Additional Screw Research Articles

Humeral shaft cerclage wiring: a safe technique to prevent radial nerve injury

AbstractHumeral periprosthetic fractures are a challenging problem and their occurrence has increased, particularly over the last decade. The role of cerclage wires or cables in these fractures includes revisions with longer stems, and augmentation of a plate osteosynthesis in which the stem does not allow additional screw placement or structural bone grafts as supplementary fixation. These procedures are demanding because of the proximity of the radial nerve within the operating field.Placing a cerclage wire or cable around the fractured fragments offers a simple and safe procedure to avoid radial nerve injury or palsy in the treatment of complex humeral shaft fractures. This new technique is a simple and safe procedure to place a cerclage wire or cable around the humeral shaft.

Facteurs de risque de défaut de fixation d’un implant acétabulaire press-fit dans l’arthroplatie totale de hanche

BackgroundSurgeon at primary total hip arthroplasty, sometimes cannot achieve sufficient cementless acetabular press-fit fixation and must resort to other fixation methods. Despite a predominant use of cementless cups, this issue is not fully clarified, therefore we performed a large retrospective study to: (1) identify risk factors related to patient or implant or surgeon for unsuccessful intraoperative press-fit, (2) check for correlation between surgeons’ volume of operated cases and the press-fit success rate. HypothesisUnsuccessful intra-operative press-fit more often occurs in older female patients, particular implants, due to learning curve and low-volume surgeons. Materials and methodsRetrospective observational cohort of prospectively collected intra-operative data (2009–2016) included all primary total hip arthroplasty patients with implant brands that offered acetabular press-fit fixation only. Press-fit was considered successful if acetabulum was of the same implant brand as the femoral component without additional screws or cement. Logistic regression models for unsuccessful acetabular press-fit, included patients’ gender/age/operated side, implant, surgeon approach (posterior n=1206, direct-lateral n=871) and surgery date (i.e. learning curve). ResultsIn 2077 patients (mean 65.5years, 1,093 females, 1,163 right hips) were implanted three different implant brands (973 ABG-II™-Stryker, 646 EcoFit™Implantcast, 458 Procotyl™L-Wright) by eight surgeons. Their unsuccessful press-fit fixation rates ranged from 3.5 % to 23.7 %. Older age (odds ratio 1.01 [95 % CI 0.99–1.02]), female gender (2.87 [95 % CI 2.11–3.91]), right side (1.44 [95 % CI 1.08–1.92]), surgery date (0.90 [95 % CI 1.08–1.92]) and particular implants were significant risk factors only in three surgeons with less successful surgical technique (higher rates of unsuccessful press-fit with Procotyl™-L and EcoFit™ [P=0.01]). Direct-lateral hip approach had a lower rate of unsuccessful press-fit than posterior hip approach (P<0.01) but there was no correlation between surgeons’ volume and rate of successful press-fit (Spearman's rho=0.10, P=0.82). Subcohort of 961 patients with 5–7years, follow-up indicated higher early/late cup revision rates with unsuccessful press-fit. DiscussionSuccess of press-fit fixation depends entirely on the surgeon and surgical approach. With proper operative technique, the unsuccessful press-fit fixation rate should be below 5 % and the impact of patients’ characteristics or implants on press-fit fixation is then insignificant. Findings of huge variability in operative technique between surgeons of the presented study emphasize the need for surgeon-specific data stratification in arthroplasty studies and indicate the possibility of false attribution of clinically observed phenomena to patient-related factors in pooled data of large centres or hip arthroplasty registers. Level of evidenceLevel III, retrospective observational case control study.

2D and 3D assessment of sustentaculum tali screw fixation with or without Screw Targeting Clamp

IntroductionPrecise placement of sustentaculum tali screw(s) is essential for restoring anatomy and biomechanical stability of the calcaneus. This can be challenging due to the small target area and presence of neurovascular structures on the medial side. The aim was to evaluate the precision of positioning of the subchondral posterior facet screw and processus anterior calcanei screw with or without a Screw Targeting Clamp. The secondary aim was to evaluate the added value of peroperative 3D imaging over 2D radiographs alone. MethodsTwenty Anubifix™ embalmed, human anatomic lower limb specimens were used. A subchondral posterior facet screw and a processus anterior calcanei screw were placed using an extended lateral approach. A senior orthopedic trauma surgeon experienced in calcaneal fracture surgery and a senior resident with limited experience in calcaneal surgery performed screw fixation in five specimens with and in five specimens without the clamp. 2D lateral and axial radiographs and a 3D recording were obtained postoperatively. Anatomical dissection was performed postoperatively as a diagnostic golden standard in order to obtain the factual screw positions. Blinded assessment of quality of fixation was performed by two surgeons. ResultsIn 2D, eight screws were considered malpositioned when placed with the targeting device versus nine placed freehand. In 3D recordings, two additional screws were malpositioned in each group as compared to the golden standard. As opposed to the senior surgeon, the senior resident seemed to get the best results using the Screw Targeting Clamp (number of malpositioned screws using freehand was eight, and using the targeting clamp five). In nine out of 20 specimens 3D images provided additional information concerning target area and intra-articular placement. Based on the 3D assessment, five additional screws would have required repositioning. Except for one, all screw positions were rated equally after dissection when compared with 3D examinations. ConclusionThis study does not show a substantial benefit between the Screw Targeting Clamp and the freehand technique as well between experienced and inexperienced surgeons. Data suggest that the clamp might help positioning sustentaculum tali screws, especially for inexperienced surgeons. Perioperative 3D recordings facilitate identification of malpositioned screws.

Plate osteosynthesis of patellar fractures

Anatomic reconstruction of the retropatellar articular surface and repair of the extensor mechanism of the knee joint. The osteosynthesis should allow immediate mobilization as part of an early functional postoperative rehabilitation protocol. Displaced fractures of the patella, especially multifragment and comminuted fractures with aretropatellar incongruity or dislocation of >2 mm. Critical local soft tissue because of the risk of postoperative infection. Median skin incision. For simple (transverse) fractures, preservation of the soft tissue and reduction control via the index finger. For complex fractures, lateral arthrotomy and eversion of the patella. Reconstruction of the articular surface from the joint side with optimal visibility. Temporary fixation with Kirschner wires, osteosynthesis with the fixed angle plate. If necessary, additional screws or wires. Immediate mobilization with full weightbearing in full extension with aknee brace. Extension/flexion 0/0/60° for 4weeks, then 0/0/90° until the 7th week. Active extension after 6weeks. Climbing stairs after 12weeks. Good functional results in combination with alow rate of complications and revisions.

Healing at the Interface Between Autologous Block Bone Grafts and Recipient Sites Using n-Butyl-2-Cyanoacrylate Adhesive as Fixation: Histomorphometric Study in Rabbits.

The aim of the present split-mouth (split-plot) study was to describe the sequential healing in the interface between autologous bone grafts and recipient parent bone, fixed using an n-butyl-2-cyanoacrylate adhesive with or without an additional titanium fixation screw. Bone grafts were collected from the calvaria and fixed to the lateral aspect of the mandible in 24 rabbits. The cortical layers of the recipient sites were perforated, and the grafts were randomly fixed using an n-butyl-2-cyanocrylate adhesive, either alone or in conjunction with a 1.5 mm × 6.0 mm titanium fixation screw. The animals were sacrificed after 3, 7, 20, and 40 days, and histomorphometric evaluations of the interface between graft and parent bone were performed. Only 2 of 6 grafts in each group were partially incorporated to the parent bone after 40 days of healing. The remaining grafts were separated from the parent bone by adhesive and connective tissue. It was concluded that the use of n-butyl-2-cyanoacrylate as fixation of an autologous bone graft to the lateral aspect of the mandible was able to maintain the fixation over time but did not incorporate the graft to the recipient sites. Use of fixation screws did not improve the healing.

Exchange nailing with enhanced distal fixation is effective for the treatment of infraisthmal femoral nonunions.

The treatment options for nonunions of infraisthmal femoral shaft fractures after internal fixation are controversial. Methods such as exchanging an existing nail with a nail of a larger size, dynamization, removal of the nail followed by plating, and bone grafting have all been reported. Among those options, exchange nailing seems to be the most popular choice. In this study, a Poller screw, or an additional interlocking screw, was used in conjunction with exchange intramedullary nailing. The purpose of this study was to evaluate the effectiveness of treating femoral shaft nonunions using insertion of a Poller screw or an additional interlocking screw in conjunction with intramedullary nail fixation. This study included 18 patients who presented with nonunion of femur shaft fractures after internal fixation at the infraisthmal level. These patients included 13 men and 5 women, with a mean age of 46.8years (range 15-78years). The mean postsurgical period of nonunion was 7.8months (range 6-12months). The patients were classified into two groups: the atrophic nonunion group and the hypertrophic nonunion group. In all patients, nailing was enhanced with a Poller screw or additional interlocking screws. All patients were followed up with plain film examinations and were assessed for their functional recovery status to determine the osseous union conditions. All 18 patients achieved postoperative bony union after a mean time of 7.5months (range 3-12months), and all patients were able to walk with full weight-bearing and without pain within 3months. There were no significant complications, such as broken hardware, implant back-outs, axial or rotational malalignments, or deep infections. Poller screws and additional interlocking screws, along with intramedullary nailing exchange, may be an effective and reliable alternative for treating infraisthmal femoral shaft nonunions.

Costs Associated With Single-Use and Conventional Sets for Distal Radius Plating

Volar plating of distal radius fractures is an increasingly common procedure. Presterilized, single-use volar plate fixation sets have been purported to increase operating room efficiency and decrease cost. The purpose of this study was to compare the actual cost of using a conventional set compared with the projected cost of using its single-use counterpart. We retrospectively analyzed 30 consecutive cases of volar plate fixation in which conventional instrument sets were used. Hardware and processing costs were calculated for the conventional sets and compared with the projected cost of using single-use sets. The mean total cost of hardware and processing for the conventional sets was $2,728, whereas the projected cost for the single-use sets was slightly higher at $2,868. Twenty-three of the 30 cases would have required additional screws not available in the single-use set. The cost of the additional screws needed to supplement the single-use set would have added an average of $282/case. Overall, the combined hardware and processing cost was lower for conventional sets in 25 of the 30 cases. Although the price of the single-use set is less than the mean charge for use of a conventional set, additional screws not available in the single-use set were required in 77% of cases and consequently rendered the conventional set cheaper in 83% of cases. Stocking the single-use sets with additional screws to reflect the most commonly used screw lengths could make these sets more cost effective in the future. Economic and decision analysis IV.

Spinal Hydatid Cyst Disease.

A hydatic cyst (HC) is a zoonotic infection affecting the liver and lungs, with rare spinal involvement. We discuss the long-term results in 8 patients with spinal HC who were monitored at our clinic for 7 to 15 years. The demographic data and clinicopathologic characteristics of 8 patients with spinal HC diagnosed between 2000 and 2016 were evaluated for their contribution to recurrence, and the long-term follow-up results were examined. Four male and 4 female patients with a median age of 30.75 years (range, 17-45 years) at the first surgery were included. Infections were localized in the thoracic (3), thoracolumbar (1), lumbar (1), sacral (1), cervicothoracic (1), and lumbosacral (1) regions. Two patients had secondary HCs that spread from another organ (lung and kidney). Patients underwent 2 to 5 surgeries during the study period, with an average follow-up time of 8.5 years (range, 7-15 years) after the first surgery. The surgical treatments included an anterior corpectomy and anterior plate for a patient with cervical localization and cystectomy for a patient with sacral localization; the other patients underwent cystectomy with corpectomy and stabilization with an anterior approach, cyst excision and laminectomy with a posterior approach, or additional posterior transpedicular screw stabilization. The patients were prescribed albendazole. Spinal HC treatment is difficult, particularly in patients with vertebral and paraspinal involvement, spinal instability, and recurrence. Long-term follow-up is critical, and patients require medical and surgical treatment, with regular clinical, radiologic, and serologic examinations. The cysts must be removed without rupture during surgery, and the surgical area must be irrigated with hypertonic saline solution to reduce the risk of recurrence.

Retrospective Analysis of Non-Union Rate Associated with Immediate Weightbearing Following A Modified Lapidus Arthrodesis

Category: Bunion Introduction/Purpose: A 6-8 week non-weightbearing period post modified lapidus arthrodesis has traditionally been universally accepted. A review of the literature reports nonunion rates between 5-33% after modified lapidus with 6-8 weeks of non- weightbearing. There are only a few reports in the literature that discuss immediate weightbearing after the modified lapidus procedure. In this retrospective review, we examine the nonunion rate among patients undergoing the modified lapidus arthrodesis who were immediately weightbearing in a controlled ankle motion (CAM) boot. It is our hypothesis that the non- union rate will be comparable to the traditional post-operative protocol nonunion rate. Methods: In this retrospective study, we evaluated chart data on patients who underwent a modified Lapidus arthrodesis with immediate weight- bearing in a CAM boot. The goal of the study was to determine if a modified Lapidus surgical technique in conjunction with rigid internal fixation produces the necessary stability post-operatively in order to allow bony consolidation while being stressed with immediate weight bearing forces. Patients who underwent a modified Lapidus arthrodesis using either a 3 screw construct or a medially placed locking plate with an interfragmentary screw were included in the study. Patients with other adjunctive procedures that would prevent early weight bearing were not included in the investigation. Results: A total of 376 patients were identified with 74 patients meeting inclusion criteria. 4 patients had bilateral procedures performed at separate times for a total of 78 Lapidus procedures. 31 patients had a 3 screw construct while 43 patients had a medial locking plate with an interfragmentary screw. 15 patients admitted to using nicotine. Additionally, 7 patients had type II Diabetes Mellitus. Autogenous shear- strain relief bone graft was used in 75 of the 79 procedures.Three patients (3.8%) experienced a post-operative non-union. Interestingly, none of the patients with non-unions were smokers and only one patient was diabetic. Conclusion: The results of this study found a 3.8% nonunion rate. Based on these results we conclude that a modified Lapidus procedure using a long, solid interfragmentary screw with either additional screw support or a locking plate, we may permit patients to ambulate safely in a CAM boot immediately post- operative period without affecting surgical outcome.

334 Anterior Screw Plate Fixation for Odontoid Fractures

Abstract INTRODUCTION Certain unstable odontoid fractures (anterior oblique fracture, displaced distal fragment, disrupted alar ligament) are usually offered posterior C1-C2 fixation by Goel-Harms technique. Anterior submandibular extrapharyangeal approach offers a simple safe and biomechanically correct option to treat these fractures. Fracture manipulation, reduction and repositioning is feasible along with fixation in compression mode with a VSP plate and screws. Additional instability of the atlantoaxial joints, if present, can be treated with anterior transarticular screws. METHODS The right sided submandibular extrapharyangeal approach was used to expose the fractured odontoid. Open manipulation to reduce displaced fracture fragments followed by fixation with a VSP plate (Titanium customized from Jayon Inc Pallakad India) using 3.5 mm thick titanium screws. If fracture was associated with disruption of alar ligament then additional bilateral tranarticular screws were passed to fix the joints in neutral position after abrading the opposing endplates and corticocancellous bone grafts into the joints. RESULTS &gt;Since February 2011 January 2017 45 patients with unstable odontoid fractures have been offered this procedure. No transfusion was required in any case and no case required additional procedure. All patients showed bone union across fracture site at 3 months. Five elderly patients (70 yrs and 76 yrs) complained of dysphagia for 2–3 days after surgery, 4 patients (including the ones with dysphagia) had mild hypoglossal weakness which recovered in a week. Neck pain persisted in 9 patients for 4 weeks which responded to analgesics. Long-term follow-up imaging has been at 3 years in 8 patients, without implant failure and 100% bone fusion. CONCLUSION Anterior submandibular extrapharyangeal approach offers a simple safe and biomechanically correct option to treat these fractures.

Humeral fractures

Humeral fractures are challenging injuries to deal with. Thorough patient assessment is necessary on presentation, to evaluate for concurrent injuries and to rule out pathologic fractures. External coaptation is not considered a viable treatment option for the vast majority of humeral fractures and surgical stabilisation is recommended. Humeral fractures are classified as proximal, midshaft and distal, with various sub-classifications within each category. Fractures of the greater tubercle and humeral head are generally stabilised using a tension band apparatus and additional K-wires or lag screws where necessary. Humeral neck fractures are commonly transverse and amenable to compression plate fixation craniolaterally, but for comminuted fractures a form of bridging fixation is required. Fractures of the midshaft of the humerus can be repaired via a range of fixation strategies including plates, external skeletal fixation, interlocking nails, intramedullary pins and cerclage wires, and combination techniques. Distal humeral fractures include those of the medial or lateral humeral condyle, commonly stabilised using a transcondylar screw and a supracondylar K-wire or plate, and intracondylar fractures, which are challenging and commonly stabilised using bilateral plate fixation in conjunction with a transcondylar screw. The prognosis following humeral fracture stabilisation is generally good to excellent although the articular fractures, particularly the intracondylar fractures may have a slightly more guarded prognosis for long-term resolution of lameness.

Risk factors for unsuccessful acetabular press-fit fixation at primary total hip arthroplasty

BackgroundSurgeon at primary total hip arthroplasty sometimes cannot achieve sufficient cementless acetabular press-fit fixation and must resort to other fixation methods. Despite a predominant use of cementless cups, this issue is not fully clarified, therefore we performed a large retrospective study to: (1) identify risk factors related to patient or implant or surgeon for unsuccessful intraoperative press-fit; (2) check for correlation between surgeons’ volume of operated cases and the press-fit success rate. HypothesisUnsuccessful intra-operative press-fit more often occurs in older female patients, particular implants, due to learning curve and low-volume surgeons. Materials and methodsRetrospective observational cohort of prospectively collected intraoperative data (2009–2016) included all primary total hip arthroplasty patients with implant brands that offered acetabular press-fit fixation only. Press-fit was considered successful if acetabulum was of the same implant brand as the femoral component without additional screws or cement. Logistic regression models for unsuccessful acetabular press-fit included patients’ gender/age/operated side, implant, surgeon, approach (posterior n=1206, direct-lateral n=871) and surgery date (i.e. learning curve). ResultsIn 2077 patients (mean 65.5 years, 1093 females, 1163 right hips), three different implant brands (973 ABG-II™-Stryker, 646 EcoFit™ Implantcast, 458 Procotyl™ L-Wright) were implanted by eight surgeons. Their unsuccessful press-fit fixation rates ranged from 3.5% to 23.7%. Older age (odds ratio 1.01 [95% CI: 0.99–1.02]), female gender (2.87 [95% CI: 2.11–3.91]), right side (1.44 [95% CI: 1.08–1.92]), surgery date (0.90 [95% CI: 1.08–1.92]) and particular implants were significant risk factors only in three surgeons with less successful surgical technique (higher rates of unsuccessful press-fit with Procotyl™-L and EcoFit™ [P=0.01]). Direct-lateral hip approach had a lower rate of unsuccessful press-fit than posterior hip approach (P<0.01), but there was no correlation between surgeons’ volume and rate of successful press-fit (Spearman's rho=0.10, P=0.82). Subcohort of 961 patients with 5–7-years follow-up indicated higher early/late cup revision rates with unsuccessful press-fit. DiscussionSuccess of press-fit fixation depends entirely on the surgeon and surgical approach. With proper operative technique, the unsuccessful press-fit fixation rate should be below 5% and the impact of patients’ characteristics or implants on press-fit fixation is then insignificant. Findings of huge variability in operative technique between surgeons of the presented study emphasize the need for surgeon-specific data stratification in arthroplasty studies and indicate the possibility of false attribution of clinically observed phenomena to patient-related factors in pooled data of large centers or hip arthroplasty registers. Level of evidenceLevel III, retrospective observational case control study.

Treatment of thoracolumbar burst fractures by short-segment pedicle screw fixation using a combination of two additional pedicle screws and vertebroplasty at the level of the fracture: a finite element analysis

BackgroundTraditional one-above and one-below four-screw posterior short-segment instrumentation is used for unstable thoracolumbar burst fractures. However, this method has a high rate of implant failure and early loss of reduction. The purpose of this study was to use finite element (FE) analysis to determine the effect of treating thoracolumbar burst fractures by short-segment pedicle screw fixation using a combination of two additional pedicle screws and vertebroplasty at the level of the fracture.MethodsAn intact T11-L1 spine FE model was created from the computed tomography images of a male subject. Four fixation models with posterior fusion devices (pedicle screws, rods, cross-link) were established to simulate an unstable thoracolumbar fracture with different fusion surgeries: short-segment fixation with: 1) a link (S-L); 2) intermediate bilateral screws (S-I); 3) a link and calcium sulfate cement (S-L-C); 4) intermediate bilateral screws and calcium sulfate cement (S-I-C). Different loading conditions (flexion, extension, lateral bending, and axial rotation) were applied on the models and analyzed with a FE package. The range of motion (ROM), and the maximum value and distribution of the implant stress, and the stress in the facet joint, were compared between the intact and fixation models.ResultsThe ROM in flexion, extension, axial rotation, and lateral bending was the smallest in the S-I-C model, followed by the S-I, S-L-C, and S-L models. Maximum von Mises stress values were larger under lateral bending and axial rotation loadings than under flexion and extension loading. High stress was concentrated at the crosslink and rod junctions. Maximal von Mises stress on the superior vertebral body for all loading conditions was larger than that on the inferior vertebral body. The maximal von Mises stress of the pedicle screws during all states of motion were 265.3 MPa in S-L fixation, 192.9 MPa in S-I fixation, 258.4 MPa in S-L-C fixation, and 162.3 MPa in S-I-C fixation.ConclusionsShort-segment fixation with two intermediate pedicle screws together with calcium sulfate cement at the fractured vertebrae may provide a stiffer construct and less von Mises stress of the pedicle screws and rods as compared to other types of short-segment fixation.

English

English

Anterior retropharyngeal plate screw fixation with bilateral anterior transarticular screws for odontoid fractures ... a new comprehensive technique

Introduction: A certain group of odontoid fractures (Anderson and D’ Alonzo Type-2) are usually offered surgical treatment. Common surgical option is an anterior odontoid screw. Some of the fractures are not suitable for anterior odontoid screw (anterior oblique, displaced distal fragments and those with atlantoaxial instability) and these are usually offered posterior transarticular screws (Magerl’s) or posterior atlantoaxial screw rod/plate fixation (Goel-Harms technique). Posterior surgery involves atlantoaxial fixation with an indirect attempt to reduce and fuse the fracture . Posterior surgery has a risk of injury to the vertebral arteries, hemorrhage from the paravertebral venous plexus and the C2 root ganglion.Methods: A direct anterior submandibular retropharyangeal approach with open reduction and fixation (ORIF) using a customized variable screw placement (VSP) plate was used to realign and fix the fracture fragments in compression mode under direct vision. Twenty patients of type-II odontoid fractures (unsuitable for anterior odontoid screw) underwent an anterior retropharyngeal approach with anterior variable screw position (VSP) plate and screw fixation and eight amongst them, who had associated atlantoaxial instability underwent additional bilateral anterior transarticular screws.Results: All patients treated by this technique had 100% fracture site bone union without any implant failure. Longest follow-up has been for 3 years.Conclusion: Anterior retropharyangeal approach allows direct fracture fragment realignment under vision with an opportunity to fix in compression mode using the VSP plate, which ensures early fusion across the type-II odontoid fracture. Any associated instability can be treated by additional bilateral anterior transarticular screws. The approach is simple and safe without any risk to the vertebral arteries and biomechanically appealing.

Anterior Approach for Ankle Arthrodesis.

End-stage ankle arthritis may be treated successfully with either an ankle arthrodesis or arthroplasty. Both surgical interventions have demonstrated success with regard to pain relief and function. Ankle arthrodesis is indicated for patients with recalcitrant ankle pain despite appropriate nonoperative intervention. Patients who have a history of posttraumatic arthritis from a high-energy injury, soft-tissue compromise, limited range of motion, or deformity may be superior candidates for arthrodesis. The surgical technique can be undertaken with either an open or an arthroscopic approach. An open anterior approach with an anatomic precontoured locking plate is ideal for patients with deformity and/or bone loss. Additionally, the use of a precontoured plate assists with achieving a neutral alignment in both the coronal and the sagittal plane, which is critical to the long-term success of the procedure. No hardware, however, substitutes for appropriate surgical technique, which is the focus of this video article. The procedure includes the following steps:An anterior extensile incision is made immediately lateral to the anterior tibial tendon, extending to the level of the talonavicular joint.Dissection is taken with care to avoid the superficial peroneal nerve in the distal aspect of the incision. The extensor retinaculum is incised either longitudinally or in a z-shaped fashion to facilitate closure.Deep dissection may be taken through the sheath of the anterior tibial tendon, which substantially decreases the risk of injury to the deep neurovascular bundle. Alternatively, dissection may be taken through the extensor hallucis longus (EHL) to avoid violation of the anterior tibial tendon sheath. The neurovascular bundle is directly posterior to the EHL at the level of the ankle joint.The ankle joint is exposed, with the removal of tibial and talar osteophytes.The joint surfaces are prepared.The precontoured ankle arthrodesis plate, which is used to improve alignment, is positioned and placed.Compression is achieved using the "Achilles tension band technique," which furthers compression through the ankle.An additional transarticular screw is placed. The expected outcome of the procedure, based on recent clinical outcomes, is osseous union, and the rate of union has been reported to range from 91% to 96%. Improvement in function and pain relief are associated with a successful arthrodesis. Despite a slow deterioration of functional outcomes and radiographic progression of arthritis, clinical improvement with a high rate of patient satisfaction has been noted at a mean of 9 years postoperatively.

A comparative analysis of outcomes of treatment of fracture neck of femur with 9.5mm sliding hip screw and plate with an additional derotation screw versus three parallel cannulated hip screws

Fracture neck of femur has always attracted the mankind due to its peculiar nature of going into non union and osteonecrosis of femoral head even with best fixation method and adequate reduction. A novel way to treat fracture neck of femur is with small diameter dynamic hip screw and an additional derotation screw. 30 patients aged 18-60 years presenting to Deen Dayal Upadhyay Hospital with fresh (

Comparison of 3 Methods for Maintaining Inter-Fragmentary Compression After Fracture Reduction and Fixation.

It is recommended that the intra-articular component of a supracondylar distal femoral fracture be stabilized by a lag screw to create interfragmental compression. Generally, it is thought that lag screw fixation should precede any positional screw or locking screw application. This study compared 3 methods of maintaining interfragmentary compression after fracture reduction with a reduction clamp. Intra-articular vertical split fractures were created in synthetic femora. A force transducer was interposed between the medial and lateral condyles and 20 lbs of compression was applied to the fracture with a reduction clamp. 3.5-mm cortical lag screws (group 1), 3.5-mm cortical position screws (group 2), and 5.4-mm distal locking screws through a distal femur locking plate (group 3) were placed across the fracture (n = 4/group). After screw placement, the clamp was removed and the amount of residual interfragmentary compression was recorded. After 2 minutes, a final steady-state force was measured and compared across groups. Locking screws placed through the plate (group 3) maintained 27% of the initial force applied by the clamp (P = 0.043), whereas positional screws (group 2) maintained 90% of the initial force applied by the clamp (P = 0.431). The steady-state compression force measured with lag screws (group 1) increased by 240% (P = 0.030) relative to the initial clamp force. The steady-state force in the lag screw group was significantly greater than groups 1 and 2 (P = 0.012). When reducing intra-articular fractures and applying interfragmentary compression with reduction clamps, additional lag screws increase the amount of compression across the fracture interface. Compressing a fracture with reduction clamps and relying on locking screws to maintain the compression result in a loss of interfragmentary compression and should be avoided. This study lends biomechanical support that lag screws placed outside of the plate before locking screws for fracture fixation help maintain optimal interfragmentary compression.

Lapidus arthrodesis

The tarso-metatarsal1 joint (TMT-I) arthrodesis is atreatment option or moderate to severe hallux valgus (HV) deformities. Instability of the TMT1 joint is still adebatable indication. Using stable osteosynthesis techniques allows early postoperative weight bearing. Plantar plating combined with alag screw is the biomechanical most stable construct. An additional intermetatarsal screw can improve the horizontal stability. Clinical results are good and radiological parameters stay constant, even in the long term.

Is pelvic fixation the only option to provide additional stability to the sacral anchorage in long lumbar instrumentation? A comparative biomechanical study of new techniques

BackgroundSupplementary iliac screws have the highest potential to protect S1-pedicle-screws from loosening in long fusion constructs. However, this technique bridges the iliosacral joint with potential disadvantages for the patient. This study aimed to evaluate if two different established fixation techniques can be used in addition to pedicle screws as alternative to iliac screws, and if these two techniques can provide similar stability when S1-pedicle-screws are loosened. MethodsFlexibility testing with pure moments of 7.5Nm was performed with six human osteopenic/osteoporotic L4-pelvis specimens. The following conditions were investigated: 1. Intact; 2. Destabilization L5/S1; 3. Fixation with rigid L4-S1 pedicle-screw-system; 4. Condition 3- loosening of S1-screws; 5. Condition 4- L5-S2-lamina-hooks; 6. Condition 4- L5/S1-translaminar-screws; 7. Condition 4- S2-ala-ilium screws. FindingsApplication of compressive L5-S2-lamina-hooks or L5/S1-translaminar-screws next to pedicle screws in L5 and S1 was feasible in all specimens. L4-S1-pedicle-screw-instrumentation reduced the Range of Motion significantly compared to the destabilized condition. After simulation of S1 screw loosening, lamina hooks only reduced the Range of Motion in flexion/extension significantly. L5/S1-translaminar-screws had a higher stabilizing effect in lateral bending and axial rotation, but the effect of both systems was smaller than with an instrumentation extension to the os ilium. InterpretationIn long lumbar pedicle screw instrumentations including L5/S1, additional ilium screws have the highest potential to protect the S1-anchorage. Additional L5/S1-translaminar-screws can increase stability of the lumbosacral junction without bridging the iliosacral joint, whereas lamina hooks showed no significant biomechanical benefit.