient age was 68. There was a delayed presentation in seven patients, of which two presented with neurological compromise. The neurological deficit did not change with surgery and there were no neurological complications as a result of surgery. The mean length of stay was 24 days, with no direct surgical complications. The mean drop in haemoglobin level was 2.1, with three patients requiring a blood transfusion. The patients were followed up to a mean of 22 months, with a mean ODI of 16 and pain VAS of 1.1. At the time of follow up, two patients had died with no loss to follow up.

DISCUSSION

Even minor trauma can result in fracture in the ankylosed spine, requiring a high index of suspicion from the physician. The risks of missing such a fracture are significant neurological injury. The biomechanics of the spine are significantly altered, and treatment is demanding. We propose that minimally invasive spinal surgery can achieve good outcomes, low complication rates and high rates of satisfaction.

Posterior percutaneous reduction and fixation of thoraco-lumbar burst fractures

BACKGROUND

Treatment of A3 thoraco-lumbar and lumbar spinal fractures nowadays remains a controversial issue. Percutaneous techniques are becoming very popular in the last few years to reduce the approach-related morbidity associated with conventional techniques.

HYPOTHESIS

Purpose of the study was to analyze the clinical and radiological outcome of patients who underwent percutaneous posterior fixation without fusion for the treatment of thoraco-lumbar and lumbar A3 fractures.

MATERIALS AND METHODS

Sixty-three patients, having sustained a single-level thoraco-lumbar fracture, underwent short segment percutaneous instrumentation and were retrospectively analyzed. sagittal index (SI) was calculated in all patients. Clinical and functional outcome were evaluated by Visual Analog Scale (VAS), Oswestry Disability Index (ODI) and Short Form General Health Status (SF-36).

RESULTS

Average operative blood loss was 82 mL (50-320). Mean pre-operative SI in the thoraco-lumbar segment was 13.3° decreased to 5.8° in the immediate postoperative with a mean deformity correction of 7.5. Mean pre-operative SI in the lumbar segment was 16.5° decreased to 11.3° in the immediate postoperative with a mean deformity correction of 5.2. Not statistically significant correction loss was registered at 1-year minimum follow-up. Constant clinical conditions improvement in the examined patients was observed.

CONCLUSION

Percutaneous pedicle screw fixation for A3 thoraco-lumbar and lumbar spinal fractures is a reliable and safe procedure.

LEVEL OF EVIDENCE

Level IV. Retrospective study.

Minimal invasive para-rectus approach for limited open reduction and percutaneous fixation of displaced acetabular fractures

INTRODUCTION

Minimal invasive fixation has been reported as an alternative option for treatment of acetabular fractures to avoid blood loss and complications of extensive approaches. Closed reduction and percutaneous lag screw fixation can be done in minimally displaced acetabular fractures. Open reduction is indicated, if there is wide displacement. In this study, we report the use of a mini-open anterior approach to manipulate and reduce anteriorly displaced transverse acetabular fractures combined with percutaneous lag screw fixation.

METHODS

This report included eight patients. All had anterior displaced simple transverse acetabular fractures. An oblique mini-incision was made above and medial to the mid-inguinal point, and lateral to the lateral border of rectus abdominis muscle. The external abdominal oblique aponeurosis was incised along its fibres. The arched fibres of internal abdominal oblique were displaced medially above the inguinal ligament to expose and incise the fascia transversalis. Care was taken to avoid injury of ilioinguinal nerve, inferior epigastric vessels, and spermatic cord. The external iliac vessels were palpated and protected laterally. A blunt long bone impactor was introduced through this small incision to manipulate and reduce the fracture under fluoroscopic control. Fluoroscopic guided percutaneous lag screw fixation was done in all patients.

RESULTS

The average time to operation was 4 days. Average blood loss was 110mL. Operative time averaged 95min. Maximum fracture displacement averaged 10mm preoperatively and 1.3mm postoperatively. According to Matta score, anatomical reduction of the fracture was achieved in five patients and imperfect in three. Follow up averaged 27 months. Wound healing occurred without complications and fracture union was achieved without secondary displacement in all patients. Average time to fracture healing was 14 weeks. According to the modified Merle d'Aubigné score, functional outcome was good to excellent in all patients.

DISCUSSION AND CONCLUSION

Limited open reduction can solve the problem of fracture reduction, which is the main concern in minimal invasive fixation of acetabular fractures. It may help the inclusion of displaced acetabular fractures for percutaneous lag screw fixation. This mini-para-rectus approach has the advantages of minimal soft tissue dissection with the possible anatomical reduction of simple transverse displaced acetabular fractures.

Managing scaphoid fractures. How we do it?

The scaphoid is the common carpal bone to be fractured. Proper clinical and radiological evaluation is required to establish it's diagnosis. The management of acute fractures includes conservative treatment with cast in minimally displaced to open reduction and internal fixation in case of displaced ones. The established nonunion requires open reduction, bone grafting and internal fixation.

Long term results of percutaneous fixation of proximal humerus fractures

BACKGROUND

Proximal humerus fracture in elderly osteoporotic patients usually leads to severe displaced and multifragmentary fractures. Associated comorbidities may limit surgical options and conservative treatment is commonly indicated, however, with variable results. In most cases, surgery is the treatment of choice in order to restore anatomical integrity, and allow early functional recovery. Several techniques were used over the years, each with specific indication. Percutaneous pinning after closed reduction, a mini-invasive technique and fixation by use of K-wires is not preferred commonly. We present our experience with this approach, focusing on its indications and advantages.

PATIENTS AND METHODS

A study group of 41 consecutive patients with a mean age of 65.5 years were evaluated clinically (VAS, Constant-Murley score, range of motion), and with radiological analysis: 35 patients finally completed a minimum followup of 24 months.

RESULTS

K-wires were removed after a mean interval of 4 weeks. Clinical and radiographic healing occurred in a mean time of 8.2 weeks in all fractures but one, with improvements in mean Constant-Murley score of 87.6 points, mean VAS of 2.3. In 33 patients, the reduction was considered satisfactory. In two cases, reduction was poor, but the patients however presented acceptable functional outcome.

CONCLUSIONS

Percutaneous pinning may represent a suitable option of treatment for 2-or 3-part proximal humerus fractures in selected subjects.

Fractures of the proximal fifth metatarsal: percutaneous bicortical fixation

Background

Displaced intraarticular zone I and displaced zone II fractures of the proximal fifth metatarsal bone are frequently complicated by delayed nonunion due to a vascular watershed. Many complications have been reported with the commonly used intramedullary screw fixation for these fractures. The optimal surgical procedure for these fractures has not been determined. All these observations led us to evaluate the effectiveness of percutaneous bicortical screw fixation for treating these fractures.

Methods

Twenty-three fractures were operatively treated by bicortical screw fixation. All the fractures were evaluated both clinically and radiologically for the healing. All the patients were followed at 2 or 3 week intervals till fracture union. The patients were followed for an average of 22.5 months.

Results

Twenty-three fractures healed uneventfully following bicortical fixation, with a mean healing time of 6.3 weeks (range, 4 to 10 weeks). The average American Orthopaedic Foot & Ankle Society (AOFAS) score was 94 (range, 90 to 99). All the patients reported no pain at rest or during athletic activity. We removed the implant in all cases at a mean of 23.2 weeks (range, 18 to 32 weeks). There was no refracture in any of our cases.

Conclusions

The current study shows the effectiveness of bicortical screw fixation for displaced intraarticular zone I fractures and displaced zone II fractures. We recommend it as one of the useful techniques for fixation of displaced zone I and II fractures.