Robot-assisted pedicle screw insertion versus navigation-based and freehand techniques for posterior spinal fusion in scoliosis: a systematic review and meta-analysis

PURPOSE

The role of robotics in spine surgery remains controversial, especially for scoliosis correction surgery. This study aims to assess the safety and efficacy of robotic-assisted (RA) surgery specifically for scoliosis surgery by comparing RA to both navigation systems (NS) and conventional freehand techniques (CF).

METHODS

As per the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, a systematic review and meta-analysis were conducted via an electronic search of the following databases: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL). All papers comparing RA to either NS or CF for posterior spinal fusion in scoliosis were included. Fixed and random effects models of analysis were utilised based on analysis heterogeneity.

RESULTS

10 observational studies were included in total. RA had significantly greater odds of accurate pedicle screw placement relative to both NS (OR = 2.02, CI = 1.52-2.67, p < 0.00001) and CF (OR = 3.06, CI = 1.79-5.23, p < 0.00001). The downside of RA was the significantly greater operation duration relative to NS (MD = 10.74, CI = 3.52-17.97, p = 0.004) and CF (MD = 40.27, CI = 20.90, p < 0.0001). Perioperative outcomes including estimated blood loss, radiation exposure, length of hospital stay, cobb angle correction rate, postoperative SRS score, VAS pain score, JOA score, as well as rates of neurological injury and revision surgery, were comparable between the groups (p > 0.05).

CONCLUSION

RA offers significantly greater pedicle screw placement accuracy relative to NS and CF, however, surgery can take longer. In terms of perioperative outcomes, all three techniques are comparable.

Aseptic Revision Total Hip Arthroplasty Through an Anterior Approach: Survivorship and Risk Factors for Re-Revision

BACKGROUND

The utilization of anterior-based approaches for total hip arthroplasty (THA) is increasing. Literature on the outcomes of revision THA (rTHA) through an anterior approach, however, is sparse. This study reports the survivorship and risk factors for re-revision in patients undergoing aseptic rTHA through an anterior approach.

METHODS

This was a single-institution, retrospective cohort analysis of patients who underwent aseptic rTHA through an anterior approach (direct anterior, anterior-based muscle sparing) from January 2017 to December 2021, regardless of the original surgical approach. Exclusion criteria were age <18 years, conversion THA, and septic revisions. Patient demographics, complications, and postoperative outcomes were collected. Kaplan-Meier curves were used to measure survivorship while Cox regression analyses were used to identify risk factors for re-revision of THA.

RESULTS

We identified 251 total anterior rTHAs, of which 155 were aseptic anterior revisions. There were 111 patients (111 rTHAs; 63 anterior-based muscle sparing and 48 direct anterior) who met criteria and had a mean follow-up of 4.2 years (range, 2.1 to 6.9). There were a total of 54 (49%) anterior-based index approaches and 57 (51%) posterior index approaches. The most common indications for rTHA were femoral loosening (n = 25, 22.5%), followed by instability (n = 16, 14.4%) and wear or osteolysis (n = 16, 14.4%). At 2 years, the survivorship from reoperation and re-revision was 89% (95% confidence interval: 84 to 95) and 91% (95% confidence interval: 86 to 96), respectively. Reoperation occurred in 14 patients (12.6%) at a mean time of 7.8 months (range, 0.5 to 28.6). Re-revision occurred in 12 patients (10.8%) at a mean time of 7.3 months (range, 0.5 to 28.6). Instability was the most common reason for re-revision (4.5%). Neither index approach type, revision approach type, nor any patient-specific risk factors were identified as predictors of re-revision or reoperation in multivariable regression analysis.

CONCLUSIONS

This study demonstrates an acceptable rate of re-revision when aseptic rTHA is performed through an anterior approach, with the most common reason for aseptic re-revision being instability.

Prospective evaluation of a novel device for ultrasound-guided percutaneous treatment of carpal tunnel and trigger finger disease. Efficacy and safety of sono-instruments®

PURPOSE

To evaluate the safety and effectiveness of percutaneous release procedures under sonography using Sono-Instruments® in the treatment of carpal tunnel syndrome (CTS) and trigger finger (TF).

METHODS

Prospective study involving 30 patients, divided into two groups (15 CTS, and 15 TF). The primary outcomes were surgical performance-related outcomes (visibility, ease of use, satisfaction, duration) using Sono-Instruments® and patient-related outcomes (pain, activity limitations, time to return to work, functional scores). Secondary outcomes included complications. Patients were followed for two months post-operatively.

RESULTS

In the CTS group, the average age of the patients was 58.7 years. The percutaneous release of the transverse carpal ligament was effectively completed in all cases, with excellent device performance and no adverse events. At one week, all patients could wash their hands, 80% could perform activities of daily living, and 80% of those working had returned to their activities. At two months, all patients had resumed all activities. Pillar pain was still present in 53.3%. In the TF group, the patients had an average age of 57.9 years. The percutaneous release of the A1 annular pulley was successful in all cases, with excellent device performance and no adverse events. At one week, all patients could wash their hands, 93.3% could do all activities of daily living, and 75% of those working were back to their professional activities. At two months, all patients were back to all activities of daily living and work. The DASH score was significantly improved at two months, compared to preoperative, for both groups (p < 0.001).

CONCLUSION

Percutaneous sono-guided release using Sono-Instruments® is safe and efficient, and associated with quick functional recovery.

LEVEL OF EVIDENCE

II.

Modified Gritti-Stokes amputation: tips and tricks

Major amputations of the lower extremity may be required after trauma and a variety of underlying diseases such as peripheral vascular disease, diabetes, and malignancies. The goal of any major amputation is an optimal functional result with a maximum limb length in combination with optimal wound healing. The preservation of the knee joint is essential for successful rehabilitation, and this is best achieved by the Burgess below-knee amputation (BKA). Whenever a BKA is not possible, the Gritti-Stokes amputation is our first choice. This technique mainly consists of a through-knee amputation with the creation of a pedicled patella flap consisting of the patella, patellar ligament, and overlying soft tissue. After osteotomy of the distal femur and resection of the articular surface of the patella, the anterior flap is rotated in order to cover the femur defect while performing a patellofemoral arthrodesis. The aim of this paper is to describe our surgical technique and experience with GSA and to point out the important steps of this procedure. In conclusion, GSA is an excellent surgical option for patients requiring major lower limb amputations where BKA cannot be considered. Particular attention must be paid to careful preoperative evaluation and optimization of comorbidities. A meticulous surgical technique is warranted, including atraumatic tissue handling and an optimal patellofemoral arthrodesis technique.

Marlex Mesh Reconstruction of the Extensor Mechanism: A Concise 5-Year Follow-up of 2 Previous Reports

LEVEL OF EVIDENCE

Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Transformation of transverse fractures of the acetabulum in T-shaped fractures and sequential approaches

Transverse acetabular fractures are difficult to reduce and generally associated with poorer clinical outcomes than other types of acetabular fractures. For these fractures affecting both columns, the surgical strategy is subject to controversy and there is currently no optimal method of management. The transformation of these transverse fractures in to a T-shaped fracture makes it possible to make the anterior and posterior components of the fracture independent and to reduce them sequentially. This technique has made it possible to obtain a satisfactory reduction of the fracture in certain cases and gives hope for good long-term functional results. LEVEL OF EVIDENCE: IV.

Navigating the Divide: A Comprehensive Review of the Mechanical and Anatomical Axis Approaches in Total Knee Replacement

This comprehensive review explores the mechanical and anatomical axis approaches in total knee replacement (TKR) surgery, addressing the ongoing debate within the orthopedic community. Emphasizing the significance of TKR in alleviating knee-related disorders, this review underscores the pivotal role of accurate alignment in achieving optimal surgical outcomes. The purpose is to navigate the divide between the well-established mechanical axis approach, focusing on a straight-line alignment, and the anatomical axis approach, aligning with natural knee landmarks. The analysis delves into the advantages, disadvantages, and clinical implications of each approach, offering a nuanced perspective on their efficacy. The conclusion emphasizes a patient-centric approach, recommending the adoption of hybrid strategies and the incorporation of emerging technologies for enhanced precision. The future of TKR aligns with personalized medicine, leveraging advancements in computer-assisted navigation, robotics, and patient-specific implants. Ongoing professional development and interdisciplinary collaboration are crucial for surgeons, and as the field evolves, innovations in artificial intelligence, imaging, and 3D printing are expected to shape the trajectory of TKR alignment approaches.

Successful Management of Impending Skin Necrosis After a Posterolateral Knee Dislocation

Incarcerated medial soft tissue after posterolateral knee dislocations has been described, but limited information pertaining to the etiology and management of cutaneous injuries from incarceration exists. We present the case of a 64-year-old man, where reduction of a posterolateral knee dislocation resulted in incarceration of medial ligamentous structures and impending skin necrosis. The patient avoided full-thickness skin necrosis, which could have complicated treatment options. Careful consideration of the soft-tissue envelope of the knee for preventing additional skin injury in the perioperative period should be considered to potentially avert additional necrosis in patients with a 'pucker' sign after knee dislocations.

Polyvinyl Alcohol Hydrogel Hemiarthroplasty of First Metatarsophalangeal Joint Hallux Rigidus

Background Hallux rigidus (HR) is the most common arthritic condition of the foot. Although first metatarsophalangeal joint (MTPJ) arthrodesis has been the historical gold-standard treatment, polyvinyl alcohol (PVA) hydrogel implants have gained popularity as a joint-sparing technique. However, recent studies have shown variable failure rates of PVA hydrogel implants. The purpose of this study was to report the five-year experience with PVA hydrogel implants performed by a single surgeon. Methodology Health records were queried from August 2016 to 2021 for patients who underwent primary PVA hydrogel implant hemiarthroplasty for symptomatic late-stage HR. Patient demographics and postoperative outcomes variables were evaluated. Kaplan-Meier analysis was used to evaluate implant survival. A total of 146 PVA hydrogel implant procedures were performed with a minimum six-month follow-up. Results The majority of patients were female (n = 103, 70.5%), with a mean age of 58.1 (±10.1) years, body mass index of 27.3 (±5.2) kg/m2, and American Society of Anesthesiologists score <3 (n = 131, 89.7%). The majority had stage II or III disease (n = 115, 78.8%). Patients experienced significant improvement in visual analog scale score (p < 0.0001) and hallux dorsiflexion (p = 0.0005). There were 22 (15.1%) complications, including implant subsidence (n = 15, 10.3%), deep infection (n = 6, 4.1%), and hypertrophic ossification (n = 1, 0.7%). Revision surgeries were required in 12.3% (n = 18) of patients at an average of 9.4 (±9.2) months postoperatively. This included nine (6.2%) revision PVA hydrogel implant procedures and nine (6.2%) first MTJP arthrodesis. The one- and two-year survival rates for MTPJ arthrodesis (n = 9) were 95.9% and 86.3%, respectively. Conclusions In the largest single-surgeon series reported, first MTPJ hemiarthroplasty with a PVA hydrogel implant significantly improved pain and hallux dorsiflexion at an average of 14.5 months postoperatively. There was a high two-year survivorship of 86.3% until failure which required first MTPJ arthrodesis. Future studies should be performed to refine the indications for PVA hydrogel implants and identify risk factors.

Postoperative Return to Play and the Role of Imaging

Return to play (RTP) following surgery is a complex subject at the interface of social and internal pressures experienced by the athlete, psychological readiness, and intrinsic healing of the surgically repaired structures. Although functional testing, time from surgery, clinical examination, and scoring metrics can help clarify an athlete's readiness to return to sport, imaging can allow for a more direct assessment of the structures in question. Because imaging is often included in the diagnostic work-up of pain following surgery, the radiologist must be familiar with the expected postsurgical imaging appearance, as well as the associated complications. We briefly review such findings following anterior cruciate ligament reconstruction, Achilles tendon repair, syndesmotic fixation, and ulnar collateral ligament reconstruction in the context of the athlete, highlighting issues related to RTP.

[Reverse Shoulder Arthroplasty - Current Concepts]

Due to first promising long term outcome data, reverse shoulder arthroplasty experienced an immense increase of usage during the past decade. Moreover, the initial Grammont concept has constantly been refined and adapted to current scientific findings. Therefore, clinical and radiological problems like scapular notching and postoperative instability were constantly addressed but do still remain an area of concern.This article summarises current concepts in reverse shoulder arthroplasty and gives an overview of actual indications like cuff tear arthropathy, severe osteoarthritis, proximal humerus fractures, tumours, fracture sequelae as well as revision surgery and their corresponding clinical and radiological results.

Corona mortis: clinical evaluation of prevalence, anatomy, and relevance in anterior approaches to the pelvis and acetabulum

PURPOSE

To evaluate the clinical prevalence, characteristics, and relevance of the corona mortis (CM) in anterior approaches to the pelvis and acetabulum.

METHODS

Retrospective analysis of 185 theater reports from patients (73 females; mean age 62.8 ± 17.2 years) who underwent surgeries for pelvic ring injuries, acetabular fractures, or combined injuries using anterior approaches (Modified Stoppa or Pararectus) at our institution between 01/2008 to 12/2022. During procedures, the CM was routinely identified, evaluated, and occluded. Bilateral exposure of the superior pubic branch in 25 cases led to 210 hemipelvises analyzed.

EXCLUSIONS

CM not mentioned in report and revisions via the initial approach.

RESULTS

In the 210 hemipelvises examined, the prevalence of any CM vessel was 81% (170/210). Venous anastomoses were found in 76% of hemipelvises (159/210), arterial in 22% (47/210). Sole venous anastomoses appeared in 59% (123/210), sole arterial in 5% (11/210). Both types coexisted in 17% (36/210), while 19% (40/210) had none. A single incidental CM injury occurred without significant bleeding. In ten cases, trauma had preoperatively ruptured the CM, but bleeding was readily managed. Females had a significantly higher CM prevalence than males (p = 0.001).

CONCLUSION

Our findings show a CM prevalence aligning more with anatomical studies than prior intraoperative series. Although we observed one incidental and ten trauma-related CM injuries, we did not encounter uncontrollable bleeding. Our data suggest that in anterior pelvic approaches, when the CM is actively identified and occluded, it is not associated with bleeding events, despite its high prevalence.

The effect of eccentric glenoid reaming in reverse shoulder artrhoplasty for glenohumeral osteoarthritis

Background

The objective of this study was to evaluate the abilitiy of eccentric reaming in reverse total shoulder arthroplasty (RSA), in patients with glenohumeral osteoarthritis (GHOA), to correct preoperative glenoid retroversion and to compare with cuff tear arthopaty (CTA) cases.

Methods

Fifty-nine patients who underwent RSA with GHOA or CTA diagnosis between 2013 and 2022 and who had pre- and postoperative computed tomography scans were included in the study. Preoperative glenoid version and postoperative glenoid component versions of 17 patients with GHOA and 40 patients with CTA were measured by Friedman method.

Results

The median preoperative glenoid versions in GHOA and CTA groups were measured as 16° and 4° retroverted respectively (p < 0.01). The median postoperative glenoid component versions in GHOA and CTA groups were 5° and 3° retroverted respectively (p = 0.09). The version change differences between the two groups varied significantly (p < 0.01).

Conclusions

GHOA is related with higher preoperative glenoid retroversion compared to CTA. However; with eccentric glenoid reaming, adequate version correction and similar postoperative glenoid version can be achieved in GHOA compared to CTA when performing a RSA.

Level of evidence

Level III. Retrospective study. Treatment study.

Unveiling the learning curve of periacetabular osteotomy

Aims

Periacetabular osteotomy (PAO) is widely recognized as a demanding surgical procedure for acetabular reorientation. Reports about the learning curve have primarily focused on complication rates during the initial learning phase. Therefore, our aim was to assess the PAO learning curve from an analytical perspective by determining the number of PAOs required for the duration of surgery to plateau and the accuracy to improve.

Methods

The study included 118 consecutive PAOs in 106 patients. Of these, 28 were male (23.7%) and 90 were female (76.3%). The primary endpoint was surgical time. Secondary outcome measures included radiological parameters. Cumulative summation analysis was used to determine changes in surgical duration. A multivariate linear regression model was used to identify independent factors influencing surgical time.

Results

The learning curve in this series was 26 PAOs in a period of six months. After 26 PAO procedures, a significant drop in surgical time was observed and a plateau was also achieved. The mean duration of surgery during the learning curve was 103.8 minutes (SD 33.2), and 69.7 minutes (SD 18.6) thereafter (p < 0.001). Radiological correction of acetabular retroversion showed a significant improvement after having performed a total of 93 PAOs, including anteverting PAOs on 35 hips with a retroverted acetabular morphology (p = 0.005). Several factors were identified as independent variables influencing duration of surgery, including patient weight (β = 0.5 (95% confidence interval (CI) 0.2 to 0.7); p < 0.001), learning curve procedure phase of 26 procedures (β = 34.0 (95% CI 24.3 to 43.8); p < 0.001), and the degree of lateral correction expressed as the change in the lateral centre-edge angle (β = 0.7 (95% CI 0.001 to 1.3); p = 0.048).

Conclusion

The learning curve for PAO surgery requires extensive surgical training at a high-volume centre, with a minimum of 50 PAOs per surgeon per year. This study defined a cut-off value of 26 PAO procedures, after which a significant drop in surgical duration occurred. Furthermore, it was observed that a retroverted morphology of the acetabulum required a greater number of procedures to acquire proficiency in consistently eliminating the crossover sign. These findings are relevant for fellows and fellowship programme directors in establishing the extent of training required to impart competence in PAO.

Medial Patellofemoral Ligament Reconstruction Using the Medial Third of the Patellar Tendon: Camanho's Technique

The reconstruction of the medial patellofemoral ligament (MPFL) is an essential procedure in the surgical treatment of patellar instability. The medial third of the patellar tendon is a good graft option for this reconstruction, maintaining the insertion of the graft in the patella, with no need for hardware for patellar fixation. The objective of this article is to describe the MPFL reconstruction technique with the patellar tendon graft.

Image-Guided Navigation in Spine Surgery: From Historical Developments to Future Perspectives

Intraoperative navigation is critical during spine surgery to ensure accurate instrumentation placement. From the early era of fluoroscopy to the current advancement in robotics, spinal navigation has continued to evolve. By understanding the variations in system protocols and their respective usage in the operating room, the surgeon can use and maximize the potential of various image guidance options more effectively. At the same time, maintaining navigation accuracy throughout the procedure is of the utmost importance, which can be confirmed intraoperatively by using an internal fiducial marker, as demonstrated herein. This technology can reduce the need for revision surgeries, minimize postoperative complications, and enhance the overall efficiency of operating rooms.

Management of Extensive Buccosinusal and Bucconasal Communications After Maxillary Giant Cell Tumor Resection Using the Cortical Bone Lamina Technique: A Case Report

Giant cell tumors are rare, locally aggressive non-odontogenic osteolytic tumors associated with high rates of local recurrence. Treatment modalities are subject to considerable controversy, with successful outcomes hinging on achieving complete tumor elimination through thorough curettage. A 78-year-old male referred in December 2023 for a persistent mucosal lesion in the right maxilla under a removable denture. Clinical examination revealed a well-defined erythematous nodular lesion measuring approximately 3 cm along its long axis, localized on ridge quadrant 1. Biopsy confirmed the diagnosis of giant cell tumor. Although complete resection with healthy margins may be justified for aggressive lesions, it often results in significant morbidity and requires immediate defect reconstruction. Some studies suggest favorable long-term outcomes with guided bone regeneration (GBR). The bone lamina technique uses a xenogeneic cortical bone membrane to maintain space and promote bone healing. This surgical approach promotes bone healing through the mechanical support and biological properties of the lamina. The purpose of this case report is to evaluate the efficacy of the bone lamina technique and its role in managing complications following giant cell tumor resection.

Does a simultaneous ventral/dorsal approach provide better reduction quality in treating acetabular fracture involving both columns with displaced posterior wall?

INTRODUCTION

Various surgical techniques have been proposed to manage acetabular fractures involving both columns with posterior wall displacement. However, the optimal surgical approach to achieve satisfactory reduction quality remains controversial.

MATERIALS AND METHODS

This retrospective study evaluated 34 patients with fractures who were treated at a single medical institution. The patients were divided into two groups according to the ventral/dorsal surgical approach employed: simultaneous (SI) and sequential (SE). Perioperative parameters, as well as radiological and functional outcomes, were analyzed and compared between the two groups.

RESULTS

The SI and SE groups comprised 9 and 23 out of the 34 patients, respectively. The SI group exhibited a significantly shorter surgical time and lower estimated blood loss than the SE group (p = 0.04 and 0.03, respectively). The quality of reductions of the anterior and posterior columns was similar between the two groups; however, superior reduction in the fracture gap of the posterior wall was observed in the SI group, as revealed by axial and coronal computed tomography scans.

CONCLUSIONS

A simultaneous ventral and dorsal approach through the pararectus and the modified Gibson approach confer clinical advantages in reducing the fracture gap, surgical time, and intraoperative blood loss when managing acetabular fractures involving both columns and a displaced posterior wall. Therefore, these surgical approaches may be considered to be optimal for achieving satisfactory reduction quality in such fractures.

Current Management of Acute and Posttraumatic Critical Bone Defects

SUMMARY

Limb reconstruction in patients with critical-sized bone defects remains a challenge due to the availability of various technically demanding treatment options and a lack of standardized decision algorithms. Although no consensus exists, it is apparent from the literature that the combination of patient, surgeon, and institutional collaborations is effective in providing the most efficient care pathway for these patients. Success relies on choosing a particular surgical approach that manages infection, soft tissue defects, stability, and alignment. Recent systematic reviews demonstrate high success rates with the following management options: Ilizarov bone transport, Masquelet (induced membrane) technique, cancellous bone grafting, and vascularized bone grafts.

Making the cut: a technical note and literature review of Bernese periacetabular osteotomy techniques with special attention to ischial osteotomy initiation and completion with an inside to anterior curved osteotomy

Periacetabular osteotomy includes a fluoroscopy-guided ischial cut without direct visualization. Previously described techniques include a mediolateral ischial cortex cut, which is associated with the risk of injuring nearby nerves. Another drawback of that technique is the difficulty connecting an ischial cortex cut with a retroacetabular cut due to orthogonal nature of the osteotomy. In general, an additional cut from medial to lateral is required. The present study aimed to describe a technique that eliminates those problems due to use of only a central cut of the ischium and the curved nature of the osteotomy.

Perioperative Takotsubo Stress Cardiomyopathy During Endoscopic Spinal Surgery: A Case Report

CASE

A 37-year-old man American Society of Anesthesiologists grade 1 patient with lumbar canal stenosis at the L4-L5 level underwent endoscopic decompression. Toward the end of the procedure, the patient developed sudden-onset bradycardia, followed by ventricular arrhythmia and acute pulmonary edema. The patient was successfully managed with resuscitation and supportive management and recovered uneventfully thereafter. A diagnosis of perioperative stress cardiomyopathy was subsequently made after evaluation of the patient.

CONCLUSION

The possibility of takotsubo cardiomyopathy should be considered in cases of acute perioperative cardiac decompensation and pulmonary edema in patients undergoing spinal surgery.

A Convergent Tibial Tunnel Technique for Concomitant Anterior Cruciate Ligament Reconstruction and Meniscal Root Repair

Modern arthroscopic knee-reconstruction techniques involve the use of multiple bone tunnels and fixation devices to restore the anatomy and stability of the knee after traumatic injury. In these injuries, however, tunnel collision can be problematic, especially when combining anterior cruciate ligament reconstruction with meniscal root repairs or multiligament reconstructions. We describe a multiple tibial tunnel technique to allow fixation of both anterior cruciate ligament graft and meniscal roots through convergence to a single tibial cortical aperture.

Dislocation Following Anterior and Posterior Total Hip Arthroplasty in the Setting of Spinal Deformity and Stiffness: Evolving Trends Using a High-Risk Protocol at a Single Tertiary Center

BACKGROUND

Patients who have spinal stiffness and deformity are at the highest risk for dislocation after total hip arthroplasty (THA). Previous reports of this cohort are limited to antero-lateral and postero-lateral (PL) approaches. We investigated the dislocation rate after direct anterior (DA) and PL approach THA with a contemporary high-risk protocol to optimize stability.

METHODS

We investigated patients undergoing THA who had preoperative biplanar imaging from January-December 2019. Patients were identified using radiographic criteria of spinal-stiffness (<10-degree change in sacral slope from standing to seated) and deformity (flatback deformity with >10-degree difference in pelvic incidence and lumbar lordosis). There were 367 patients identified (181 DA, 186 PL). The primary outcome was dislocation rate at 2-years postoperatively. Risk-factors for dislocation were evaluated using logistic regressions (significance level of 0.05).

RESULTS

There were 6 (1.6%) dislocations in the entire cohort, with low dislocation rates for both DA (0.6%) and PL-THA (2.7%). We observed increased utilization of dual mobility with larger outer head bearings (>38 mm) with PL-THA (34.4 versus 5.0%, P < .01) and conversely increased utilization of 32-mm femoral-heads with DA-THA (39.4 versus 7.0%, P < .001). Surgical approach (PL) was not a significant risk-factor for dislocation (odds ratio: 5.03, P = .15). Patients who had a history of lumbar-fusion had 8-times higher odds for dislocation (OR: 8.20, P = .020).

CONCLUSIONS

To the best of our knowledge, this is the largest series to date evaluating DA and PL-THA in the hip-spine 2B-group. Our results demonstrate lower dislocation rate than expected with either surgical approach using a high-risk protocol.

A feasibility cadaver study for placing screws in various pelvic osseous fracture pathways using a robotic arm

INTRODUCTION

The use of a robotic system for the placement of pedicle screws in spine surgeries is well documented in the literature. However, there is only a single report in the United States describing the use of a robotic system to place two screws in osseous fixation pathways (OFPs) commonly used in the treatment of pelvic and acetabular fractures in a simulated bone model. The purpose of this study was to demonstrate the use of a robotic system to place screws in multiple, clinically relevant OFPs in a cadaveric model and to quantitatively measure accuracy of screw placement relative to the preoperative plan.

METHODS

A single cadaveric specimen was obtained for the purpose of this study. All surrounding soft tissues were left intact. Screws were placed in OFPs, namely iliosacral (IS), trans-sacral (TS), Lateral Compression-II (LC-II), antegrade anterior column (AC) and antegrade posterior column (PC) of the right hemipelvis using standard, fluoroscopically assisted percutaneous or mini-open technique. Following the placement of screws into the right hemipelvis using standard techniques, screws were planned and placed in the same OFPs of the contralateral hemipelvis using the commercially available ExcelsiusGPS® robotic system (Globus Medical Inc., Audubon, PA). After robotic-assisted screw placement, a post-procedure CT scan was obtained to evaluate actual screw placement against the pre-procedure plan. A custom-made image analysis program was devised to measure screw tip/tail offset and angular offset on axial and sagittal planes.

RESULTS

For different OFPs, the mean tip offset, tail offset and angular offsets were 1.6 ± 0.9 mm (Range 0.0-3.6 mm), 1.4 ± 0.4 mm (Range 0.3-2.5 mm) and 1.1 ± 0.4° (Range 0.5-2.1), respectively.

CONCLUSION

In this feasibility study, surgeons were able to place screws into the clinically relevant fracture pathways of the pelvis using ExcelsiusGPS® for robotic-assisted surgery. The measured accuracy was encouraging; however, further investigation is needed to demonstrate that robotic-assisted surgery can be used to successfully place the screws in the bony corridors of the pelvis to treat traumatic pelvic injuries.

Intramedullary Kirschner Wire Fixation for Metatarsal Fractures: A Comprehensive Review of Treatment Outcomes

Metatarsal fractures pose significant challenges in orthopedic practice, necessitating effective treatment methods to ensure optimal patient outcomes. This comprehensive review focuses on intramedullary Kirschner wire fixation as a promising intervention for metatarsal fractures. Beginning with an overview of metatarsal fractures and the imperative for effective treatments, the review delves into intramedullary fixation's definition, historical background, advantages, and disadvantages. Indications for its use in metatarsal fractures are discussed, providing a foundation for understanding its application. The surgical technique section outlines critical aspects, including patient selection criteria and preoperative planning. Before presenting a detailed step-by-step procedure for intramedullary Kirschner wire fixation, anesthesia considerations are explored. Emphasizing precision, fluoroscopic guidance, and meticulous postoperative care, this section provides insights for surgeons and healthcare practitioners. Considerations for rehabilitation follow, addressing postoperative care, expected recovery timelines, and physical therapy recommendations. Early mobilization, weight-bearing guidelines, and a structured rehabilitation program play pivotal roles in recovery. In the conclusion, key findings are summarized, highlighting the efficacy of intramedullary Kirschner wire fixation, its advantages, and recommendations for clinical practice. Additionally, areas for future research are identified, guiding further exploration and refinement of this surgical approach. This review is valuable for clinicians, researchers, and healthcare practitioners involved in metatarsal fracture management, contributing to the evolution of treatment strategies and improving patient care.

Attempted repair of chest wall injury following penetrating injury with surgical stabilization rib and autologous bone graft: A case report

Rib fractures are one of the most common injuries following blunt trauma. When associated with penetrating trauma, the projectile velocity and immense energy transfer cause significant rib fracture displacement and fragmentation. As a result, these patients are potentially exposed to an even higher risk of complications compared to those seen in more simple rib fractures. Unfortunately, there is limited research regarding technical considerations for surgical stabilization of rib fractures (SSRF) in severely displaced rib fractures with bone loss following penetrating injury. We present the case of a 21-year-old male gunshot wound victim with severely displaced and comminuted rib fractures in which we utilized an autologous bone graft bridge during SSRF to enhance fracture unionization, chest wall stability, and cosmesis. Unfortunately, the bone graft failed to incorporate into surrounding tissue.

Salvage Reconstruction of a 12-cm Tendon Defect Following Chronic Achilles Rerupture-15-Year Follow-Up: A Case Report

CASE

A 39-year-old man with a chronic Achilles rupture status post (1) failed primary repair and (2) secondary xenograft repair with graft rejection, resulting in a 12-cm Achilles tendon defect, which was reconstructed utilizing an Achilles bone block allograft and flexor hallucis longus (FHL) tendon transfer. At 15-year follow-up, the patient reported good functionality and satisfaction with the repair, with positive patient-reported outcome measures. Physical examination revealed excellent strength and range of motion. Magnetic resonance imaging confirmed the integrity and incorporation of the Achilles/FHL graft composite.

CONCLUSION

This case study provides valuable insight into successful long-term management of complex chronic Achilles ruptures with large defects.

MRI-Based Classification for Tibial Spine Fracture: Detection Efficacy, Classification Accuracy, and Reliability

RATIONALE AND OBJECTIVES

Recently, a new MRI-based classification for evaluating tibial spine fractures (TSFs) was developed to aid in treating these injuries. Our objective was to assess the detection efficacy, classification accuracy, and reliability of this classification in detecting and grading TSFs, as well as its impact on treatment strategy, compared to the Meyers and McKeever (MM) classification.

MATERIALS AND METHODS

A retrospective study included 68 patients with arthroscopically confirmed TSFs. All patients had plain radiography and conventional MRI of the affected knee before arthroscopy. Three experienced radiologists independently reviewed all plain radiographs and MRI data and graded each patient according to MM and MRI-based classifications. The detection efficacy, classification accuracy, and inter-rater agreement of both classifications were evaluated and compared, using arthroscopic findings as the gold standard.

RESULTS

The final analysis included 68 affected knees. Compared to the MM classification, the MRI-based classification produced 22.0% upgrade of TSFs and 11.8% downgrade of TSFs. According to the reviewers, the fracture classification accuracy of the MRI-based classification (91.2-95.6%) was significantly higher than that of the MM classification (73.5-76.5%, p = 0.002-0.01). The fracture detection rate of MRI-based classification (94.1-98.5%) was non-significantly higher than that of the MM classification (83.8-89.7%, p = 0.07-0.4). The soft tissue injury detection accuracy for MRI-based classification was 91.2-94.1%. The inter-rater reliability for grading TSFs was substantial for both the MM classification (κ = 0.69) and MRI-based classification (κ = 0.79).

CONCLUSION

MRI-based classification demonstrates greater accuracy and reliability compared to MM classification for detecting and grading TSFs and associated soft tissue injuries.

Instrument-based anterolateral rotatory laxity assessment of the knee has a high intra-observer and inter-observer reliability: a systematic review

IMPORTANCE

A reliable evaluation of anterolateral rotatory instability in the anterior cruciate ligament (ACL) deficient knee is important to help surgeons determine which patients might need concurrent anterolateral augmentation procedures.

OBJECTIVE

The purpose of this study was to systematically review studies that assess the intra-observer and inter-observer reliability of instruments used to measure anterolateral rotatory laxity of the knee.

EVIDENCE REVIEW

A comprehensive literature review was conducted according to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, using PubMed, Embase, Scopus, and Google Scholar databases for original, English-language studies evaluating the reliability of objective or instrument-based anterolateral rotatory laxity of the knee until October 31, 2022. Reliability data were extracted from text, tables, and figures.

FINDINGS

Twelve studies, with patients between the ages of 14-63 years, were included. The instruments used to measure anterolateral rotatory knee laxity included inertial sensors (n ​= ​9), magnetic resonance imaging (n ​= ​1), and navigation systems (n ​= ​2). The global intra-observer intraclass correlation coefficient for these devices was between 0.63 and 0.97, and the global inter-observer reliability was between 0.63 and 0.99.

CONCLUSION AND RELEVANCE

Instrument-based anterolateral rotatory knee laxity assessment has moderate to good intra- and inter-observer reliability. Evaluating anterolateral instability in ACL-deficient knees with these devices could help in decision-making when considering anterolateral augmentation.

LEVEL OF EVIDENCE

IV.

Thinner Tibial Spine Fracture Fragments Are Associated With Risk of Fixation Failure

Purpose

To determine the rate of and risk factors for failure of tibial spine fracture (TSF) repair.

Methods

This was a retrospective review of patients aged 18 years or younger with TSF who underwent arthroscopic repair performed by a single orthopaedic surgeon at a large tertiary academic hospital between 2015 and 2022. Demographic, clinical, injury, fracture, and surgical characteristics were collected. Coronal length and sagittal length and height of the fracture fragment were measured on preoperative plain radiographs and magnetic resonance imaging of the knee.

Results

Of 25 patients who underwent arthroscopic reduction with internal fixation of TSFs, 2 (8%) experienced fixation failure. In 16 (64%), internal fixation was performed with suture anchors, whereas 8 (32%) underwent internal fixation with screws. There were 19 male patients (76%). There were no differences in demographic factors (age, race, sex, and body mass index), injury characteristics (laterality, mechanism of injury, and activity causing injury), modified Meyers-McKeever fracture classification, or method of internal fixation between the group with fixation failure and the group without failure. Coronal length (14.2 mm vs 18 mm, P = .17) and sagittal length (13.9 mm vs 18.7 mm, P = .17) of the fracture fragment also did not differ significantly between groups. Sagittal height of the fracture fragment was thinner in patients with failure of fixation (4.3 mm) than in those without failure (8 mm) (P = .02).

Conclusions

Decreased bone thickness of the displaced fragment was associated with an increased likelihood of fixation failure.

Level of Evidence

Level III, retrospective cohort study.

Impact of Pronator Quadratus Muscle Tear in Distal Radius Fractures on Patient Outcomes: Analyses of 55 Patients in a Volar Locking Plate Arm of a Randomized Clinical Trial

Background The advantage of pronator quadratus (PQ) repair following internal fixation via the volar approach in distal radius fracture (DRF) surgery remains unconfirmed in the literature. The aim of this study was to compare grip strength, patient-reported outcomes, and functional results between patients with an intact PQ and those with a ruptured PQ before undergoing surgery with a volar locking plate for dorsally displaced unstable extra-articular DRFs. Methods A total of 120 patients aged 55 years and older were included in a randomized controlled trial comparing a volar locking plate with a dorsal nail plate. Of the 60 patients randomized to the volar plate group, the integrity of the PQ muscle was recorded during surgery for 55 patients, who were included in this study. The outcomes measured were the Quick Disabilities of the Arm, Shoulder, and Hand Outcome Measure (QuickDASH) score, the Patient-Rated Wrist Evaluation (PRWE) score, the EQ-5D index, the visual analog scale (VAS) score, grip strength, and range of motion (ROM). Results The median age was 67 years (range 55 to 88), and the one-year follow-up rate was 98%. Patients with an identified intact PQ (28/55) before surgical release had better QuickDASH scores after one year (2.5 vs 8.0, mean difference 5.5, 95% CI: 1.3 to 9.8, p=0.028). Patients in the intact group also had better EQ-5D Index scores after one year (0.94 vs 0.85, mean difference 0.089, 95% CI: 0.004 to 0.174, p=0.031), and demonstrated better grip strength throughout the trial; after one year: 24 kg vs 20 kg (mean difference 3.9; 95% CI: 0.3 to 7.6, p=0.016). After one year, the intact group had regained 96% of their grip strength and the nonintact group had regained 93% of their grip strength compared to the uninjured side. The observed differences may be of questionable clinical importance, as they were lower than those of previously proposed minimal clinically important differences (MCIDs). Conclusions Patients with a DRF and a ruptured PQ prior to surgery exhibited higher QuickDASH scores and lower EQ-5D index scores after one year. The integrity of the PQ should be reported in future studies.

Arthroscopic Modified Lasso-Loop Stitch Technique for Chronic Lateral Ankle Instability in Skeletally Immature vs Mature Patients

BACKGROUND

In recent years, arthroscopic lateral ankle ligament repair has become increasingly popular. However, reports on the clinical outcomes of arthroscopic ankle stabilization for skeletally immature patients remain scarce. This study investigated the clinical outcomes of arthroscopic lateral ankle ligaments repair in skeletally immature patients compared to skeletally mature patients.

METHODS

Our retrospective analysis compared skeletally immature patients and skeletally mature adults who underwent arthroscopic repair of the ankle lateral ligaments with a modified lasso-loop stitch using a suture anchor. Skeletal immaturity was defined as patients whose epiphyseal line of the distal fibula remained open on plain radiography. Clinical outcomes were evaluated using the Self-Administered Foot Evaluation Questionnaire (SAFE-Q) at 2 years after surgery. The time to postoperative walking, jogging, and return to full sports activities were also evaluated.

RESULTS

Sixty-four skeletally immature patients (IM group) and 103 skeletally mature adults (M group) were included. No significant differences were observed during both walking and jogging after surgery between the groups; however, return to full athletic activities was significantly earlier in IM group (P = .05). The mean scores in all SAFE-Q subscales significantly improved in both groups after surgery (P < .001). There were also no statistically significant differences between the groups in the mean postoperative SAFE-Q scores for all subscales. All patients in the IM group returned to playing sports at their preinjury levels postoperatively.

CONCLUSION

We found that skeletally immature patients with chronic lateral ankle instability had generally similar responses to arthroscopic lateral ankle as skeletally mature adult patients at minimally 2 years' follow-up with a high rate of successful return to sport.

LEVEL OF EVIDENCE

Level III, retrospective case control study.

Low revision rate throughout the adoption of the direct superior approach in primary total hip arthroplasty: an analysis based on 1551 total hip arthroplasties from the Dutch Arthroplasty Register

BACKGROUND

Recently, surgeons introduced a minimally invasive modification on the classic posterolateral approach (PLA) in total hip arthroplasty (THA): the direct superior approach (DSA). We investigated the association between surgeon's experience and the risk of early revision of the DSA in primary THA, using data from the Dutch Arthroplasty Register (LROI).

METHODS

We retrieved all primary THAs performed using the DSA in 4 hospitals between 2016 and 2022 (n = 1551). Procedures were sorted in 5 groups using the date of operation and number of previous procedures per surgeon: 1-25; 26-50; 51-75; 76-100; >100. Subsequently, data from different surgeons were pooled together and the risk of revision was calculated via a multilevel time-to-event analysis.

RESULTS

The overall revision rate was 1.5% after a mean follow-up of 2 years. Patients from the 1-25 group had comparable risks of revision compared to patients in the >100 group (hazard ratio [HR] 1.0 [CI, 0.3-3.2]). The risk for patients in groups 26-50, 51-75 and 75-100 was also not statistically different from the >100 group (resp. HR 1.5 [CI, 0.5-5.0], 1.8 [CI, 0.5-6.4] and 0.5 [CI, 0.1-4.0]). Main reasons of revision were dislocation (0.5%) and infection (0.4%).

CONCLUSIONS

We did not identify an association between the surgeon's experience and the early risk of revision for the DSA in primary THA in the Netherlands. The DSA seems safe in the early adoption phases with a low risk of revision due to dislocation and revision for all other causes.

The Use of Glenoid Structural Allografts for Glenoid Bone Defects in Reverse Shoulder Arthroplasty

Background: The use of reverse shoulder arthroplasty as a primary and revision implant is increasing. Advances in implant design and preoperative surgical planning allow the management of complex glenoid defects. As the demand for treating severe bone loss increases, custom allograft composites are needed to match the premorbid anatomy. Baseplate composite structural allografts are used in patients with eccentric and centric defects to restore the glenoid joint line. Preserving bone stock is important in younger patients where a revision surgery is expected. The aim of this article is to present the assessment, planning, and indications of femoral head allografting for bony defects of the glenoid. Methods: The preoperative surgical planning and the surgical technique to execute the plan with a baseplate composite graft are detailed. The preliminary clinical and radiological results of 29 shoulders which have undergone this graft planning and surgical technique are discussed. Clinical outcomes included visual analogue score of pain (VAS), American Shoulder and Elbow Surgeons score (ASES), Constant-Murley score (CS), satisfaction before and after operation, and active range of motion. Radiological outcomes included graft healing and presence of osteolysis or loosening. Results: The use of composite grafts in this series has shown excellent clinical outcomes, with an overall graft complication rate in complex bone loss cases of 8%. Conclusion: Femoral head structural allografting is a valid and viable surgical option for glenoid bone defects in reverse shoulder arthroplasty.

Causes of Intraoperative Neuromonitoring Events in Adult Spine Deformity Surgery: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVES

Intraoperative neuromonitoring (IOMN) has become a standard practice in the detection and prevention of nerve damage and postoperative deficit. While multicenter studies have addressed this inquiry, there have been no systematic reviews to date. This systematic review identifies the leading causes of IONM alerts during adult spinal deformity (ASD) surgeries.

METHODS

Following PRISMA guidelines, a literature search was performed in PubMed and Embase. IONM alert causes were grouped by equivalent terms used across different studies and binned into larger categories, including surgical maneuver, Changes in blood pressure/temperature, Oxygenation, Anesthesia, Patient position, and Unknown.

RESULTS

Inclusion criteria were studies on adult patients receiving ASD correction surgery using IONM with documented alert causes. 1544 references were included in abstract review, 128 in full text review, and 16 studies qualified for data extraction. From those studies, there was a total of 3945 adult patients with 299 IONM alerts. Surgical maneuver led the alert causes (258 alerts/86.3%), with signal loss most commonly occurring at correction or osteotomy (101/33.8% and 95/31.8% respectively). Pedicle screw placement caused 35 alerts (11.7%). Changes in temperature and blood pressure were the third largest category (34/11.4%).

CONCLUSIONS

The most frequent causes of IONM alerts in ASD surgery were surgical maneuvers such as correction, osteotomy, and pedicle screw placement. This information provides spine surgeons with a quantitative perspective on the causes of IONM changes and show that most occur at predictable times during ASD surgery.

Efficient hip joint distraction using the AO large femoral distractor in treating acetabular fractures associated with marginal impaction and intraarticular incarcerated fragments

PURPOSE

The results after acetabular fracture are primarily related to the quality of articular reduction. Using the AO large femoral distractor, incarcerated fragments can be easily removed, and marginally impacted fragments can be elevated under direct visualization without further re-dislocating the joint. The current study aimed to evaluate our early results of using the AO large femoral distractor as an assisting tool during ORIF of acetabular fractures associated with marginal impaction or intraarticular incarcerated fragments.

METHODS

Eighteen patients were included in this retrospective case series study diagnosed with an acetabular fracture associated with either marginal impaction injury or an intraarticular incarcerated fragment. On a usual operative table, all patients were operated upon in a prone position through the Kocher Langenbeck approach. The AO large femoral distractor was used to facilitate hip joint distraction. Postoperative fracture reduction and joint clearance were assessed in the immediate postoperative CT scans.

RESULTS

The average age of the patients was 30 ± 8.2 years; 13 (72.2%) were males. All cases had a posterior wall fracture, and it was associated with transverse fractures, posterior column fractures, and T-type fractures in five (27.8%), two (11.1%), and one (5.6%) patients, respectively. Intraarticular incarcerated fragments were present in 13 (72.2%) cases and marginal impaction in five (27.8%). Fracture reduction measured on the postoperative CT scans showed an anatomical reduction in 14 (77.8%) patients, imperfect in four (22.2%), and complete clearance of the hip joint of any incarcerated fragments.

CONCLUSION

The use of the AO large femoral distractor is a reliable and reproducible technique that can be applied to assist in the removal of incarcerated intraarticular fragments and to ease the reduction of marginally impacted injuries associated with acetabular fractures.

Management of fixed flexion contracture in primary total knee arthroplasty: recent systematic review

INTRODUCTION

This study aimed to systematically review the literature and identify the surgical management strategy for fixed flexion contracture in primary total knee arthroplasty (TKA) surgery, pre-, intra-, and post-operatively. Secondary endpoints were etiologies and factors favoring flexion contracture.

MATERIALS AND METHODS

Searches were carried out in November 2023 in several databases (Pubmed, Scopus, Cochrane, and Google Scholar) using the following keywords: "flexion contracture AND TKA", "fixed flexion deformity AND TKA", "posterior capsular release AND TKA", "posterior capsulotomy in TKA", "distal femoral resection AND TKA". Study quality was assessed using the STROBE checklist and the Downs and Black score. Data concerning factors or strategies leading to the development or prevention of flexion contracture after TKA were extracted from the text, figures, and tables of the included references. The effect of each predictive factor on flexion contracture after TKA was recorded.

RESULTS

Thirty-one studies were identified to meet the inclusion and exclusion criteria. These studies described a variety of preoperative and intraoperative factors that contribute to the development or correction of postoperative flexion contracture. The only clearly identified predictor of postoperative flexion contracture was preoperative flexion contracture. Intraoperative steps described to correct flexion contracture were: soft-tissue balancing (in posterior and medial compartments), distal femoral resection, flexion of the femoral component, and posterior condylar resection. However, no study has investigated these factors in a global model.

DISCUSSION

This review identified various pre-, intra-, and post-operative factors predictive of post-operative flexion contracture. In practice, these factors are likely to interact, and it is therefore crucial to further investigate them in a comprehensive model to develop an algorithm for the management of flexion contracture.

LEVEL OF EVIDENCE

IV.

Association of Smokeless Tobacco and Complications Following Ankle and Hindfoot Arthrodesis

BACKGROUND

The purpose of this study was to (1) evaluate the rates of postoperative complications following ankle or hindfoot arthrodesis among current smokeless tobacco users and people who smoke compared to matched controls, and (2) compare rates of postoperative complications in current smokeless tobacco users vs people who smoke tobacco cigarettes.

METHODS

A retrospective cohort study was conducted using a large national database. For patients who underwent ankle or hindfoot arthrodesis, smokeless tobacco users (n = 131) and people who smoke (n = 1948) were matched 1:4 with controls, and smokeless tobacco users (n = 131) were matched 1:4 with people who smoke tobacco cigarettes (n = 524). Orthopaedic complications within 90 days, 1 year, and 2 years were compared using multivariable logistic regressions.

RESULTS

Within 90 days of ankle or hindfoot arthrodesis, smokeless tobacco users demonstrated significantly higher rates of hardware removal (odds ratio [OR] 5.01, 95% CI 1.65-15.20), wound disruption or dehiscence (OR 3.00, 95% CI 1.21-7.44), and pooled complications (16.0% vs 5.9%, OR 2.84, 95% CI 1.50-5.38) compared with tobacco-naïve controls. The rates of hardware removal, wound disruption and dehiscence, and pooled complications remained significant in the smokeless tobacco cohort at 1 and 2 years. At 2 years following ankle or hindfoot arthrodesis, smokeless tobacco users additionally demonstrated significantly higher rates of infection (OR 6.08, 95% CI 1.15-32.05) and nonunion (OR 2.35, 95% CI 1.31-4.20) compared with tobacco-naïve controls. Within 90 days of ankle or hindfoot arthrodesis, smokeless tobacco users demonstrated significantly lower rates of malunion or nonunion than patients who smoke tobacco cigarettes (OR 0.34, 95% CI 0.12-0.97), whereas all other complications were not significantly different.

CONCLUSION

Smokeless tobacco use is associated with higher rates of complications following ankle or hindfoot arthrodesis compared with tobacco-naïve controls, and physicians should screen for smokeless tobacco use specifically and encourage cessation before operating electively.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Arthroscopic fixation techniques for tibial eminence fractures in pediatric patients: a review

The introduction of new internal fixation devices and arthroscopic techniques has led to significant changes in the surgical treatment of tibial eminence fractures (TEFs) in children. In recent years, arthroscopic surgery has arisen as the gold standard for the treatment of TEFs. This popularity of arthroscopic techniques has reduced surgical complications and improved patient prognosis. In this paper, we investigate the current situation of the use of arthroscopic fixation techniques for pediatric TEFs. We searched the PubMed database using the terms "arthroscopic treatment and tibial eminence," "arthroscopic treatment and tibial spine," "tibial eminence avulsion", "tibial spine fracture", with no limit on the year of publication. From these articles, we reviewed the use of various arthroscopic TEFs fixation techniques reported in the current literature. Overall, we found that the choice of fixation method seems to have no effect on clinical outcomes or imaging results. However, if an easy, strong fixation that is less prone to epiphyseal damage is desired, as a junior practitioner, the anchor technique should be mastered first, whereas for senior practitioners, a variety of fixation techniques for TEFs should be mastered, including anchors, sutures, and screws, so that personalized fixation can be achieved with the least amount of trauma, operative time, and complications. Higher quality studies are needed in the future to provide Useful evidence to determine the optimal fixation technique in terms of clinical outcomes, function, and complications.

Contribution of the Medial Iliofemoral Ligament to Hip Stability After Total Hip Arthroplasty Through the Direct Anterior Approach

BACKGROUND

Dislocation after total hip arthroplasty (THA) is a primary reason for THA revision. During THA through the direct anterior approach (DAA), the iliofemoral ligament, which provides the main resistance to external rotation (ER) of the hip, is commonly partially transected. We asked: (1) what is the contribution of the medial iliofemoral ligament to resisting ER after DAA THA? and (2) how much resistance to ER can be restored by repairing the ligament?

METHODS

A fellowship-trained surgeon performed DAA THA on 9 cadaveric specimens. The specimens were computed tomography scanned before and after implantation. Prior to testing, the ER range of motion of each specimen to impingement in neutral and 10° of extension was computationally predicted. Each specimen was tested on a 6-degrees-of-freedom robotic manipulator. The pelvis was placed in neutral and 10° of extension. The femur was externally rotated until it reached the specimen's impingement target. Total ER torque was recorded with the medial iliofemoral ligament intact, after transecting the ligament, and after repair. Torque at extremes of motion was calculated for each condition. To isolate the contribution of the native ligament, the torque for the transected state was subtracted from both the native and repaired conditions.

RESULTS

The medial iliofemoral ligament contributed an average of 68% (range, 34 to 87) of the total torque at the extreme of motion in neutral and 80% (58 to 97) in 10⁰ of extension. The repaired ligament contributed 17% (1 to 54) of the total torque at the extreme of motion in neutral and 14% (5 to 38) in 10⁰ of extension, restoring on average 18 to 25% of the native resistance against ER.

CONCLUSIONS

The medial iliofemoral ligament was an important contributor to the hip torque at the extreme of motion during ER. Repairing the ligament restored a fraction of its ability to generate torque to resist ER.

GPT-4 as a Source of Patient Information for Anterior Cervical Discectomy and Fusion: A Comparative Analysis Against Google Web Search

STUDY DESIGN

Comparative study.

OBJECTIVES

This study aims to compare Google and GPT-4 in terms of (1) question types, (2) response readability, (3) source quality, and (4) numerical response accuracy for the top 10 most frequently asked questions (FAQs) about anterior cervical discectomy and fusion (ACDF).

METHODS

"Anterior cervical discectomy and fusion" was searched on Google and GPT-4 on December 18, 2023. Top 10 FAQs were classified according to the Rothwell system. Source quality was evaluated using JAMA benchmark criteria and readability was assessed using Flesch Reading Ease and Flesch-Kincaid grade level. Differences in JAMA scores, Flesch-Kincaid grade level, Flesch Reading Ease, and word count between platforms were analyzed using Student's t-tests. Statistical significance was set at the .05 level.

RESULTS

Frequently asked questions from Google were varied, while GPT-4 focused on technical details and indications/management. GPT-4 showed a higher Flesch-Kincaid grade level (12.96 vs 9.28, P = .003), lower Flesch Reading Ease score (37.07 vs 54.85, P = .005), and higher JAMA scores for source quality (3.333 vs 1.800, P = .016). Numerically, 6 out of 10 responses varied between platforms, with GPT-4 providing broader recovery timelines for ACDF.

CONCLUSIONS

This study demonstrates GPT-4's ability to elevate patient education by providing high-quality, diverse information tailored to those with advanced literacy levels. As AI technology evolves, refining these tools for accuracy and user-friendliness remains crucial, catering to patients' varying literacy levels and information needs in spine surgery.

Long-Term Follow-up of Untreated Adult Patients with Spondylothoracic Dysostosis (Jarcho-Levin Syndrome)

BACKGROUND

Spondylothoracic dysostosis (STD), also known as Jarcho-Levin syndrome (JLS), is a rare autosomal recessive disorder affecting the formation of the spine, characterized by a complete bilateral fusion of the ribs at the costovertebral junction, producing a "crablike" appearance of the thorax. Despite being declared a core indication for a V-osteotomy vertical expandable prosthetic titanium rib (VEPTR) expansion thoracoplasty of the posterior thorax, the natural history of STD in untreated subjects remains poorly documented. In this study, we report radiographic and pulmonary function findings and Patient-Reported Outcomes Measurement Information System (PROMIS) and 24-Item Early Onset Scoliosis Questionnaire (EOSQ-24) scores for untreated adult subjects with STD to gain insights into the natural history.

METHODS

We identified 11 skeletally mature, untreated subjects with STD. Findings on medical evaluation, demographics, radiographic parameters, pulmonary function, genetic testing results, PROMIS measures, and EOSQ-24 scores were assessed.

RESULTS

Five male and 6 female subjects (mean age, 32.3 years [range, 15 to 70 years]) with a confirmed STD diagnosis based on radiographs and genetic testing were evaluated. Mean body mass index (BMI) was 24.4 kg/m 2 (range, 18 to 38.9 kg/m 2 ), and mean thoracic height was 16 cm (range, 12 to 17 cm). Pulmonary function tests (PFTs) showed a mean forced vital capacity (FVC) of 22% of predicted, mean forced expiratory volume in 1 second (FEV1) of 24% of predicted, and FEV1/FVC ratio of 107% of predicted. The mean PROMIS dyspnea score was 40 ± 8 points (range, 27.7 to 52.1 points). The mean total EOSQ-24 score was 77.3 ± 18 points (range, 43.9 to 93.2 points).

CONCLUSIONS

Our study characterizes the natural history of STD in untreated subjects. We confirmed the expected restrictive pattern in pulmonary function, but interestingly, our subjects exhibited better EOSQ scores compared with those reported in neuromuscular populations. PFT results and thoracic height did not correspond to PROMIS and EOSQ scores, questioning the use of those parameters as a surgical indication. We therefore suggest that the STD diagnosis as an absolute indication for VEPTR expansion thoracoplasty surgery be reconsidered.

LEVEL OF EVIDENCE

Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Case Report: Technical description and clinical evaluation of three cases of unilateral biportal endoscopic decompression for symptomatic spinal epidural lipomatosis

Objective

To investigate the clinical characteristics and outcomes of three patients with symptomatic Spinal epidural lipomatosis (SEL) treated using Unilateral Biportal Endoscopic (UBE) surgery.

Methods

This report retrospectively analyzed the clinical data of three patients with SEL admitted to our hospital. The analysis covers onset characteristics, clinical manifestations, and the most recent radiologic grading system of neural compression (Manjila classification). Furthermore, it details the decompression accomplished through the application of a minimally invasive UBE surgical technique, specifically targeting the removal of proliferated fat responsible for nerve and spinal cord compression.

Results

This technique was performed successfully in 3 patients with SEL. Radiating pain was reduced, and the functional disability and radiologic compression were improved in all three patients. Postoperative spinal instability and surgical complications related to the procedure were not observed.

Conclusions

For SEL, timely diagnosis and appropriate intervention can prevent the progression of neurological disability. UBE is a minimally invasive muscle-preserving technique that achieves neural decompression directly by the removal of excessive intraspinal adipose tissue buildup.

Fusion mass to pelvis internal distraction technique using multiple-hook fixation for scoliosis correction: illustrative case

BACKGROUND

Internal distraction rods have been described as an alternative to halo gravity traction for the treatment of severe scoliosis. Distraction rods can be challenging to use in patients with existing fusion masses. The authors report an internal distraction, construct-to-construct rod technique using multiple-hook fixation in a patient with a sharply angulated cervicothoracic scoliosis fusion mass.

OBSERVATIONS

A 12-year-old female with previously diagnosed congenital scoliosis who had undergone cervical fusion in situ at age 2 presented to the clinic with shortness of breath exacerbated by increased levels of activity. Standing anteroposterior and lateral scoliosis radiographs revealed a left >150° cervicothoracic curve, right 140° thoracolumbar curve, and left 28° lumbosacral fractional curve with pelvic obliquity. The authors indicated this patient for a 3-stage all-posterior approach for spinal fusion and deformity correction. In the final fusion surgery, the authors set up a construct-to-construct internal distraction configuration connecting the left hemipelvis to the cervicothoracic fusion mass to aid in deformity correction.

LESSONS

A construct-to-construct internal distraction rod technique connecting a fusion mass to the pelvis can assist with curve correction in severe scoliosis.

Intraosseous Versus Intravenous Vancomycin in Tourniquetless Primary Total Knee Arthroplasty: A Randomized Trial

INTRODUCTION

Intraosseous (IO) administration of vancomycin at the time of total knee arthroplasty (TKA) has been shown to be safer and more effective than intravenous (IV) administration at preventing early periprosthetic joint infection. Previous studies have relied on tourniquet inflation to enhance local tissue concentrations and mitigate systemic release.

METHODS

A single-blinded, randomized clinical trial was performed on 20 patients (10 IV, 10 IO) undergoing primary TKA. The control (IV) group received weight-dosed vancomycin approximately 1 hour prior to the incision and weight-dosed cefazolin immediately prior to the incision. The interventional (IO) group received weight-dosed cefazolin immediately prior to the incision and 500 mg of vancomycin delivered via the IO technique at the time of the incision. Systemic samples for vancomycin levels were taken prior to the incision and at closure. During the procedure, tissue samples were taken from the distal femur, proximal tibia, and suprapatellar synovium. There were no differences in patient demographics or changes in serum creatinine from preoperative to postoperatively between groups.

RESULTS

Significant differences in systemic vancomycin levels (ug/mL) were found at the start of the case (IV = 27.9 ± 4.9 versus IO = 0 ± 0, P = 0.0004) and at the end of the case (IV = 19.6 ± 2.6 versus IO = 7.8 ± 1.0, P = 0.001). No significant differences were seen in the average vancomycin concentration in the distal femur (IV = 61.0 ± 16.0 versus IO = 66.2 ± 12.3, P = 0.80), proximal tibia (IV = 52.8 ± 13.5 versus IO = 57.1 ± 17.0, P = 0.84), or suprapatellar synovial tissue (IV = 10.7 ± 5.3 versus IO = 9.0 ± 3.3, P = 0.80). There were no complications associated with vancomycin administration in either group.

CONCLUSION

This study demonstrates the utility of IO vancomycin in tourniquetless TKA with similar local tissue and significantly lower systemic concentrations than IV administration.

Does the pararectus approach have better outcomes and fewer complications than the modified Stoppa approach for the fixation of acetabular fractures in adults: A systematic review and meta-analysis?

BACKGROUND

The pararectus approach is a minimally invasive surgical approach for anterior acetabulum fracture, with an advantage of the medial window of the modified Stoppa approach (MSA). However, it is unclear whether the pararectus approach is superior to MSA. We aimed this systematic review and meta-analysis to compare the outcomes and complications of pararectus and MSA.

METHODS

We performed a data search by conducting an electronic search across databases of PubMed, Embase, Scopus, Cinahl, CNKI, and Cochrane Library and included seven comparative studies for analysis. Statistical analysis was performed using the RevMan software 5.4.1. The risk of bias was evaluated using the Cochrane Collaboration's risk of bias tool for RCTs and the MINORS tool for non-RCTs.

RESULTS

Two randomized control trials (RCTs), one prospective study, and four retrospective studies were included. Meta-analysis revealed a better Matta's reduction quality [OR 1.58, 95% CI 1.06, 2.37; p = 0.03] and radiological outcome [OR 2.18, 95% CI 1.03, 4.60; p = 0.04] in MSA than in pararectus approach. However, the pararectus approach has less intraoperative blood loss [MD - 9.79 (95% CI - 176.75, - 6.83; p = 0.03)] and a shorter hospital stay [MD - 2.61 (95% CI - 5.03, - .18; p = 0.04)] than MSA. Both approaches have failed to show a difference concerning overall complication rates [OR 0.66 (95% CI 0.28, 1.55; p = 0.34)], postoperative infection, DVT, duration of surgery [MD - 15.09 (95% CI - 35.38, 5.20; p = 0.15)], functional outcome, and incision length.

CONCLUSION

The pararectus approach offers an advantage with lesser operative blood loss and shorter hospital stay, whilst MSA stands out with better reduction quality and radiological outcomes. Nevertheless, both approaches exhibit no difference in complication rates, duration of surgery, incision length, and functional outcome. Hence, the pararectus approach can be considered an alternative to MSA; however, the existing literature fails to demonstrate a distinct advantage over MSA.

A Comparison of Mini Open Transverse Incision and Longitudinal Incision for the Release of Moderate and Severe Carpal Tunnel Syndrome

OBJECTIVES

Carpal tunnel syndrome is a common condition seen in daily clinical practice. Multiple minimally invasive techniques have emerged in the last decades for median nerve decompression. However, many research are needed to study the outcome on the patients and their safety profile.

METHODS

We will compare group A that includes patients operated on using the minimally invasive transverse incision (number of patients = n = 221, females 76.7% and males 22.8%) versus group B that includes patients operated on using the longitudinal incision (n = 194, female 70.1% and male 29.9%) in term of clinical satisfaction and safety. The mean age of group A is 58.1±5.1 and that of group B is 58.8±4.8. The male and female distribution in both groups and the mean age were both similar with no statistically significant difference for the age (p = 0.79) or the gender distribution (p = 0.1). Data collected prospectively at regular intervals in time (preoperatively and at one month, three months, and six months post-carpal tunnel release (CTR)) between January 2006 and December 2021 were reviewed retrospectively. Patients' clinical findings, grip strength measurement using a hand dynamometer, and postoperative satisfaction measured using the BCTQ (Boston Carpal Tunnel Syndrome Questionnaire) scoring system were recorded and analyzed for each technique.

RESULTS

A total of 415 patients were included in our study. All patients included had moderate to severe median nerve compression documented by nerve-conducted studies with positive Tinel's and Phalen's signs. Baseline demographics between group A (CTR through a longitudinal palmar mini-incision) and group B (CTR with a mini-transverse incision at the palmar crease) didn't show a statistically significant difference. Both groups showed improved grip strength and BCTQ scores at the post-operative follow-up.

CONCLUSIONS

Median nerve decompression using both types of incisions has resulted in the same functional outcomes and patient satisfaction.

Early radiographic outcomes after anterior cervical discectomy and fusion with anatomic versus lordotic cages

Background

Anterior cervical discectomy and fusion (ACDF) interbody implants are shaped anatomically, with a convex superior aspect, or lordotically, with an angle and flat surfaces. However, the effect of implant shape on cervical sagittal balance (CSB) is not well described.

Methods

Of the 192 cases reviewed from 2018 to 2019, 118 were included with matching pre- and postoperative imaging. Cases were categorized by interbody implant type (anatomic or lordotic) and number of levels fused (1-level, 2-level, etc.). SurgiMap was used to measure cervical lordosis (CL), C2-C7 sagittal vertical axis (cSVA), T1 slope (T1S), and T1S minus CL (T1S-CL) on pre- and postoperative imaging. Pre- and postoperative parameters were compared within and between each cohort. Change in CL (ΔCL), cSVA (ΔcSVA), and T1S-CL (ΔT1S-CL) were calculated as the difference between pre- and postoperative values and were compared accordingly (1) anatomic versus lordotic and (2) 1-level versus 2-level versus 3-level fusion.

Results

Thirty-nine (33.1%), 57 (48.3%), and 22 (18.6%) cases comprised the anatomic, lordotic, and mixed (anatomic and lordotic) groups, respectively. ACDFs improved CL and T1S-CL by 5.71° (p<.001) and 3.32° (p<.01), respectively. CL was improved in the lordotic (5.27°; p<.01) and anatomic (4.57°; p<.01) groups, while only the lordotic group demonstrated improvement in T1S-CL (3.4°; p=.02). There were no differences in ΔCL (p=.70), ΔcSVA (p=.89), or ΔT1S-CL (p=.1) between the groups. Two- and 3-level fusions improved CL by 7.48° (p<.01) and 9.62° (p<.01), and T1S-CL by 4.43° (p<.01) and 5.96° (p<.01), respectively.

Conclusions

Overall, ACDFs significantly improved CL and T1S-CL however, there were no differences in CSB correction between the anatomic and lordotic groups. Two- and 3-level fusions more effectively improved CL (vs. single-level) and T1S-CL (vs. 3-level). These results suggest that implants should continue to be personalized to the patient's anatomy, however, future research is needed to validate these findings and incorporate the effects of preoperative deformities.