Anterior Placement Research Articles

Sagittal plane deformity after temporary epiphysiodesis of the distal femur for correcting limb length discrepancy

BackgroundOutcome of the temporary epiphysiodesis procedure for limb length discrepancy (LLD) is commonly evaluated in the coronal plane. The purpose of this study was to investigate implant position and complications of the distal femur and patella in the sagittal plane after the temporary epiphysiodesis. MethodsWe retrospectively reviewed 27 patients with LLD who underwent temporary epiphysiodesis of the distal femur using staples (11 patients) or eight-plates (16 patients) between 2007 and 2015. The mean age was 9.7 years (range, 6.3–13.8) at the time of epiphysiodesis. The implants were removed after a mean period of 2.6 years (range, 0.8–4.8) from the epiphysiodesis. Correction amount of LLD was measured on anteroposterior long leg standing radiographs. Implant position, extension deformity of the distal femur (>5° from epiphysiodesis to removal of implant) and patella baja (the epiphyseal line midpoint method < 1.0) were evaluated using lateral knee radiographs. ResultsThe average correction amount of LLD was 17.4 mm (range, 2–34). The average implant position was 43.1% (range, 35–55) from the anterior edge of the distal femoral epiphysis. At removal surgery, 16 patients (59%) had extension deformity of the distal femur and 14 patients (52%) showed patella baja. There were significant correlations between implant position and extension deformity (r = −0.51, p < 0.01) and as well as between correction amount of LLD and patella baja (r = −0.64, p < 0.01). ConclusionAfter temporary epiphysiodesis for the treatment of LLD, extension deformity of the distal femur and patella baja occurred frequently. Anterior placement of the implants is associated with extension deformity of the distal femur. The implant should be placed in the center of distal femoral physis, not the center of femoral shaft. Excessive correction of LLD should be avoided due to a risk of patella baja.

All-Arthroscopic Reconstruction of Severe Chronic Acromioclavicular Joint Dislocations

To report the outcomes of all-arthroscopic coracoclavicular (CC) ligament reconstruction and simultaneous diagnosis and treatment of glenohumeral pathologies in patients with symptomatic, chronic (>6weeks), complete (Rockwood type III-V) acromioclavicular joint (ACJ) separations. We prospectively followed up 57 consecutive patients treated arthroscopically for chronic Rockwood type III (n= 11), type IV (n= 19), and type V (n= 27) ACJ dislocations. Previous ACJ surgery failed in 11 (19%). The mean delay between injury and surgery was 39months (range, 6months to 17years). The mean age at surgery was 42years (range, 19-71years). After glenohumeral exploration, an arthroscopic modified Weaver-Dunn procedure with CC suture button fixation (Twinbridge) was performed. The CC reduction and tunnel position were analyzed with radiographs and computed tomography. The mean follow-up period was 36months (range, 12-72months). Intra-articular pathology was treated arthroscopically in 27 patients (48%): 17 labral tears, 8 rotator cuff tears (3 partial and 5 complete), and 15 biceps lesions (4 SLAP lesions and 11 subluxations). At last follow-up, 7 patients (12%) experienced recurrent ACJ instability: 2 frank dislocations (1 trauma and 1 infection) and 5 ACJ subluxations. There was no significant correlation between subluxation and clinical outcome. The rate of recurrent ACJ instability was significantly higher in patients with higher-grade ACJ dislocations (P < .01) and/or previous failed surgery (P < .001). Recurrent subluxation was observed in 3 cases of lateral migration of the coracoid button with lateral tunnel placement, as well as 2 cases of anterior migration of the clavicular button with anterior tunnel placement. The Constant score increased from 67 (range, 28-89) to 85.5 (range, 66-100), and the mean Subjective Shoulder Value increased from 54% to 85% (P < .001). At last follow-up, 95% of patients (54 of 57) were satisfied. All-arthroscopic treatment allows successful CC ligament reconstruction and simultaneous diagnosis and treatment of frequently associated (48%) glenohumeral lesions. Higher-grade ACJ dislocations, previous ACJ surgery, and misplacement of bone tunnels are risk factors for recurrent instability. Level IV, case series.

Does the placental strain ratio correlate with the umbilical artery Doppler values?

Objective: The aim of this study is to reveal whether there is any relationship between strain elastography (SE) values and Doppler ultrasonography (US) findings, and to investigate the availability of SE in early diagnosis of preeclampsia (PE). Material and Methods: The authors examined 21-24 week old patients who applied to this clinic for anomaly screening. Only 55 pregnant women with anterior or anterolateral placental placement were included in the study. Doppler US data and placental strain elastography values were compared statistically. Results: There was an inverse correlation between umbilical artery resistance index (RI) values and placental strain ratios. Discussion: Histopathological examination shows that, as a result of the increasing extracellular matrix proteins due to increased inflammation, elasticity in the placental tissue decreases, and this may lead to an increase in placental stiffness. Also it is known that, abnormal Doppler US findings are considered to be a weak positive predictor of placental insufficiency. Therefore the present authors compared Doppler US with placental elastography and found an inverse correlation between umbilical artery RI value and placental strain ratio. Conclusion: Placental elasticity can be used for placental abnormalities in addition to other methods, but further studies are needed to use placental elasticity as a positive predictive marker for placental insufficiency.

Abdominal Versus Standard Placement of the Sacral Nerve Stimulator Implantable Pulse Generator

ObjectivesTo determine patient factors prompting anterior abdominal wall placement of the sacral nerve stimulator implantable pulse generator and investigate revision and infection rates for buttock (standard) and abdominal placement. MethodsWe retrospectively reviewed records of consecutive sacral nerve stimulation procedures by a single surgeon from 2012 to 2017 at a single institution. Results75 patients underwent sacral nerve stimulation––60 with standard and 15 with abdominally placed implantable pulse generators. The mean age and body mass index of the standard group was higher than that of the abdominal group and the majority was female. A greater proportion of patients in the abdominal group had a neurological diagnosis and was wheelchair-dependent. Overall, a total of 20 patients underwent 38 revision surgeries. The indications for revision surgery were pain, loss of efficacy, or lead migration. The standard group accounted for more revisions than the abdominal group (34vs 4 cases, P = .048), with no revisions due to pain in the abdominal group. The infection rate (2% vs 13%, P = .10), average time from implantation to revision, and operative duration were not statistically different between groups. ConclusionIn a subset of patients who were wheelchair-dependent or lacked gluteal fat, placement of the implantable pulse generator in the anterior abdominal wall resulted in no revisions due to pain. Operative duration and infection rates were similar between abdominal and standard placement. Abdominal placement with extended length leads could be considered as a primary or revision option in these select patients.

A retrospective analysis of dental implant survival in HIV patients.

This 5years retrospective cohort survival study compared failure rates of dental implants placed in HIV (+) and HIV (-) patients relative to several risk factors. Between 2006 and 2015, 484 implants placed in HIV (+) patients and 805 implants placed in HIV (-) patients were assessed for survival. The effects of HIV were estimated using propensity weighting. The effects of age, smoking status, diabetes, restoration status, gender, implant type, placement site, hepatitis C status, baseline CD4 count and CD4%, post-placement average CD4%, nadir CD4%, nadir CD4 count and antiviral therapy were analysed. Implants placed in HIV (+) patients and HIV (-) patients had similar failure rates (HR=1.4, p=0.34). Increased failure rates were observed in HIV (+) patients with baseline CD4% ≤20 (HR=2.72, p=0.04), post-placement CD4% average ≤20% (HR=2.71, p=0.04), protease inhibitor administration (HR=2.74, p=0.04), smoking (HR=2.61, p=0.05) and anterior maxillary placement (HR=5.82, p<0.01). Hepatitis C coinfection, viral titre, baseline CD4 count, gender, implant type and restoration type were non-contributory. Implants placed in HIV (+) patients had similar survival rates as HIV (-) patients. Failure rates increase significantly when confounding risk factors are present in HIV (+) patients.

Kinematic assessment of an elastic-core cervical disc prosthesis in one and two-level constructs.

IntroductionAnterior cervical discectomy and fusion has been associated with the development of adjacent segment degeneration (ASD), with clinical incidence of approximately 3% per year. Cervical total disc arthroplasty (TDA) has been proposed as an alternative to prevent ASD.HypothesesTDA in optimal placement using an elastic‐core cervical disc (RHINE, K2M Inc., Leesburg, Virginia) will replicate natural kinematics and will improve with optimal vs anterior placement.MethodsSeven C3‐T1 cervical cadaver spines were tested intact first, then after one‐level TDA at C5‐C6 anterior placement, after TDA at C5‐C6 optimal placement, after two‐level TDA at C5‐C6 and C6‐C7 optimal placement, and finally after two‐level TDA at C5‐C6 lateral placement and C6‐C7 optimal placement. The specimens were subjected to: Flexion‐Extension moments (+1.5 Nm) with compressive preloads of 0 N and 150 N, lateral bending (LB) and axial rotation (AR) (+1.5 Nm) without preload.Results C5‐C6 TDA in optimal placement resulted in a non‐significant increase in flexion‐extension ROM compared to intact under 0 N and 150 N preload (P > 0.05). Both LB and AR ROM decreased with arthroplasty (P < 0.01). Optimal placement of C6‐C7 TDA resulted in an increase in flexion‐extension ROM with preload compared to intact (P < 0.05) while LB and AR ROM decreased with arthroplasty (P < 0.01).ConclusionThis six degree of freedom elastic‐core disc arthroplasty effectively restored flexion‐extension motion to intact levels. In LB the TDA maintained 42% ROM at C5‐C6 and 60% at C6‐C7. In AR 57% of the ROM was maintained at C5‐C6 and 70% at C6‐C7. These findings are supported by literature which shows cervical TDA results in restoration of approximately 50% ROM in LB and AR, which is a multifactorial phenomenon encompassing TDA design parameters and anatomical constraints. Anterior placement of this viscoelastic TDA device shows motion restoration similar to optimal placement suggesting its design may be less sensitive to suboptimal placement.

Population-based opportunistic osteoporosis screening: Validation of a fully automated CT tool for assessing longitudinal BMD changes.

The automated BMD tool was retrospectively applied to non-contrast abdominal CT scans in 1603 consecutive asymptomatic adults (mean age, 55.9 years; 770 M/833 F) undergoing longitudinal screening (mean interval, 5.7 years; range, 1.0-12.3 years). The spinal column was automatically segmented, with standardized L1 and L2 anterior trabecular ROI placement. Automated and manual L1 HU values were compared, as were automated supine-prone measures. L1-L2 CT attenuation values were converted to BMD values through a linear regression model. BMD values and changes were assessed according to age and gender. Success rate of the automated BMD tool was 99.8 % (four failed cases). Both automated supine vs prone and manual vs automated L1 attenuation measurements showed good agreement. Overall mean annual rate of bone loss was greater in females than males (-2.0% vs -1.0%), but the age-specific rate declined faster in females from age 50 (-2.1%) to age 65 (-0.3%) compared with males (-0.9% to -0.5%). Mean BMD was higher in females than males at age 50 (143.6 vs 135.1 mg cm-3), but post-menopausal bone loss in females reversed this relationship beyond age 60. By age 70, mean BMD in females and males was 100.8 and 107.7 mg cm-3 , respectively. This robust, fully automated CT BMD tool allows for both individualized and population-based assessment. Mean BMD was lower in men than women aged 50-60, but accelerated post-menopausal bone loss in women resulted in lower values beyond age 60. This fully automated tool can be applied to routine abdominal CT scans for prospective or retrospective opportunistic BMD assessment, including change over time. Mean BMD was lower in men compared with women aged 50-60 years, but accelerated bone loss in women during this early post-menopausal period resulted in lower BMD values for women beyond age 60.

Children's Consonant Acquisition in 27 Languages: A Cross-Linguistic Review.

The aim of this study was to provide a cross-linguistic review of acquisition of consonant phonemes to inform speech-language pathologists' expectations of children's developmental capacity by (a) identifying characteristics of studies of consonant acquisition, (b) describing general principles of consonant acquisition, and (c) providing case studies for English, Japanese, Korean, and Spanish. A cross-linguistic review was undertaken of 60 articles describing 64 studies of consonant acquisition by 26,007 children from 31 countries in 27 languages: Afrikaans, Arabic, Cantonese, Danish, Dutch, English, French, German, Greek, Haitian Creole, Hebrew, Hungarian, Icelandic, Italian, Jamaican Creole, Japanese, Korean, Malay, Maltese, Mandarin (Putonghua), Portuguese, Setswana (Tswana), Slovenian, Spanish, Swahili, Turkish, and Xhosa. Most studies were cross-sectional and examined single word production. Combining data from 27 languages, most of the world's consonants were acquired by 5;0 years;months old. By 5;0, children produced at least 93% of consonants correctly. Plosives, nasals, and nonpulmonic consonants (e.g., clicks) were acquired earlier than trills, flaps, fricatives, and affricates. Most labial, pharyngeal, and posterior lingual consonants were acquired earlier than consonants with anterior tongue placement. However, there was an interaction between place and manner where plosives and nasals produced with anterior tongue placement were acquired earlier than anterior trills, fricatives, and affricates. Children across the world acquire consonants at a young age. Five-year-old children have acquired most consonants within their ambient language; however, individual variability should be considered. https://doi.org/10.23641/asha.6972857.

Comparative Analysis of the Safety and Functional Outcomes of Anterior versus Retropupillary Iris-Claw IOL Fixation.

Purpose To compare the functional and clinical outcomes of the iris-claw intraocular lens (IOL) placed on the anterior versus posterior surface of the iris. Patients and Methods A multicenter, retrospective study. Data on eyes that underwent anterior or retropupillary iris-claw IOL implantation because of inadequate capsular support secondary to complicated cataract surgery, trauma, and dislocated/opacified IOLs since January 2015 were analyzed. For study inclusion, evaluation results had to be available in the medical records both preoperatively and at 1 and 12 months after implantation. The following parameters were compared between the groups: best-corrected distance visual acuity (BCDVA), spherical and cylindrical refractive error, endothelial cell density (ECD), central macular thickness (CMT), and percentage and type of postoperative complications. Results In total, 60 eyes of 60 patients aged 73 ± 13 years were included: 28 eyes (47%) involved anterior, and 32 eyes (53%) retropupillary, iris-claw IOL fixations. Preoperatively, the groups were similar in all parameters except for a significantly higher proportion of retropupillary fixations in patients who had previously experienced a closed-globe trauma (p=0.03). The groups showed comparable improvements in BCDVA after surgery (final BCDVA: 0.34 ± 0.45 vs. 0.37 ± 0.50 logMAR in the anterior and retropupillary placement groups, respectively). During follow-up, no group difference was observed in refractive error or CMT. Both groups experienced similarly marked ECD loss and showed similar incidence of postoperative complications, with cystoid macular edema being the most common complication. Multivariable linear regression showed that BCDVA at 1 month was the best predictor of the final BCDVA. Conclusions Anterior chamber and posterior chamber iris-claw IOL fixations proved equally effective and safe for aphakic correction in eyes with inadequate capsular support.

How does anteroposterior cup placement affect bone coverage and range of motion in primary total hip arthroplasty for hip dysplasia?

BackgroundDue to anterior bone defects, high and/or posterior placement of an acetabular cup is often required to achieve sufficient coverage in patients with hip dysplasia. We examined whether posterior cup placement affected the postoperative range of motion (ROM) in primary total hip arthroplasty (THA). MethodsUsing computer software, bone coverage and ROM were examined in 32 patients with unilateral osteoarthritis of the hip with Crowe type II or III hip dysplasia. We determined the cup position to satisfy cup center-edge (Cup-CE) angle ≥0° and the required ROM. The cup was placed at the anatomic hip center and moved in 2-mm increments anteroposteriorly and 10-mm increments vertically. ResultsAt vertical anatomic hip center, less than 68.8% hips fulfilled Cup-CE ≥0° regardless of anteroposterior position. Significantly more hips at higher hip center with posterior cup placement achieved Cup-CE ≥0° than hips at vertical anatomic hip center, and 10 mm higher hip center was the most suitable for achieving bone coverage. However, posterior and superior cup placement significantly decreased the flexion and IR due to early bone impingement, whereas ER and extension were not affected. A smoothing spline curve demonstrated that more posterior cup placement than 4.8 mm and 3.6 mm did not satisfy the required ROM at 10 mm and 20 mm higher hip center, respectively. ConclusionsPosterosuperior cup placement gained more bone coverage but decreased the range of hip flexion and internal rotation. Consequently, posterosuperior cup placement did not satisfy the required ROM.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P129. True percutaneous transforaminal lumbar interbody fusion (pTLIF) with an expandable interbody cage using the endoscopic posterolateral approach: a long-term follow-up report of 50 cases

BACKGROUND CONTEXT Interbody fusion by open discectomy is the usual treatment for degenerative disc disease but requires a relatively long recovery period. The transforaminal posterolateral approach is a well-known standard in endoscopic spine surgery that allows direct access to the disk with progressive tissue dilation, avoiding tissue and bone dissection. PURPOSE The aim of this study was to assess the efficacy and safety of percutaneous transforaminal interbody fusion (pTLIF) for lumbar spinal fusion. pTLIF consists of percutaneous insertion of an expandable implant with the endoscopic posterolateral approach through an endoscopic cannula with progressive tissue dilatation. The anterior cage placement is complemented with a percutaneous posterior fixation. STUDY DESIGN/SETTING Prospective, nonrandomized, single-arm, single-center, single surgeon sequential case series study. PATIENT SAMPLE Between 2009 and 2017, the pTLIF procedure was performed in one center for 50 patients with an expandable interbody cage. OUTCOME MEASURES Patient outcome was scored pre- and post-operatively with visual analogic scale (VAS), Oswestry disability index (ODI) and modified Macnab criteria. Scores were performed preoperatively and at 1 month, 3 months, 6 months, 1 year and at least 2yearspost-operatively. A CT scan was performed immediately after surgery. Conventional X-ray controls were performed at 1 month and 1 year post-operatively. METHODS Indication for surgery was degenerative disc disease of the lumbar spine with or without spondylolisthesis up to grade 2, and for revision surgery. Percutaneous transforaminal interbody fusion was performed by inserting an expandable implant with the endoscopic posterolateral approach through an endoscopic cannula with progressive tissue dilatation. Percutaneous posterior fixation comprised transpedicular screws and rods, interspinous spacer and transfacet screws depending on each case. Significance between pre- and postoperative scores was analyzed with Student's paired t-test. RESULTS The mean follow-up period was 33.1 (SD 20.4) months. The outcome was excellent in 28 (56%), good in 17 (34%), fair in 3 (6%) and poor in 2 (4%) cases according to Macnab criteria. The latter two cases were lost before 6 months of follow-up and consequently classified as poor. Significant differences (p CONCLUSIONS The pTLIF technique shows 90% of Excellent and Good postoperative results and no major complications for a long-term mean follow-up of 33 months, proving the efficacy and safety of the pTLIF procedure for primary and revision surgery cases. Percutaneous transforaminal interbody fusion allows bypassing posterior scar tissue from previous operations in revision surgery cases hereby reducing the risk of dural tear and nerve injury. Postoperative median time until walking (6 hours) and until hospital discharge was faster compared to standard open TLIF (25hours vs. 5 days), probably due to the less invasive handling of the soft and bony tissues with the endoscopic posterolateral approach. The pTLIF technique has disruptive potential as it opens the way to ambulatory fusion surgery in an outpatient clinical setting.

Balloon kyphoplasty and additional anterior odontoid screw fixation for treatment of unstable osteolytic lesions of the vertebral body C2: a case series

BackgroundUnstable osteolytic lesions of the occipitocervical junction are rare and may occur in hematological malignancy or vertebral hemangioma, among others. Different case reports have been published about vertebroplasty for treatment of spinal metastases of the upper cervical spine. Only few cases concern balloon kyphoplasty of C2. We present a consecutive case series including four patients with an osteolytic lesion of the dens axis and describe a technical note for balloon kyphoplasty of C2 and an additional anterior odontoid screw fixation.MethodsFour consecutive patients with an osteolytic lesion of the vertebral body of C2 were treated by anterior balloon kyphoplasty and additional anterior odontoid screw fixation of the dens axis. The radiological imaging showed a lytic process of the vertebral body C2 with no vertebral collapse but involvement of more than 50% of the vertebral body in all patients.ResultsTwo cases of potentially unstable osteolytic lesions of C2 by myeloma, one case with metastatic osteolytic lesion of C2 by adenocarcinoma of the colon and one patient with vertebral hemangioma located in C2 were presented to our clinic. In all cases, surgical treatment with an anterior balloon kyphoplasty of C2 and an additional anterior, bicortical odontoid screw placement was performed. Control x-rays showed sufficient osteosynthesis and cement placement in the vertebral body C2.DiscussionAnterior balloon kyphoplasty and anterior odontoid screw placement is a safe treatment option for large osteolytic lesions of C2. The additional odontoid screw placement has the advantage of providing more stabilization and may prevent late complications, like odontoid fractures. For patients with potentially unstable or large osteolytic lesions of the dens without spinal cord compression or neurological symptoms we recommend the placement of an anterior odontoid screw when performing a balloon kyphoplasty. Level of evidence: - IV: retrospective or historical series.

Treatment of Large Incisional Hernias in Sandwich Technique - A Review of the Literature.

IntroductionIn a systematic review of the surgical treatment of large incisional hernia sublay repair, the sandwich technique and aponeuroplasty with intraperitoneal mesh displayed the best results. In this systematic review only the sandwich technique, which used the hernia sac as an extension of the posterior and anterior rectus sheath and placement of a non-absorbable mesh in the sublay position, was included. Other modifications of the sandwich technique are published in the literature and were also analyzed in this literature review.MethodsA systematic search of the available literature was performed in November 2017 using Medline, PubMed, and the Cochrane Library using the terms “sandwich technique”, “double prosthetic repair”, “double mesh intraperitoneal repair”, and “component separation technique with double mesh”. This review is based on 24 relevant publications. Unfortunately, the evidence of the available studies is not very high since only prospective and retrospective case series have been published. There are no comparative studies at all. Therefore, the findings of the published case series must be viewed in a critical light.ResultsThe published studies report a remarkably low recurrence rate of 0-13% with a follow-up of 1–7 years. One limitation that must be mentioned here is that in around half of the studies the method of follow-up was not specified and in the remaining cases this was based on clinical examination by the surgical team. This puts into perspective the reported results, which appear to be too favorable given the complex nature of the hernias involved.The major disadvantage of the sandwich technique is a very high rate of wound complications of up to 68%, mainly induced by creation of large skin and subcutaneous cellular tissue flaps.ConclusionIt is difficult to evaluate the significance of the various modifications of the “sandwich technique” based on the available literature since it includes only case series and no comparative studies. The techniques used are associated with very high wound complication rates but with only relatively low recurrence rates despite the complexity of the cases involved. This must be verified in studies with a well-designed methodology.

Arthroscopic Anterior and Posterior Glenoid Bone Augmentation With Capsular Plication for Ehlers-Danlos Syndrome With Multidirectional Instability

Recurrent multidirectional shoulder instability is a difficult clinical problem. This can be compounded in patients with connective tissue diseases such as Ehlers-Danlos syndrome. We present an all-arthroscopic technique involving extra-articular anterior and posterior glenoid bone grafting to augment a capsular repair in a patient with Ehlers-Danlos syndrome and recurrent multidirectional shoulder instability. Graft options include either distal tibial allograft or iliac crest autograft. Anterior graft placement uses a dilated far medial portal using an inside-out technique. The posterior graft is placed through a dilated posterior portal. A 1-mm edge of anterior and posterior glenoid rim is denuded of cartilage for later capsular repair, and grafts are secured flush to the osseous surface. A capsular plication is then completed and repaired to the prepared native glenoid surface, using the grafts as extra-articular osseous bumpers.

Comparison of anterior palatoplasty and uvulopalatal flap placement for treating mild and moderate obstructive sleep apnea.

We prospectively compared the efficacy of anterior palatoplasty and the uvulopalatal flap procedure for the treatment of patients with mild and moderate obstructive sleep apnea syndrome (OSAS). Our study group was made up of 45 patients who had been randomly assigned to undergo one of the two procedures. Palatoplasty was performed on 22 patients-12 men and 10 women, aged 28 to 49 years (mean: 39.2)-and the flap procedure was performed on 23 patients-14 men and 9 women, aged 28 to 56 years (mean: 41.3). Our primary outcomes measure was the difference in pre- and postoperative apnea-hypopnea index (AHI) as determined by polysomnography at 6 months after surgery. Surgical success was observed in 18 of the 22 palatoplasty patients (81.8%) and in 19 of the 23 flap patients (82.6%). Compared with the preoperative values, mean AHIs declined from 17.5 to 8.1 in the former group and from 18.5 to 8.6 in the latter; the improvement in both groups was statistically significant (p < 0.001). In addition, significant postoperative improvements in both groups were seen in mean visual analog scale (VAS) scores for snoring, in Pittsburgh Sleep Quality Index values, and in Epworth Sleepiness Scale scores (p < 0.001 for all). VAS scores for pain at rest were significantly lower in the palatoplasty group than in the flap group at 2, 4, and 8 hours postoperatively and on postoperative days 4 through 7 (p < 0.002). Likewise, VAS scores for pain during swallowing were significantly lower in the palatoplasty group at 2, 4, 8, and 16 hours and on days 4 through 7 (p < 0.009). We conclude that both anterior palatoplasty and uvulopalatal flap procedures are effective for the treatment of mild and moderate OSAS in patients with retropalatal obstruction. However, our comparison of postoperative pain scores revealed that anterior palatoplasty was associated with significantly less morbidity.

Management of C2-C3 fracture subluxation by anterior cervical approach and C2-C3 trans-cortical screw placement

AbstractCervical spine injuries are the major cause of morbidity and mortality in trauma victims. Upper cervical spine injuries account for about 24% of acute fractures and dislocations and one third of fractures occur at the level of C2, while one half of injuries occur at the C6 or C7 levels. In contrast to this approach we used the transverse cervical, platysma splitting incision at a lower (C3-C4 disc) to expose the upper cervical spine particularly lower border of C3 (entry point for the screw).

Anterior versus Posterior Tibial Tunnel Placement in ACL Reconstruction

Objectives:Previously, we reported that the use of the posterior border of the anterior horn of the lateral meniscus as a landmark for tibial tunnel placement during anatomic ACL reconstruction resulted in a wide variation of tunnel location in the sagittal plane. The effects of such tibial tunnel variations on functional outcomes have not been previously reported.Hypothesis:Anteriorly placed tibial tunnels lead to better anterior knee stability than posteriorly placed tunnels.Study Design:Cohort study, Level of evidence 3.Methods:71 patients (aged 18-55) underwent isolated unilateral anatomic single bundle primary ACL reconstruction with quadrupled hamstring tendons or bone patellar tendon bone autografts between March 2013 and June 2014 by the same surgeon using an accessory medial portal technique. All guide pins for the tibial tunnel were placed using a 55-degree guide using the posterior border of the anterior horn of the lateral meniscus as a landmark. Following pin placement, a true lateral fluoroscopic image was obtained and these were digitally analyzed to measure the location of the pin along the length of the tibial plateau using the method described by Amis and Jakob. The patients were divided into two groups—one anterior and the other posterior to 40% of the tibial plateau length. Side-to-side difference in anterior knee translation (KT-1000), thigh circumference, range of motion, IKDC and Marx activity scale were evaluated and compared between the groups at a minimum of 2 years following ACL reconstructive surgery.Results:50 patients (26 in the anterior group and 24 in the posterior group) were avaliable for follow-up at a mean of 2.5 years. There was no difference in the terms of age, sex, BMI, loss of extension, graft type (Hams-BPTB) and size (mm) between the groups (p>.05). In terms of stability, the mean side-to-side difference was 0.19±1.3 mm for anterior group and 1.27 ±1.3 mm for posterior group based on KT-1000 measurements (P<.005). The IKDC (75.1±4.1 vs 79.2±2.8) and Marx activity (6.6±1.05 vs 8.3±1.04) scores were similar in both groups. No difference in thigh circumference was found between the involved and uninvolved extremities of the both groups (-1.48±1.41 vs -1.52±1.17).Conclusion:Using the posterior border of the anterior horn of the lateral meniscus as a landmark yields a wide range of tibial tunnel locations along the tibial plateau. Anterior placement of the tibial tunnel leads to better anterior knee stability than posterior placement does.

Difference of uveal parameters between the acute primary angle closure eyes and the fellow eyes

PurposeTo measure the anterior and posterior ocular biometric characteristics concurrently and to explore the relationship between iris, ciliary body and choroid in acute primary angle closure eyes (APAC) and fellow eyes.MethodsIt is a prospective, cross-sectional study. Thirty patients with recent APAC were finally enroled in it. Anterior and posterior uveal parameters were measured simultaneously by anterior segment optical coherence tomography (AS-OCT), swept-source optical coherence tomography (SS-OCT) and ultrasound biomicroscopy (UBM). The parameters were measured including: pupil diameter (PD); iris thickness, curvature (ICURV), area (IAREA); anterior chamber depth (ACD), width (ACW), area (ACA), volume (ACV); lens vault (LV); choroidal thickness and retinal thickness; maximum ciliary body thickness (CBTmax); ciliary body thickness at the point of the scleral spur (CBT0) and 1000 mm away (CBT1000); anterior placement of the ciliary body (APCB); and trabecular-ciliary angle (TCA).ResultsCompared with fellow eyes, APAC eyes had narrower anterior biometric parameters and presented with smaller anterior segment parameters (including ACD and ACW); (p < 0.01)), smaller IAREA and ICURV (p < 0.001), larger LV (p = 0.035), thinner ciliary body and less anterior ciliary process (p < 0.01). After adjustment for potential confounders (axial length, spherical equivalent and PD), APCB was positive correlated with choroidal thickness and CBT, and CBT was positive correlated with choroidal thickness.ConclusionsCompared with fellow eyes, APAC eyes had narrower anterior biometric parameters, thinner ciliary body and smaller iris area and curvature. APCB, CBT and choroidal thickness were positively correlated. However, further studies are required before these conclusions are generalised.

A Technique for the Reduction of Complications Associated With Anterior Portal Placement During Ankle Arthroscopy Using a Peripheral Vein Illumination Device

Ankle arthroscopy is a minimally invasive technique for ankle joint treatment. However, injury to the intermediate dorsal cutaneous nerve (IDCN) and the medial dorsal cutaneous nerve (MDCN) is a common complication during anterior portal placement. To prevent injuries, methods such as palpating the nerves topographically and marking the nerves by transilluminating the skin with an arthroscope have been proposed. Easier and more definitive methods of identifying the IDCN and MDCN should result in a reduction of complications. Recently, a vein imaging system was developed that projects images of subcutaneous vasculature directly onto the skin with the use of near-infrared (NIR) light. Because anatomic studies have shown that superficial veins accompany the IDCN and MDCN, protecting the subcutaneous veins could lower the risk of nerve injury. We introduce our technique for the creation of an ankle arthroscopic portal using an NIR imaging system, which displays the vein image on the skin, to prevent injury to the superficial veins and, consequently, reduce IDCN and MDCN injuries. This is the first technical report on the prevention of vein and nerve injuries using an NIR imaging system. Our technique for avoiding vein injury using a peripheral vein illumination device during anterior portal placement in ankle arthroscopy could lower the risk of complications.

Predictors of deep brain stimulation outcome in tremor patients

BackgroundDeep brain stimulation of the ventro-intermedius nucleus of the thalamus is an established treatment for tremor of differing etiologies but factors that may predict the short- and especially long-term outcome of surgery are still largely unknown. MethodsWe retrospectively investigated the clinical, pharmacological, electrophysiological and anatomical features that might predict the initial response and preservation of benefit in all patients who underwent deep brain stimulation for tremor. Data were collected at the following time points: baseline (preoperative), one-year post-surgery, and most recent visit. Tremor severity was recorded using the Fahn-Tolosa-Marin Tremor Rating Scale and/or the Unified Parkinson's Disease Rating Scale. ResultsA total of 52 patients were included in the final analysis: 31 with essential tremor, 15 with cerebellar tremor of different etiologies, and 6 with Parkinson's disease. Long-term success (mean follow-up duration 34.7 months, range 1.7–121.1 months) was reported in 63.5%. Predictors of long-term benefit were: underlying tremor etiology (best outcome in Parkinson's disease, worst outcome in cerebellar tremor); age at surgery (the older the better); baseline tremor severity (the greater the better); lack of response to benzodiazepines; a more anterior electrode placement and single-unit beta power (the greater the better). ConclusionsSpecific patients' features (including single unit beta activity) and electrode locations may predict the short- and long-term benefit of thalamic stimulation for tremor. Future prospective studies enrolling a much larger sample of patients are needed to substantiate the associations detected by this retrospective study.