Bony Fragments Research Articles

3D visualization and simulation of frontoorbital advancement in metopic synostosis

Current multislice computed tomography (CT) technology can be used for diagnosis and surgical planning applying computer-assisted three-dimensional (3D) visualization and surgical simulation. The usefulness of a technique for surgical simulation of frontoorbital advancement is demonstrated here in a child with metopic synostosis. Postprocessing of multi-slice CT data was performed using the software 3D slicer. 3D models were created for the purpose of surgical simulation. These allow planning the course of the osteotomies and individually placing the different bony fragments by an assigned matrix to simulate the surgical result. Photo documentation was obtained before and after surgery. Surgical simulation of the procedure allowed determination of the osteotomy course and assessment of the positioning of the individual bony fragments. Computer-assisted postprocessing and simulation is a useful tool for surgical planning in craniosynostosis surgery. The time-effort for segmentation currently limits the routine clinical use of this technique.

Arthroscopic Stabilization in Patients with an Inverted Pear Glenoid

Background Recent literature has demonstrated that the success rates of arthroscopic stabilization of glenohumeral instability deteriorate in patients with an anteroinferior glenoid bone deficiency, also known as the “inverted pear” glenoid. Purpose This study was conducted to assess the outcomes of arthroscopic stabilization for recurrent anterior shoulder instability in patients with a mean anteroinferior glenoid bone deficiency of 25% (range, 20%-30%). Study Design Cohort study; Level of evidence, 3. Methods Twenty-one of 23 patients (91% follow-up) undergoing arthroscopic stabilization surgery and noted to have a bony deficiency of the anteroinferior glenoid of 20% to 30% were reviewed at a mean follow-up of 34 months (range, 26-47). The mean age was 25 years (range, 20-34); 2 patients were female and 19 were male. All patients were treated with a primary anterior arthroscopic stabilization using a mean of 3.2 suture anchors (range, 3-4). Eleven patients had a bony Bankart that was incorporated into the repair; 10 had no bone fragment and were considered attritional bone loss. Outcomes were assessed using the Rowe score, the American Shoulder and Elbow Surgeons (ASES) Score, the Single Assessment Numeric Evaluation (SANE), and the Western Ontario Shoulder Instability (WOSI) Index. Findings of recurrent instability and dislocation events were documented. Results Two patients (9.5%) experienced symptoms of recurrent subluxation, and 1 (4.8%) sustained a recurrent dislocation that required revision open surgery. The mean postoperative outcomes scores were as follows SANE = 88.1 (range, 65-100; standard deviation [SD] 9.0); Rowe = 85.2 (range, 55-100; SD 14.1); ASES Score = 93.1 (range, 78-100; SD 5.3); and WOSI Index = 398 (82% of normal; range, 30-1175; SD 264). No patient with a bony fragment experienced a recurrent subluxation or dislocation, and mean outcomes scores for patients with a bony fragment were better than those with no bony fragment (P = .08). No patient required medical discharge from the military for his or her shoulder condition. Conclusions Arthroscopic stabilization for recurrent instability, even in the presence of a significant bony defect of the glenoid, can yield a stable shoulder; however, outcomes are not as predictable especially in attritional bone loss cases. Longer-term follow-up is needed to see if these results hold up over time.

Posterior Avulsion Fracture at Adjacent Vertebral Body During Cervical Disc Replacement With ProDisc-C

A case report. To report posterior avulsion fractures at the adjacent vertebral bodies that occurred during cervical arthroplasty with ProDisc-C, which was thought to be related to design of the prosthesis and lack of the prudence in surgical technique. There is no previous report on the avulsion fracture of the posterior vertebral body during cervical arthroplasty. A 32-year-old-man presented with painful numbness and weakness of the right upper extremity for 2 months. On magnetic resonance imaging and computer tomography scans, a huge disc herniation at C6-C7 segment compressing the right C7 root and the spinal cord was identified. To prevent acceleration of degeneration of the C5-C6 segment, disc replacement of the C6-C7 with the ProDisc-C after anterior discectomy was planned. Nearing the end of the second chiseling with a box cutting chisel, and following further mallet impaction to insert the chisel a bit more, copious bleeding occurred. Hurried hemostasis was accomplished. The posterior central vertebral bodies of C6 and C7 were found to be fractured and avulsed bony fragments were displaced posteriorly compressing the spinal cord. The bony fragments were carefully removed and the ProDisc-C was inserted as planned. The patient recovered without neurologic deficit. Owing to keel design of the prosthesis, the possibility of posterior avulsion fracture of the vertebral body should always be appreciated in cervical disc arthroplasty with ProDisc-C, especially during chiseling with the box cutting chisel and inserting the prosthesis. Further, insertion of either of them beyond the posterior ends of the keel cuts made by a keel cutting chisel should not be tried.

Bicortical Biodegradable Screws for Rigid Fixation of Traumatic Sagittal Split Mandibular Fracture

Rigid fixation is the most important issue in the bone healing process. Although internal metallic bone fixation has become increasingly popular over the past 10 years, the presence of several potential problems of metallic bone implants with the popularity of the use of biodegradable plates and screws for craniomaxillofacial fixation have increased in the last 10 years. Rigid fixation of bony fragments was achieved by bicortical applied biodegradable screws in a patient with a sagittal oblique mandibular fracture. Precise bone reduction was maintained with bicortical applied biodegradable screws in the postoperative period. The postoperative period was uneventful and the patient retained the intraoperatively achieved perfect occlusion within a 9-month follow-up period. In this particular case, the advantages of use of resorbable fixation systems are combined with the advantages of bicortical screw fixation of split osteotomy without sacrificing the stability of rigid fixation.

Transverse Divergent Dislocation of the Elbow With Ipsilateral Distal Radius Fracture in a Child

We report a rare case of an irreducible transverse divergent dislocation of the elbow with an ipsilateral distal radius torus fracture and a fracture of the coronoid process in a 9-year-old male. Closed reduction of the elbow was attempted, but the humeroulnar joint remained dislocated. At surgery, the avulsed anterior band of the medial collateral ligament complex of the elbow was found to be interposed between the medial condyle of the humerus and the olecranon. The dislocation was reduced after relieving the ligament entrapment, which was then repaired. The unstable proximal radioulnar joint was fixed with a Kirschner wire. Two years after surgery, the patient had a painless left elbow with full range of motion and no instability. He was able to use his upper extremity for all activities in his daily life and had returned to sports. No radiographic abnormalities were found at this follow-up, particularly premature epiphyseal closure of the radial head. Closed reduction has been successful in a majority of reported cases of transverse divergent dislocation of the elbow, yet the presence of an incomplete reduction of the ulnohumeral joint should alert the physician to the possible interposition of soft tissues or bony fragments necessitating an open reduction.

Irreducible anterior dislocation of the shoulder

A38-yearoldright-handedmanemployedasastablehandfellapproximately3 mfromaladderlandingonhis left shoulder. He was seen in the Accident andEmergency department where clinical examinationsuggestedthathehadsustainedanisolatedanterior—inferior dislocation of his left shoulder with no neu-rovascularcompromise.Hehadnoprevioushistoryofshoulder problems. Plain radiographs confirmed ananterior—inferior dislocation of the gleno-humeraljoint with an avulsed bony fragment, thought to bethe greater tuberosity (Fig. 1). Closed reduction ofthe dislocation was then attempted by senior Acci-dentandEmergencydoctorsbut,despiteheavyseda-tion, multiple attempts were unsuccessful.The patient was referred to the on-call orthopae-dic team. A further closed reduction was attemptedin theatre under general anaesthesia and fluoro-scopiccontrolbut,again,provedtobeunsuccessful.The decision was then made to proceed to an openreduction.The patient was prepared and draped in thebeach-chair position and the shoulder approachedusing a lateral incision splitting the proximal fibresof deltoid and coming down onto the rotator inter-val. The operative findings were of a comminutedbony avulsion of the insertion of subscapularis. Thelateral insertion of the capsule had also been torn(similar to an HAGL injury-humeral avulsion of thegleno-humeral ligament). The bony avulsion site atthe lesser tuberosity was identified on the humeralhead. The head had dislocated anteriorly and infer-iorly through the tear and was lying in front of thesubscapularis, capsule and bony avulsion fragment,which were infoldedinto thejointspace. This inter-position of the subscapularis and bony fragmentwere preventing the head from reducing (Fig. 2).Withsomedifficulty,thesubscapularisandcapsulewere flicked anteriorly and superiorly forward overthehumeralhead,whichcouldthenbereduced.Thebony avulsion fragment, originating from the upperpart of the lesser tuberosity, and attached to thesubscapularis tendon was reduced and held in situusing a 4.5 mm partially threaded cancellous screwwithaspikedwasher(Fig.3)andtherotatorinterval,which had also been torn, and was closed usinginterrupted No. 1 Ethibond sutures. Following this,thepatient’sshoulderappearedtobestablethrough-out a full range of motion on fluoroscopic screening.Post-operativelythepatientwaskeptinashoulderimmobilizer for 3 weeks before commencing a

The influence of wire positioning upon the initial stability of scaphoid fractures fixed using Kirschner wires: A finite element study

A finite element model of the carpal scaphoid and its joints was developed to study how wire positioning affects the initial stability of the fixation of scaphoid waist fractures using Kirschner wires. A transverse fracture of the scaphoid waist was simulated along with its fixation using five different two-wire configurations. The resulting models were subjected to a load simulating a 200 N force passing through the wrist. Friction between bony fragments was taken into account; as the friction coefficient of cancellous bone is unknown, three different values were analysed. For each of these friction coefficient values, the smallest transverse interfragmentary displacements, and consequently maximum initial stability, were obtained for the model that simulated the maximum gap between wires in the plane of fracture. Results also show that for a similar gap in the plane of fracture, more stable fixation can be achieved when wires cross each other not only in the frontal plane of the hand, but also perpendicularly to it.

O.072 Bioabsorbable fixation devices in anterior skull base fractures

Most commonly seen in the knee, elbow and ankle, osteochondritis dissecans (OCD) represents an underlying bony fragment separation from the subchondral region with or without articular involvement. Osteochondral or chondral injuries are associated with trauma and can occur in any joint. Unstable OCD and traumatic osteochondral or chondral lesions demand operative treatment, particularly if displaced. Principles of treatment include anatomic reduction, rigid fixation, enhancement of blood supply, and restoration of articular congruity. Internal fixation can be achieved through open or arthroscopic approaches with one of many devices including cannulated screws, metal pins, and bioabsorbable pins. Cannulated screws can provide rigid fixation and compression across lesions. AO screws must eventually be removed to avoid articular damage and allow weightbearing. Headless, variable pitch screws, however, can be placed below the articular margin, do not need to be removed, and provide compression because of their differential pitch designs. Metal pins in the form of Kirschner wires (K-wire) can be placed antegrade through the lesion, or retrograde from behind the lesion. K-wires can potentially migrate, bend or break, and they must eventually be removed. Bioabsorbable pins have several advantages including bioresorbable properties obviating the need to remove them, low-profile designs, and a decrease in stress-shielding compared with metal implants. The most common reported complication with bioabsorbable pins is a reactive synovitis. Newer devices recently described for OCD lesions of the capitellum include pull-out wires and dynamic staples. The purpose of this article is to present different options for operative fixation of these lesions.

O.113 Comparison of biomechanical stability of 2.0 mm standard and 2.0 mm locking screws for SSRO

Six unembalmed adult sheep mandibles were stripped of all soft tissues and sectioned at the midline. Each side had a sagittal split ramus osteotomy (SSRO) and was advanced 5 mm. Six of the hemimandibles were fixed with four-hole extended titanium miniplates and titanium screws, and the other six were fixed with four-hole extended absorbable plates and absorbable screws. All specimens were mounted in a servohydraulic testing unit, and a range of forces (0–140 N) was applied. Displacement of each proximal segment was recorded at 10 N increments from 0 to 140 N. Values for the two groups were compared using the Mann–Whitney U-test, and significant differences in displacement were seen only at loads between 10 and 50 N. The results indicate that when absorbable miniplates are used intermaxillary fixation may be necessary to stabilise the bony fragments in the early postoperative period.

Tarsal Tunnel Syndrome in Athletes

Background The details of the occurrence of tarsal tunnel syndrome in athletes have not been well documented in the literature, and more data on tarsal tunnel syndrome related to sporting activity are necessary to enable better recognition of this condition. Hypothesis Sporting activities make athletes vulnerable to the occurrence of tarsal tunnel syndrome under specific conditions. Study Design Case series; Level of evidence, 4. Methods Between 1986 and 2002, 18 patients with tarsal tunnel syndrome related to sporting activities were surgically treated, of whom 15 patients (21 feet; mean age, 17.8 years) were competitive athletes and 3 were recreational sports amateurs (4 feet; mean age, 52.7 years). To assess the role of physical factors and sporting activities in making athletes vulnerable to the occurrence of tarsal tunnel syndrome, the authors reviewed the medical charts and evaluated the results of treatment. The mean duration of follow-up was 58.6 months. Results Activities that triggered tarsal tunnel syndrome were those that applied a heavy burden on the ankle joint such as sprinting, jumping, and performing ashibarai in judo under specific physical conditions. Predisposing underlying physical factors were flatfoot deformity and an existence of talocalcaneal coalition, accessory muscles, and bony fragments around the tarsal tunnel. The majority of patients were able to return to the same sport after treatment. Conclusion Tarsal tunnel syndrome occurs in athletes involved in strenuous sporting activities, especially when predisposing physical factors are present.

Computer-Assisted Extracorporeal Orbital Reconstruction After Optic Nerve Decompression by Removal of Sphenoid Bone

The removal of sphenoid bone parts was performed by the admitting neurosurgeons on a patient who presented an optic nerve compression syndrome. Beside the orbital trauma, an extensive midfacial trauma was sustained with dislocated multifractures of the zygomatic complex. In a secondary procedure, the orbital cavity was reconstructed successfully using 3 different methods of computer-assisted surgery. First, the reconstruction of the zygomatic complex was controlled intraoperatively by a virtual model obtained by mirroring the unaffected side to the affected side. Second, extracorporeal bone parts were virtually preoperatively relocated and orientated. The reconstruction of the orbital cavity by the insertion of these bony fragments was performed intraoperatively as planned after the zygomatic complex reconstruction. Third, the virtual reconstruction of the orbital floor was performed using preoperatively individually bent and preformed orbital titanium mesh. Combinations of these methods demonstrate the practical and high value of computer-assisted surgery in complex reconstructive craniofacial surgery.

Palmar Radiocarpal Dislocation Resulting In Ulnar Radiocarpal Translocation and Multidirectional Instability

Posttraumatic ulnar radiocarpal translation is a rare, often subtle, highly unstable, and potentially devastating manifestation of severe "proximal radiocarpal ligamentous instability. Radiocarpal dislocation should alert the treating physician to the risks of the spectrum of radiocarpal instabilities. Radiocarpal instability may initially be masked or unappreciated owing to presentation without radiocarpal dislocation, local pain and swelling, initially normal standard wrist radiographs, lack of recognition, or delay in the appearance of a static lesion. The specificity, sequence, and extent of extrinsic radiocarpal and ulnocarpal ligament traumatic disruptions are not fully understood, vary with injury severity, and may differ in instances of dorsal as opposed to palmar subluxation or dislocation. Multidirectional (global) wrist instability typically accompanies this ulnar radiocarpal instability in its most severe form and consequences may be dire. The carpus may be difficult to reduce or maintain owing to marked instability, compressive forces across the wrist, and soft tissue or bony fragment interposition. Additional local distal radioulnar joint or intercarpal injuries may further confound stability and require their own specific and simultaneous treatment. Radiocarpal reduction and repair of the radioscaphocapitate ligament and radiolunate ligaments may be sufficient treatment for acute isolated palmar radiocarpal instability. Temporary K-wire fixation may be added as a precaution to prevent palmar carpal subluxation during the time of ligament healing. Radiocarpal reduction, palmar and dorsal soft-tissue repair, and temporary K-wire fixation comprise one method of treatment for early recognized cases of post-traumatic ligamentous ulnar radiocarpal transposition. Halikis et al have recommended radiolunate arthrodesis. Rayhack et al have suggested that limited or complete wrist arthrodesis may be indicated for patients with delayed presentation or in acute cases with extreme instability. Wrist arthrodesis is one means of management for patients with severe radiocarpal instability confounded by distal radioulnar joint or intercarpal instability, as seen in our patient. Damaged ligaments may have a poor blood supply and often may not hold sutures or heal well. Bone anchor sutures or some type of ligament augmentation may help to restore joint stability in some patients. Loss of stability may occur later owing to ligamentous laxity or inadequate soft-tissue healing. Radiolunate, radiocarpal, or complete wrist arthrodesis may be necessary to relieve pain, restore wrist alignment and stability, and reestablish extremity function for patients with chronic radiocarpal instability. Wrist symptoms, age, general health, hand dominance, and occupation may be among the factors that influence the necessity for and timing of reconstruction. Rayhack et al have also postulated that negative ulnar variance may accommodate the occurrence of ulnar radiocarpal translocation and confound repair owing to lack of buttress at the ulnocarpal joint. They further speculated that a joint leveling procedure might improve the support for ligamentous repair or reconstruction in these cases. Permanent functional impairment must be anticipated in patients with ulnar radiocarpal instability. Impairment has typically been commensurate with the extent of the initial lesion, additional confounding local lesions, and length of follow-up.

Comparison of Endoscopic and Open Resection for Haglund Tuberosity in a Cadaver Study

About half of patients who have Haglund disease may require treatment by surgical resection of the superior portion of the calcaneal tuberosity. Endoscopic techniques have been described as alternatives to open surgery, but only results of uncontrolled retrospective clinical investigations have been reported. Up to now no research is available which compares these different procedures. A controlled laboratory study was done to evaluate the morphologic appearance of the superior portion of the calcaneal tuberosity after endoscopic or open resection. The tuberosity was resected in 15 isolated fresh-frozen human cadaver lower limb specimens with either open (nine) or endoscopic (six) technique. Outcome was measured radiographically. Iatrogenic soft-tissue lesions of the distal Achilles tendon, plantaris tendon and sural nerve caused by the surgical procedure were evaluated by direct observation after anatomic dissection. Radiographs revealed that the slope of the resection line (osteotomy angle) was steeper (p = 0.017) and the resected protruberance was larger (p = 0.003), while the remaining posterior rim was smaller (p = 0.048) after open resection than after endoscopic resection. Macroscopic analysis indicated that both approaches may damage soft tissues particularly the medial Achilles tendon column and in the plantaris tendon (relative risk = 0.5 in either group). Iatrogenic sural nerve injuries were found after both techniques (relative risk = 0.2 for endoscopic and 0.1 for open resection). Residual bursa tissue was detected only after endoscopy (relative risk = 0.3), while loose bony fragments were present only after open surgery (relative risk = 0.4). The medial column of the Achilles tendon, the plantaris tendon, and the sural nerve are at risk in both open and endoscopic resection for Haglund disease.

Frequency and gravity of human envenomations caused by marine catfish (suborder siluroidei): a clinical and epidemiological study

Introduction and objectives Catfish occur in marine and freshwater environments worldwide. They have three serrated venomous bony stings in the dorsal and pectoral fins that are used for defence against predators and are refilled by glandular tissues under the epithelium. However, some catfishes do not have poisonous glands next to the sting and cause traumatic wounds without poisoning. The objective of this study was to provide data for, and comment on, the epidemiological and clinical problems caused by marine catfish. Patients and methods The authors have observed, followed and documented 127 injuries caused by marine catfish stings during different phases of the envenoming over a time period of 8 years at three points along the Western Atlantic Ocean coast. Results The patients presented intense pain during the acute phase of envenoming and complications, such as bacterial and fungi infections and retention of bony fragments, in the later phase. Immersion of the affected extremity in hot water was used in about 20% of cases with excellent results. Discussion Injuries caused by marine catfish are common (about 20% of injuries caused by marine animals in a series of more than 700 injuries recorded by the author) and cause intense pain and later complications. Immersion of the affected extremity in hot water results in improvement in the acute phase, but does not prevent the appearance of secondary infection or foreign body reactions.

Mass-Related Traumatic Tissue Displacement and Behavior: A Screen for Treatments that Reduces Harm to Bystander Cells and Recovery of Function

In this study, we focused on a preclinical model of brain compression injury that has relevance to pathological conditions such as tumor, hematoma, blood clot, and intracerebral bony fragment. We investigated behavioral impairment as a result of rapid-onset small mass, and the factors involved in lesion formation and neuroplasticity. An epidural bead implantation method was adopted. Two sizes (1.5 mm and 2.0 mm thick) of hemisphere-shaped beads were used. The beads were implanted into various locations over the sensorimotor cortex (SMC--anterior, middle and posterior). The effects of early versus delayed bead removal were examined to model clinical neurosurgical or other treatment procedures. Forelimb and hind-limb behavioral deficits and recovery were observed, and histological changes were quantified to determine brain reaction to focal compression. Our results showed that the behavioral deficits of compression were influenced by the location, timing of compression release, and magnitude of compression. Even persistent compression by the thicker bead (2.0 mm) caused only minor behavioral deficits, followed by fast recovery within a week in most animals, suggesting a mild lesion pattern for this model. Brain tissue was compressed into a deformed shape under pressure with slight tissue damage, evidenced by pathological evaluation on hematoxylin and eosin (H&E)- and TUNEL-stained sections. Detectable but not severe behavioral dysfunction exhibited by this model makes it particularly suitable for direct assessment of adverse effects of interventions on neuroplasticity after brain compression injury. This model may permit development of treatment strategies to alleviate brain mass effects, without disrupting neuroplasticity.

Operative Behandlung von Frakturen des thorakolumbalen Überganges mit spinalem Einstand unter besonderer Berücksichtigung der Methode der ventralen spinalen Clearance

Ziel: Umfassende Analyse und Bewertung dorsaler und kombinierter Operationsmethoden für Frakturen des thorakolumbalen Überganges mit spinalem Einstand hinsichtlich funktioneller, röntgenologischer, orthopädischer und neurologischer Parameter unter besonderer Berücksichtigung der ventralen spinalen Clearance und der Rolle postoperativer Resteinstände. Studiendesign: 105 Patienten mit Frakturen zwischen T10 und L3 und radiologischem Nachweis eines Spinalkanaleinstandes wurden in 4 Operationsgruppen analysiert: dorsale Operation (n = 10), dorsale Operation mit transpedikulärer Spongiosaplastik (n = 19), kombiniert dorso-ventrale Operation (n = 52), kombinierte Operation mit spinaler Clearance (n = 24). Datenerfassung zu Unfall und Operation erfolgte retrospektiv. Analysiert wurden Unfallmechanismus, Frakturtyp, neurologischer Status prä- und postoperativ, funktionelle Parameter, CT und Röntgenaufnahmen. Nachuntersuchung war im Mittel 3 Jahre postoperativ mit Erfassung des neurologischen Status, funktioneller Parameter und Kontroll-CT. Ergebnisse: Durchschnittsalter war 38 (14 - 74) Jahre. Häufigste Unfallursache war Sturz aus der Höhe (43,8 %). Häufigster verletzter Wirbelkörper war L1 (41,0 %) und häufigster Frakturtyp Kompressionsfraktur Typ A3 (48,6 %). 54,3 % hatten behandlungsbedürftige Begleitverletzungen, 19,0 % waren polytraumatisiert. Durchschnittliche Dauer der dorsalen Stabilisierung war 1:48 h, der ventralen Operation ohne Clearance 2:49 h und mit Clearance 4:38 h (p < 0,005). Wahrscheinlichkeit starker Blutungen war mit Clearance signifikant größer (p < 0,0001). Komplikationen waren häufiger bei kombinierten Operationen (p = 0,016). 74,3 % der Patienten wurden nachuntersucht. Hinsichtlich funktioneller Parameter (Zufriedenheit/Einschränkung Rückenbeweglichkeit/Berufs- und Freizeitaktivität/Hannover-Wirbelsäulenscore) bestanden keine Unterschiede zwischen den Operationsgruppen. 61 % der präoperativ berufstätigen Patienten blieben postoperativ in Beschäftigung. 27,6 % wiesen neurologische Ausfälle zur Aufnahme auf, bei 65,5 % verbesserte sich die Neurologie um mindestens eine Stufe auf der Frankel/McBride-Skala bis zur Entlassung. Clearance verbesserte die Neurologie um mindestens eine Stufe in 8 von 10 Fällen (80 %), dorso-ventrale Operation ohne Clearance in 10 von 17 Fällen (59 %). Die höhere Besserungsrate in der Clearance-Gruppe war statistisch nicht signifikant. Pedikelschraubenbruch war signifikant häufiger (p < 0,01) bei dorsal operierten Patienten. Bruch des ventralen USIS-Implantats erfolgte in 17,6 %. Körperwinkel und sagittaler Index betrugen präoperativ im Mittel - 14,8° und 0,66 und postoperativ - 5,8° und 0,87 (p < 0,001). Bis zur Nachuntersuchung kam es zu einem Korrekturverlust des KW auf - 8,2° und des SI auf 0,82. Am geringsten war der Verlust in der Gruppe der kombiniert operierten Patienten. Patienten mit transpedikulärer Spongiosaplastik verloren ca. 50 % des Korrekturgewinns. Noch ausgeprägter waren Veränderungen des GDW. Der mittlere spinale Einstand für alle Operationsgruppen betrug präoperativ 48 %, zur Nachuntersuchung 17 % (p < 0,001). Clearance-Patienten hatten postoperativ einen Resteinstand von ca. 5 %, alle anderen Gruppen ca. 20 % (p < 0,001). Der Spearman-Rangkorrelationskoeffizient für Einengung des Spinalkanals und dem Vorhandensein neurologischer Symptome für das Gesamtkollektiv war r = 0,56 (p = 0,01). Unterschiede in der Spinalkanalfläche zwischen postoperativen CT und CT zur Nachuntersuchung bestanden nicht. Weder sekundäre Stenosierung noch Spontanresorption konnte demonstriert werden. Schlussfolgerungen: Ein statistisch signifikanter Zusammenhang zwischen der Einengung des Spinalkanals und dem Vorhandensein neurologischer Symptome bestand. Trotzdem ist eine Verbesserung der neurologischen Situation auch bei Vorliegem von moderaten Resteinständen (ca. 20 %) möglich. Die Clearance führt zu keiner signifikant höheren Rückbildung neurologischer Ausfälle. Remodeling-Vorgänge, i. S. der Entwicklung von sekundären Spinalkanalstenosen oder Spontanresorption von verbliebenen Fragmenten konnten wir nach 3 Jahren nicht feststellen. Die Notwendigkeit zur vollständigen Clearance des Spinalkanals kann damit mit unserem Kenntnisstand (Nachuntersuchung nach 3 Jahren) nicht bestätigt werden. Langzeitstudien müssen die potenzielle Stenosierung im Spätverlauf untersuchen und die Rolle der Clearance abschließend klären. Kombiniert dorso-ventrale Operationen mit ventraler Spanabstützung sind am effektivsten für die Wiederherstellung des Wirbelsäulenprofils und weisen die geringste Rekyphosierungsrate auf. Ventrale Single-rod-/Single-clamp-Konstrukte sind obsolet.

Histologic analysis of bony Bankart lesions in recurrent anterior instability of the shoulder

The histologic examination of bony Bankart lesions was performed with hematoxylin-eosin staining of specimens obtained intraoperatively from 27 patients. We assessed the incidence and extent of degeneration in the bony fragment and the surrounding ligament and the relationship of such pathologic changes to several clinical and radiologic factors. Loss of osteocytes in the bony fragment was defined as osteonecrosis, and loss of fibroblasts in the surrounding ligament was defined as ligament degeneration. Although extensive ligament degeneration was noted in 8 patients (29.6%) (degeneration group), no bony fragment with extensive osteonecrosis was found. The degeneration group showed a statistically higher frequency of dislocation than the other group (P = .045). All bony fragments in the bony Bankart lesion seemed to be viable and could be used to treat the fractured glenoid defect. The surrounding ligaments in cases with a higher frequency of dislocation were often degenerative and might not be good for repair.

Extruded Lumbar Osseous Endplate Causing Long-Term Radiculopathy in an Adult: An Endoscopic Excision

In this report, we described an adult case that had a long-term radiculopathy due to an extruded osseous endplate of the lumbar spine at the L5-S1 intervertebral disc level. The osseous material inside the extruded material was not absorbed, and it had continued compressing the nerve root for one year. Endoscopically, the bony fragment was successfully removed. After the surgery, the patient's symptom disappeared, and neurological deficits became normalized. In conclusion, we propose that surgical intervention should be taken into account for the treatment of HNP, when the extruded material contains bony fragment such as osseous endplate.

Arthroscopic Treatment of Acute Tibial Avulsion Fracture of the Posterior Cruciate Ligament With Suture Fixation Technique Through Y-Shaped Bone Tunnels

The purpose of this study was to evaluate the clinical results of arthroscopic treatment of tibial avulsion fracture of the posterior cruciate ligament (PCL) with suture fixation technique through Y-shaped bone tunnels. Retrospective case series. We treated 29 cases of acute PCL tibial avulsion fracture arthroscopically through double posteromedial portals. The PCL and avulsion bony fragment was fixed with 2 No. 6 polyester sutures, which were pulled out through Y-shaped bone tunnels and fixed on a titanium button. The 2 branch openings of the Y-shaped bone tunnels were at the posterior edge of the tibial bed; the common outer opening was at medial side of the tibial tubercle. Through twisting of the button, the suture were tightened to ensure the fixation. The patients were followed-up for more than 2 years and were evaluated according to the International Knee Documentation Committee, Lysholm, and Tegner rating scales. There was no extension limitation. Except for 2 patients who had 5 degrees flexion limitation, all the patients gained normal flexion. Before surgery, all patients had 1 degrees to 2 degrees positive posterior drawer test, and KT-1000 examination showed that the side-to-side difference of the posterior drawer test was 7 to 14 mm, with an average of 10.3 +/- 1.7 mm. At the last follow-up, 1 patient had 1 degrees positive posterior drawer test, the other patients had negative posterior drawer tests. The side-to-side difference of the posterior drawer test was 0 to 2 mm in 28 patients, and 4 mm in 1 patient, with an average of 0.6 +/- 0.4 mm. The Lysholm score was 93 to 100, with an average of 97.4 +/- 1.4. The Tegner scores were 6.8 +/- 0.8 before injury, and 6.6 +/- 0.7 at the last follow-up (P > .05). Arthroscopic treatment of acute tibial avulsion fracture of the PCL with this fixation technique can restore the stability and function of the joint in most patients. Visualization and manipulation through double posteromedial portals are convenient. Y-shaped bone tunnels and the button-twisting technique are useful to ensure the results of reduction and fixation. Level IV.

Anmerkungen zur Septumplastik

There is a discrepancy between the occasionally heard opinion that septoplasty is an easy operation and its relatively high failure and complication rates. Here we discuss the specific difficulties and possible pitfalls of functional reconstructive septoplasty. The significance of optimal vision using a binocular operating microscope is emphasized. Most of the important measures needed to avoid postoperative complications such as redeviation, pseudo-hump nose or nasoseptal defect are painstaking subperichondrial dissection without injuring the septal cartilage, use of the so-called Cottle-tunnels, sufficient mobilisation and exact straightening of the anterior septal cartilage without remaining tension, stable reconstruction of the posterior septum with cartilaginous and/or bony fragments after selective resection of deviated septal parts, re-fixation of the mobilized anterior cartilage ("swinging-door") to the periosteum of the anterior nasal spine and, perhaps, primary suture of iatrogenic perforations of the mucoperichondrium during the operation. If postoperative complications such as septal hematoma, septal perforation or saddling of the nose are recognized during the first postoperative week, immediate revision surgery is recommended.