Circumferential Fixation Research Articles

Surgical treatment for local recurrence of spinal hemangiomas.

SH is considered to be the most common benign tumor within the human spine. 1-2% of SH get symptomatic with back pain in most cases. Less often, ingrowth of vessels into the spinal canal is seen. In these cases, more invasive surgical treatment is required. Recurrence of SH following surgical treatment is a very rare condition. We present the results of a retrospective chart review, with description of the clinical course of 12 patients with spinal canal invading SH without recurrence and of 5 patients with a recurrent SH. Recurrence was diagnosed 70 months (mean value) after the first procedure. All patients with a recurrent SH had received an incomplete tumor resection as a first treatment. The distribution of gender, age at the diagnosis, levels involved by the tumor, and initial symptoms were comparable in the group of patients with and without recurrence. The patients with recurrent SH were treated with preoperative embolization and en bloc resection or complete piecemeal resection of the affected vertebra. For stabilization, a combined, circumferential fixation was used consisting in a TSM cage filled by bone graft and posterior pedicle screw rod instrumentation in all patients. We followed these patients until 09/ 2023, mean FU 122 months (range 72-184 months). At this time, we found no evidence of tumor recurrence, good clinical conditions in all patients, no signs of implant failure or pseudarthrosis. Thus, radical excision, sufficient stabilization and fusion is considered to be an adequate treatment concept for recurrent SH.

Standardized procedure for preventing late intestinal complications following minimally invasive total gastrectomy for gastric cancer: a single-center retrospective cohort study.

Although minimally invasive total gastrectomy for gastric cancer is commonly performed, reports regarding late complications are limited. We have made several improvements each time we experienced severe late complications since 2009. This study aimed to evaluate the clinical efficacy of these improved procedures in preventing late complications. Between January 2009 and December 2019, 302 patients who underwent laparoscopic or robotic total gastrectomy for gastric cancer were enrolled. The patients were divided into two groups: Period-I (2009-2013, before established standardization of procedure, 166 patients) and Period-II (2014-2019, after established standardization of procedure, 136 patients). The standardized procedure comprised four major steps, including closure of the mesentery defects and diaphragm crus, circumferential fixation of the anastomotic site into the diaphragm, and linearization around the anastomotic site of esophagojejunostomy. The incidence of late complications was retrospectively compared between the two groups. Late overall complications that occurred over 30days after surgery were observed in 19 (6.3%) patients. In all, 14 of 24 (58.3%) patients admitted due to late intestinal complications eventually required reoperation for treatment. The most frequent complication was nonstenotic outlet obstruction of the distal jejunal limb. The incidence of late overall complications was significantly lower in Period-II than in Period-I (2.9 vs 9.0%, p = 0.030). Intestinal complications were reduced considerably in Period-II. The 3-year cumulative incidence rate of late overall complications was significantly lower in Period-II than in Period-I (0.03 vs 0.10, p = 0.035). Period-I as the only independent risk factor for the development of late intestinal complications. Late complications after laparoscopic total gastrectomy sometimes occurred, and more than half of the patients with intestinal complications required reoperation. Our standardized procedure was associated with a lower risk of late intestinal complications after minimally invasive total gastrectomy followed by intracorporeal esophagojejunostomy using linear staplers in a cohort of patients with gastric cancer.

Erratum. Biomechanical comparison of short-segment posterior fixation including the fractured level and circumferential fixation for unstable burst fractures of the lumbar spine in a calf spine model.

"Erratum. Biomechanical comparison of short-segment posterior fixation including the fractured level and circumferential fixation for unstable burst fractures of the lumbar spine in a calf spine model" published on 05 May 2023 by American Association of Neurological Surgeons.

The effect of posterior compression of the facet joints for initial stability and sagittal profile in the treatment of thoracolumbar fractures: a biomechanical study

PurposeSurgical treatment of thoracolumbar A3-fractures usually comprises posterior fixation—in neutral position or distraction—potentially followed by subsequent anterior support. We hypothesized that additional posterior compression in circumferential stabilization may increase stability by locking the facets, and better restore the sagittal profile.MethodsBurst fractures Type A3 were created in six fresh frozen cadaver spine segments (T12–L2). Testing was performed in a custom-made spinal loading simulator. Loads were applied as pure bending moments of ± 3.75 Nm in all six movement axes. We checked range of motion, neutral zone and Cobb’s angle over the injured/treated segment within the following conditions: Intact, fractured, instrumented in neutral alignment, instrumented in distraction, with cage left in posterior distraction, with cage with posterior compression.ResultsWe found that both types of instrumentation with cage stabilized the segment compared to the fractured state in all motion planes. For flexion/extension and lateral bending, flexibility was decreased even compared to the intact state, however, not in axial rotation, being the most critical movement axis. Additional posterior compression in the presence of a cage significantly decreased flexibility in axial rotation, thus achieving stability comparable to the intact state even in this movement axis. In addition, posterior compression with cage significantly increased lordosis compared to the distracted state.ConclusionAmong different surgical modifications tested, circumferential fixation with final posterior compression as the last step resulted in superior stability and improved sagittal alignment. Thus, posterior compression as the last step is recommended in these pathologies.

The effect of tracheostomy on swallowing function in open partial horizontal laryngectomies: preliminary experience.

Tracheostomy is required to ensure a safe airway in open partial horizontal laryngectomies. The presence of the tracheostomy tube can contribute to post-operative dysphagia. This study aimed to evaluate the effects of a circumferential tracheostomy technique on swallowing. A retrospective study was conducted of patients who underwent open partial horizontal laryngectomies between April 2018 and June 2019. Patients were divided into two groups based on the tracheostomy technique: group 1 had two stitches from the inferior tracheal ring to the skin; group 2 had circumferential fixation of the trachea to the skin. Demographic information, surgical data, post-operative rehabilitation course and complication details were collected and analysed. Twenty-four patients were enrolled. Patients in group 2 had significant improvement in the initial phases of swallowing rehabilitation. Tracheostomy with anchorage of the trachea to the skin by circumferential stitches could allow early removal of the tracheal tube, with a better swallowing outcome.

Single-level fusion without decompression for high-grade spondylolithesis in adolescents: a novel surgical strategy

There is no consensus on the optimal surgical treatment for high-grade spondylolisthesis (HGS) in adolescents. The purpose of this study was to assess the radiographic and clinical outcomes of a novel surgical approach to HGS consisting of a single-level anterior reduction, placement of a lordotic cage, and circumferential fixation without decompression. This was a retrospective consecutive case series of 11 adolescents who underwent anterior reduction through placement of a lordotic cage followed by posterior fusion using pedicle screws and rods confined to L5-S1. Radiographic data included slip percentage, slip angle, lumbar lordosis, and pelvic sagittal parameters assessed at clinical visits preoperatively and at 2years postoperatively. A telephone survey was conducted to obtain current information about function, activity level, work status, and retrograde ejaculation. Patients were followed for an average of 7.8years (range 2-16). Mean age was 15.5years (range 12-19). The mean percent slip corrected from 55 to 18%. The average slip angle was + 17.1° preoperatively and - 14.1° at final assessment (average correction of 20.7°). Thirty-six percent (4/11) of patients improved by three Meyerding grades and an additional 55% (6/11) improved by two grades. Complications included one instance each of superficial infection, wound dehiscence, and transient neuralgia. There were no cases of instrumentation failure, cage subsidence, pseudoarthrosis, or retrograde ejaculation. Radiographic evidence of fusion was observed in all cases. Single-level anterior reduction and circumferential fusion without decompression appears to be a safe and effective alternative for the surgical treatment of pediatric HGS. IV.

Technique for Imbricated Repair of Paraconduit Conduit Hernia After Esophagectomy

Minimally invasive esophagectomy is associated with an increased rate of paraconduit hernia. Recurrences after repair are typically adjacent to the gastroepiploic vessel passage through the hiatus. This technique provides a novel solution and approach to prevent recurrence or re-recurrence after repair by imbricating the blood supply to the conduit within the conduit, allowing circumferential fixation while protecting the conduit blood supply.

Cortical Bone Trajectory Screw Placement Accuracy with a Patient-Matched 3-Dimensional Printed Guide in Lumbar Spinal Surgery: A Clinical Study

Cortical bone trajectory (CBT) screw is an attractive technique in terms of fixation strength and less invasiveness. However, the insertion of a pedicle screw penetrating cortical bone on the ideal trajectory is technically demanding. The use of 3-dimensional (3D) patient-matched guides may facilitate the use of this technique. In this technical note and case series, the use of a patient-matched 3D targeting guide for a circumferential fixation with CBT screws is described. Eleven patients with a mean age of 49 years were treated. The MySpine MC (Medacta International SA, Castel San Pietro, Switzerland) technology was used to place CBT screws. A computed tomography (CT) scan-derived 3D model of the patient vertebra was created after the surgeons planned the best custom CBT screw trajectory. Then, scaffolds were printed and used during surgery to guide the screw through the patient pedicle. An intersomatic arthrodesis was also performed. The images of the planned trajectory were superimposed on the postoperative CT scan, confirming the accuracy of the trajectory. The mean deviation from the planned pedicle midpoint was 0.91 mm; 85.2% of the screws were placed within 2° from the planned trajectory. There were 2 grade A (<2 mm) and no grade B or C perforations. The actual entry point was always within 2 mm from the planned entry point. This technical note and case series is the first clinical description on the use of a patient-matched guide for posterior CBT screw placement. The use of these devices could also improve placement accuracy and decrease the risk of nerve damage.

Effectiveness of Prophylactic Intraperitoneal Mesh Implantation for Prevention of Incisional Hernia in Patients Undergoing Open Abdominal Surgery

Incisional hernia is a frequent complication after open abdominal surgery. Prophylactic mesh implantation in the onlay or sublay position requires dissection of the abdominal wall, potentially leading to wound-associated complications. To compare the incidence of incisional hernia among patients after prophylactic intraperitoneal mesh implantation with that among patients after standard abdominal closure. An open-label randomized clinical trial was performed in 169 patients undergoing elective open abdominal surgery from January 1, 2011, to February 29, 2014. Follow-up examinations were performed 1 year and 3 years after surgery. The study was conducted at Bern University Hospital, Bern, Switzerland, a referral center that offers the whole spectrum of abdominal surgical interventions. Patients with 2 or more of the following risk factors were included: overweight or obesity, diagnosis of neoplastic disease, male sex, or history of previous laparotomy. Patients were randomly assigned to prophylactic intraperitoneal mesh implantation or standard abdominal closure. Data were analyzed in August 2017. Intraperitoneal implantation of a polypropylene-polyvinylidene fluoride mesh with circumferential fixation. The primary end point was the incidence of incisional hernia 3 years after surgery. Secondary end points included mesh-related complications. After the exclusion of 19 patients, 150 patients (81 in the control group and 69 in the mesh group; mean [SD] age, 64.2 [11.1] years; 102 [68.0%] male) were studied. The cumulative incidence of incisional hernia was significantly lower in the mesh group compared with the control group (5 of 69 [7.2%] vs 15 of 81 [18.5%], log-rank test P = .03). Abdominal pain was observed in significantly more patients in the mesh group compared with the control group at 6 weeks (34 of 52 [65%] vs 26 of 59 [44%], P = .04) but not at 12 and 36 months postoperatively. No difference in surgical site infections was observed, but time to complete wound healing of surgical site infection was significantly longer in patients with mesh implantation (median [interquartile range], 8 [6-24] weeks compared with 5 [1-9] weeks; P = .03). Trunk extension was significantly decreased after mesh implantation compared with the control group (mean [SD], 1.73 [0.97] cm vs 2.40 [1.23] cm, P = .009). In patients at elevated risk for incisional hernia, prophylactic intraperitoneal mesh implantation reduces the incidence of hernia formation but with increased early postoperative pain and prolonged wound healing of surgical site infection. ClinicalTrials.gov Identifier: NCT01203553.

Cervical Spine Osteomyelitis: A Systematic Review of Instrumented Fusion in the Modern Era

For cases of cervical osteomyelitis that require surgery, concern has continued regarding instrumentation owing to the potential for bacterial seeding of the hardware. We performed a systematic review of the current data. A search was performed using Medline, Embase, and Ovid for articles using the keywords "cervical osteomyelitis/spondylodiscitis" and "fusion" or "instrumentation" reported from 1980 to 2017. Prospective or retrospective studies describing ≥2 patients with cervical osteomyelitis were included in the analysis; non-English reports were excluded. Individual patients were excluded from the final analysis if they had previously undergone spinal instrumentation. A total of 239 patients from 24 studies met our criteria. Surgical approaches were classified as anterior-only, combined anteroposterior, and posterior-only for 64.8%, 31.9%, and 3.3% of the patients respectively. Of the patients treated using an anterior-only approach, 76.5% had received anterior plating and 85.3%, a cage or spacer implants. Of the patients who had undergone combined approaches, 85.1% underwent circumferential fixation and 14.9%, anterior debridement with posterior instrumentation. The follow-up period ranged from 6 weeks to 11 years (mean, 31.0 months). All the studies reporting the fusion rates, except for 1, reported a 100% fusion rate. The reported rates of pain improvement and neurologic recovery were favorable. The incidence of hardware failure and wound complications was 4.6% and 4.0%, respectively. Despite placing instrumentation during active infection, the rates of hardware failure and wound complications were comparable to those of elective cervical spine procedures. These results suggest that surgical intervention with instrumentation is a safe treatment option for patients with cervical spine osteomyelitis.

Decompression with Lateral Pediculectomy and Circumferential Reconstruction for Unstable Thoracolumbar Burst Fractures: Surgical Techniques and Results in 18 Patients

To introduce our technique and results of retropleural/peritoneal lateral pediculectomy for the decompression of thoracolumbar fractures and reconstruction using an expandable titanium cage and circumferential fixation at a single stage. Eighteen patients who had single unstable, burst thoracolumbar fracture were treated by this technique between January 2014 and December 2016 (T12: n= 9, L1: n= 7, L2: n= 2). They were reviewed retrospectively in terms of radiologic outcomes (computed tomography [CT] scan and radiograph), clinical outcomes, and complications. The results were compared with another cohort of thoracolumbar fractures treated by posterior-only surgery. There were no radiologic complications implying pseudoarthrosis or instrument failure on the postoperative 6-month CT scan. There was also no neurologic deterioration or infection during the same period. Two patients (11.1%) of iatrogenic injury and 1 patient of trauma-related injury of the dura were secured without any delayed complications. Three patients (16.7%) with transient weakness in left hip flexion immediately after operation were observed and recovered within 2 weeks in all cases. Six patients (33.3%) complained of dysesthesia and/or hypoesthesia on the incision site. In this study, we suggest lateral pediculectomy as a distinct anatomic landmark to access and remove bony fragments effectively and safely in unstable thoracolumbar burst fractures. This provides a more straightforward access to the burst fragment and helps the surgeon to make better intraoperative decompression strategies. Moreover, this circumferential instrumentation with anterior support and fusion revealed better restoration of the thoracolumbar spine alignment compared with posterior-only surgery, with acceptable complications rates.

Circumferential minimally invasive approach for low-grade isthmic spondylolisthesis: A clinical and radiological study of 43 patients.

Circumferential fusion for lumbar low-grade isthmic spondylolisthesis (LGIS) provides the best spinal stability and highest fusion rates. The aim of this study is to investigate results of minimal invasive management of LGIS and correlations between Intervertebral Foramen Surface (IFS) and other parameters. We retrospectively reviewed cases of 43 patients who underwent a minimally invasive circumferential fusion (Anterior lumbar interbody fusion followed by percutaneous posterior pedicle screw fixation) for LGIS between January 2010 and December 2014 in our institution. Inclusion criteria were one-level (L4-L5 or L5-S1) LGIS with low back and/or radicular pain. Pre- and postoperative radiographic evaluations were performed at 6, 12 and 24months. Measurements (Percentage of anterior displacement, degree of slip angle, height of the intervertebral space and the IFS) were obtained using Surgimap®. Nineteen patients (44.2%) were males. Mean age was 43 years old (19-72years). The mean follow-up of the series was 18.3months (3-72months). Mean preoperative Visual Analogy Scale (VAS) for low back pain decreased from 70mm to 20mm and from 80mm to 10mm as to radicular pain. Anterior displacement was reduced from 18% to 7% (p<0.01), degree of slippage were increased from 9.8° to 15.2° (p<0.01), intervertebral height was restored from 4.4mm to 8.5mm (p<0.01) and increase of the IFS was calculated 48.8%. One stage circumferential fixation for adults' LGIS without decompression, allows restoration of intervertebral height permitting good reduction of the slippage, an increasing of the IFS and liberation of nerve roots.

Does pedicle screw fixation of the subaxial cervical spine provide adequate stabilization in a multilevel vertebral body fracture model? An in vitro biomechanical study

BackgroundCervical vertebral body fractures generally are treated through an anterior-posterior approach. Cervical pedicle screws offer an alternative to circumferential fixation. This biomechanical study quantifies whether cervical pedicle screws alone can restore the stability of a three-column vertebral body fracture, making standard 360° reconstruction unnecessary. MethodsRange of motion (2.0 Nm) in flexion-extension, lateral bending, and axial rotation was tested on 10 cadaveric specimens (five/group) at C2–T1 with a spine kinematics simulator. Specimens were tested for flexibility of intact when a fatigue protocol with instrumentation was used to evaluate construct longevity. For a C4–6 fracture, spines were instrumented with 360° reconstruction (corpectomy spacer + plate + lateral mass screws) (Group 1) or cervical pedicle screw reconstruction (C3 and C7 only) (Group 2). FindingsResults are expressed as percentage of intact (100%). In Group 1, 360° reconstruction resulted in decreased motion during flexion-extension, lateral bending, and axial rotation, to 21.5%, 14.1%, and 48.6%, respectively, following 18,000 cycles of flexion-extension testing. In Group 2, cervical pedicle screw reconstruction led to reduced motion after cyclic flexion-extension testing, to 38.4%, 12.3%, and 51.1% during flexion-extension, lateral bending, and axial rotation, respectively. InterpretationThe 360° stabilization procedure provided the greatest initial stability. Cervical pedicle screw reconstruction resulted in less change in motion following cyclic loading with less variation from specimen to specimen, possibly caused by loosening of the shorter lateral mass screws. Cervical pedicle screw stabilization may be a viable alternative to 360° reconstruction for restoring multilevel vertebral body fracture.

Evaluation of Two Novel Integrated Stand-Alone Spacer Designs Compared with Anterior and Anterior-Posterior Single-Level Lumbar Fusion Techniques: An In Vitro Biomechanical Investigation.

Study DesignIn vitro biomechanical investigation.PurposeTo compare the biomechanics of integrated three-screw and four-screw anterior interbody spacer devices and traditional techniques for treatment of degenerative disc disease.Overview of LiteratureBiomechanical literature describes investigations of operative techniques and integrated devices with four dual-stacked, diverging interbody screws; four alternating, converging screws through a polyether-ether-ketone (PEEK) spacer; and four converging screws threaded within the PEEK spacer. Conflicting reports on the stability of stand-alone devices and the influence of device design on biomechanics warrant investigation.MethodsFourteen cadaveric lumbar spines were divided randomly into two equal groups (n=7). Each spine was tested intact, after discectomy (injured), and with PEEK interbody spacer alone (S), anterior lumbar plate and spacer (AP+S), bilateral pedicle screws and spacer (BPS+S), circumferential fixation with spacer and anterior lumbar plate supplemented with BPS, and three-screw (SA3s) or four-screw (SA4s) integrated spacers. Constructs were tested in flexion-extension (FE), lateral bending (LB), and axial rotation (AR). Researchers performed one-way analysis of variance and independent t-testing (p≤0.05).ResultsInstrumented constructs showed significantly decreased motion compared with intact except the spacer-alone construct in FE and AR (p≤0.05). SA3s showed significantly decreased range of motion (ROM) compared with AP+S in LB (p≤0.05) and comparable ROM in FE and AR. The three-screw design increased stability in FE and LB with no significant differences between integrated spacers or between integrated spacers and BPS+S in all loading modes.ConclusionsIntegrated spacers provided fixation statistically equivalent to traditional techniques. Comparison of three-screw and four-screw integrated anterior lumbar interbody fusion spacers revealed no significant differences, but the longer, larger-diameter interbody spacer with three-screw design increased stabilization in FE and LB; the diverging four-screw design showed marginal improvement during AR.

The significance of spinal fixation in palliative surgery for spinal metastases

The purpose of this study is to assess appropriate fixation methods for surgical spinal stabilization for spinal metastases. 191 patients who underwent spine surgery for spinal metastases are included in this study. The surgeries included 1) posterior decompression only (29), 2) posterior decompression and fixation (153), and 3) decompression and circumferential fixation (9). We evaluated and compared all cases based upon 1) use of fixation, 2) number of levels included in the fixation, 3) type of fixation, 4) use of bone graft, 5) presence of preoperative collapse of involved vertebrae, and 6) involved area of vertebrae according to Kostuik classification. Progression of vertebral collapse on radiographs or Magnetic Resonance Imaging (MRI) or occurrence of implant failure after surgery was considered a failed case. The number of failed cases was 51 (27%). The factors that were compared between the failed and successful groups were: use of fixation (p < .01), extent of fixation (one level above and one level below affected vertebrae vs. ≧ two above and two below, p < .01), presence of preoperative collapse of affected vertebrae (p < .05), and ≧ four of six columns of vertebral involvement according to Kostuik classification (p < .01). All results were statistically significant. In conclusion, when treating metastatic spinal disease with instability, it is recommended that posterior fixation with instrumentation be used and extend at least two levels above and two below the affected vertebrae. Preoperative collapse of affected vertebrae and greater involvement of the vertebrae with metastatic disease results in greater local instability.

Surgical anatomy of the radial nerve in the deltopectoral approach for revision shoulder arthroplasty and periprosthetic fracture fixation: a cadaveric study

Radial nerve injury is a rare but clinically significant complication of revision shoulder arthroplasty and fixation of native and periprosthetic proximal humeral fractures. Understanding of the anatomic relationship between the radial nerve as it enters the humeral spiral groove and anterior shoulder landmarks in a deltopectoral approach is necessary to avoid iatrogenic radial nerve injury. Eight forequarter cadaveric specimens were dissected through a deltopectoral approach. Distances between the radial nerve entry into the proximal spiral groove and the coracoid process, distal lesser tuberosity/inferior subscapularis insertion, superior latissimus insertion, and inferior latissimus insertion were measured. Means, standard deviations, and ranges were determined for each distance. The radial nerve entry into the proximal spiral groove averaged 133.1 mm (range, 110.3-153.0 mm) from the coracoid process, 101.9 mm (range, 76.5-124.3 mm) from the distal lesser tuberosity/inferior subscapularis insertion, 81.0 mm (range, 63.4-101.5 mm) from the superior latissimus insertion, and 39.6 mm (range, 25.5-55.4 mm) from the inferior latissimus insertion. The proximal spiral groove was distal to the inferior latissimus insertion in all specimens. The risk of iatrogenic injury to the radial nerve at the spiral groove may be minimized through proper identification and protection or avoidance of circumferential fixation. However, if encircling fixation with cerclage cables is necessary, instrumentation proximal to the inferior edge of the latissimus dorsi insertion may reduce the risk of radial nerve injury.

P.091 Anterior surgical fixation for cervical spine flexion-distraction injuries

Background: Optimal surgical management for flexion--distraction cervical spine injuries remains controversial with anterior, posterior, and circumferential fixation being accepted. Here, we examined risk factors for clinical and radiographic failure in patients with one segment cervical flexion-distraction injuries having undergone anterior surgical fixation. Methods: A retrospective review of 57 consecutive patients undergoing anterior fixation for cervical flexion-distraction injuries between 2008-2012 was performed. The primary outcome was the number of patients requiring additional surgical stabilization and/or radiographic failure. Data collected inlcuded age, gender, mechanism and level of injury, facet pattern injury, and vertebral endplate fracture. Results: Six patients failed clinically and/or radiographically (11%). Four patients (7%) required additional posterior fixation. Two patients identified met radiographic failure criteria, however had fused radiographically, were stable clinically, and no further treatment was pursued. Progressive kyphosis and translation correlated with need for revision (p&lt;0.05 and p=0.02, respectively). No differences were identified for all other clinical and radiological factors assessed. Conclusions: This study supports the growing body of evidence for anterior fixation alone for flexion-distraction injuries. Findings suggest that measurements including segmental translation and kyphosis may predict radiographic failure and need for further surgical stabilization in some patients. Assessment for independent risk factors for anterior approach failure with a validated predictive scoring model should be considered.

Prosthetic mesh "slim-cigarette like" for laparoscopic repair of ventral hernias: a new technique without transabdominal fixation sutures.

Prosthetic mesh rolled up and fixed with stitches like a slim cigarette ("slim-mesh") for laparoscopic ventral hernia (VH) repair is an new technique which allows an easy intraperitoneally introduction, distension and circumferential fixation of a prosthetic mesh without transabdominal fixation sutures even for meshes larger than 16cm up to 30cm for the "slim-mesh" repair of wide ventral hernias. We report the technique of laparoscopic repair of VH with "slim-mesh". This technique enables an easy intra-peritoneally introduction of the mesh through the trocar because it reduces consistently its size, it allows a rapid intra-abdominal handling of the mesh and a fast and easy fixation for VH repair. The average time of surgery with "slim-mesh" for treatment of all 28 VH was 97min ranging from 57 to 160min. The average time for the repair of the 24 VH smaller than 10cm was 91 and 135min for the four VH larger than 10-22cm. This new surgical technique leads to a reduction of surgical risks avoiding the use of transfascial sutures with the associated complications. This new surgical procedure in our experience is fast, safe, simple and also easily reproducible by surgeons in laparoscopic training. This technique may be used in wide VH (larger than 10-22cm) that generally require open surgery.

Halo traction, single-segment circumferential fixation treating cervical tubercular spondylitis with kyphosis

ObjectiveTo evaluate the clinical efficacy and feasibility of twenty patients with cervical tubercular spondylitis with kyphosis (CTSK) treated by halo traction, single-segment circumferential instrumented fusion combined anterior debridement, decompression and bone grafting. MethodsRetrospective review of data on twenty patients who suffered from CTSK admitted to our hospital between January 2007 and December 2012. All of them were performed by halo traction, single-segment circumferential instrumented fusion (anterior titanium plate and posterior pedicle or lateral mass fixation) combined anterior debridement, decompression and titanium mesh cage (TMC) filled with allograft bone particles. X-ray and computed tomographic (CT) images were used to determined sagittal balance and bone fusion. The clinical efficacy was evaluated using statistical analysis about the visual analogue scale (VAS) scores of pain, neurological status according to the Frankel classification and erythrocyte sedimentation rate (ESR), which were collected at certain time. ResultsThe average follow-up period was 34.1±7.0months (24–48 months). In the 20 cases, no obvious postoperative complications related to instrumentation and bone grafting and neurologic function was improved in various degrees. The average pretreatment ESR was 46.4±21.7mm/h, which got normal within 3 months in all patients. The average VAS on admission was 6.7±1.7, which decreased to 1.6±1.1 postoperatively. All patients got bony fusion within 3.4–5.5 months after surgery. The Cobb angle of 30.8±10.5° on admission reduced to 2.9±3.9° performed by preoperative halo traction, became to −5.1±4.0° after operation and remained at −4.3±3.8°, with 0.9±0.7° of correction loss. ConclusionsHalo traction, single-segment circumferential instrumented fusion combined anterior debridement, decompression and TMC can be an effective and safe treatment method for the treatment of cervical tubercular spondylitis with kyphosis and the preoperative halo traction should be laid on much emphasis.

Is lateral stabilization enough in thoracolumbar burst fracture reconstruction? A biomechanical investigation

Background contextTraditional reconstruction for burst fractures involves columnar support with posterior fixation at one or two levels cephalad/caudad; however, some surgeons choose to only stabilize the vertebral column. PurposeThe aim was to distinguish biomechanical differences in stability between a burst fracture stabilized through a lateral approach using corpectomy spacers of different end plate sizes with and without integrated screws and with and without posterior fixation. Study design/SettingThis was an in vitro biomechanical study assessing thoracolumbar burst fracture stabilization. MethodsSix human spines (T11–L3) were tested on a six-degrees-of-freedom simulator enabling unconstrained range of motion (ROM) at ±6 N·m in flexion-extension (FE), lateral bending (LB), and axial rotation (AR) after a simulated burst fracture at L1. Expandable corpectomy spacers with/without integrated screws (Fi/F; FORTIFY Integrated/FORTIFY; Globus Medical, Inc., Audubon, PA, USA) were tested with different end plate sizes (21×23 mm, 22×40–50 mm). Posterior instrumentation (PI) via bilateral pedicle screws and rods was used one level above and one level below the burst fracture. Lateral plate (LP) fixation was tested. Devices were tested in the following order: intact; Fi21×23; Fi21×23+PI; F21×23+PI+LP; F21×23+LP; F22×40–50+LP; F22×40–50+PI+LP; Fi22×40–50+PI; Fi22×40–50. ResultsIn FE and AR, constructs without PI showed no significant difference (p<.05) in stability compared with intact. In LB, F22×40–50+LP showed a significant increase in stability relative to intact, but no other construct without PI reached significance. In FE and LB, circumferential constructs were significantly more stable than intact. In AR, no construct showed significant differences in motion when compared with the intact condition. ConclusionsConstructs without posterior fixation were the least stable of all tested constructs. Circumferential fixation provided greater stability in FE and LB than lateral fixation and intact. Axial rotation showed no significant differences in any construct compared with the intact state.