Instrumented Fixation Research Articles

Design of abdominal retractor.

The purpose of this paper is to present the development and design of an abdominal retractor which allows a single person to perform operations and the fixation of the operation instruments can be done with one hand. The additional devices make the operation more comfortable for surgeons. Conventional measuring devices have been designed and applied for determining axial forces in a surgeon's forearm during operations. The same forces must be transmitted by the frame of the retractor. Thus a simple truss structure of a retractor was done. Several types of fixations have been proposed and tested using the rapid prototyping. Finally, the abdominal retractor was manufactured from stainless steel. The simple-to-use abdominal retractor was built. The standard surgery instruments were modified due to the fixation system of the frame. A wide variety of additional useful devices, such as a lamp, video camera etc., were also proposed. The present abdominal retractor is user-friendly and all components are easily sterilized by conventional methods (Fig. 7, Ref. 6) Keywords: abdominal retractor, stainless steel retractor, standard surger, fixation system of the frame, lamp, video camera, conventional methods.

Post-traumatic deformities of the spine: relevance, problems, and revision surgery

Objective . To analyze tactical approaches and types of surgical interventions for post-traumatic deformity of the spine. Material and Methods . Study design: retrospective monocentric cohort study. The study included 116 patients: Group 1 consisted of 50 patients with primary post-traumatic deformities, and Group 2 of 66 patients with secondary deformities after previously performed decompression and stabilization surgery who were admitted for revision interventions. The average age of patients was 42.1 ± 11.6 years, the long-term follow-up period varied from 2 to 60 months (16.6 ± 10.2). Methods used in the study were clinical (neurological status, ASIA, VAS) one, evaluation of treatment results according to MacNub scale, radiography, CT, radiometry (local kyphosis according to Cobb, Surgimap Spine), MRI, and statistical methods. Results. The follow-up period of Group 1 patients was 31.3 ± 28.1 months, of Group 2 patients – 60.3 ± 48.1 months. Injuries were predominantly localized at the level of the thoracolumbar junction. In Group 2, more severe neurological disorders (ASIA) prevailed. All patients underwent primary or revision transpedicular fixation and Schwab vertebrotomy variants through posterior approach. The follow ing types of primary deformities according to Rajasekaran were observed: type IIA in 16 (32 %) patients, IIIA in 30 (45 %), and IIIB in 4 (6 %). Patients with secondary deformities had failure of posterior instrumental fixation (100 %), failure (56 %) or absence (73 %) of anterior fusion, and progression of deformity (100 %). In Group 1, local kyphosis was 32.0° ± 9.9° before treatment and 12.5° ± 8.8° after treatment, pain VAS score before treatment 76.6 ± 6.9, and after treatment 47.6 ± 8.8. In Group 2, local kyphosis was 31.8° and 10.1°, and pain score 80.6 and 48.4, respectively. Complications were registered in 10 % of cases. Treatment results were assessed as good/satisfactory in 32 (64 %)/18 (36 %) Group 1 patients, and in 38 (57 %)/28 (42 %) Group 2 patients, respectively. Conclusion. Classification options and tactical approaches for primary post-traumatic spinal deformities were defined; for secondary posttraumatic deformities there is no classification defining treatment tactics and criteria for assessing the parameters of local and global body balances. Joint multicenter studies are necessary for the adoption of consensual conclusions in the revision surgery of post-traumatic spinal deformities.

Atlantoaxial dislocation in an adolescent with juvenile spondyloarthritis

Atlantoaxial dislocation with spinal canal stenosis not associated with craniovertebral junction malformations and traumatic injury is a rare pathology in children and adolescents. A clinical case of the diagnosis and surgical treatment of atlantoaxial dislocation of non-traumatic genesis combined with spinal canal stenosis in an adolescent with juvenile idiopathic arthritis is presented. A minimal instrumental fixation of the upper cervical spine allowed eliminating stenosis of the spinal canal, repairing instability of the upper cervical vertebrae, and jugulating neurological disorders.

P28. Bone mineral density t-score is an independent predictor of significant blood loss in adult spinal deformity surgery

BACKGROUND CONTEXT Blood loss is an important cause of morbidity in Adult Spinal Deformity (ASD) surgery. Thus, identifying potentially modifiable factors associated with increased EBL in ASD surgery is important. Bone mineral density (BMD), as measured by Dual-energy X-ray Absorptiometry (DEXA), is important for stable instrumented fixation and is often measured preoperatively in ASD patients. However, the association between BMD and intraoperative blood loss in ASD patients has not been studied. PURPOSE Lower BMD is associated with greater odds of major blood loss in ASD surgery. STUDY DESIGN/SETTING Cross-sectional study from a single surgeon at an academic institution. PATIENT SAMPLE A total of 91 ASD patients (>5 levels fused) who had preoperative DEXA score recorded within the year preceeding surgery. OUTCOME MEASURES Our primary outcome was major blood loss, defined as >2L of estimated blood loss, using the upper 90th percentile of our study population. METHODS The lowest preoperative T-score was recorded. Patients were excluded who had liver/kidney disease or were on prescription anticoagulant medication. Binomial regression was performed controlling for age, number of vertebra fused, 3-column osteotomy, primary vs. revision surgery, preoperative platelet count, and if the patient was taking medication for osteoporosis. Significance was set at p=0.05. RESULTS Mean age of patients was 63 ± 11.6 years, 81% female. 56 (62%) of cases included revision of previous instrumentation. Patients had a mean SVA of 9.6 ± 8.6cm and median of 9 vertebra fused (range 5-22). The average T-score was -1.2 ± 1.0. Each point lower T-score was associated with significantly higher odds of major blood loss (OR 2.5, 95% CI 1.0 – 5.9) when controlling for age, number of vertebra fused, 3-column osteotomy, preoperative platelet count and primary vs. revision surgery. CONCLUSIONS Lower preoperative T-score is independently associated with increased odds of significant blood loss in ASD surgery. Surgeons should anticipate increased blood loss in ASD patients with lower bone mineral density. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Novel Screw Insertion Method for Anterior Surgical Treatment of Unstable Thoracolumbar Fracture: Quadrant Positioning Method.

ObjectiveTo develop a novel screw positioning method to improve the treatment of unstable thoracolumbar fractures.MethodsA total of 72 patients with unstable thoracolumbar fractures who were treated with anterior screw–rod interfixation from January 2011 to October 2015 were included in this clinical study. Those patients included 48 male and 24 female patients with an average age of 45.10 years (range, 26–63 years). Patients were randomly divided into two groups: an observation group (n = 36) and a control group (n = 36). The quadrant positioning method was used for screw insertion in the observation group during the operation, while the traditional screw positioning method was used in the control group. The quadrant positioning method targeted four quadrants, including the superior anterior (SA), superior posterior (SP), inferior anterior (IA) and inferior posterior (IP) quadrants, while for the traditional screw positioning, four screws were inserted into the vertebral bodies above and below the excision. Patients were followed up for approximately 40 months to record recovery. Clinical and radiological records, local angle and fractured vertebra body height, clinical outcomes, complications, neurological improvement, and fusion rate were recorded and compared between the two groups.ResultsThe quadrant positioning method was successfully used for anterior screw insertion. The quadrant center in the lateral view of the vertebral body was well marked, and screws were easily located on the scheduled quadrant. Blood loss (BL), hospital stay (HS), and operation time (OP) in the observation group were 749.40 ± 379.90 mL, 17.10 ± 4.10 days, and 167.40 ± 44.70 min, respectively. While those parameters in the control group were 1198.40 ± 339.27 mL, 23.22 ± 3.77 days, and 221.47 ± 32.15 min, respectively. The average operation time and hospital stay time were significantly shorter, and blood loss was significantly less in the observation group than in the control group (P < 0.05). Local angle and vertebral body height were markedly improved and 1–2 grade improvement was achieved in patients with neurological deficits in both groups. Both groups of patients achieved bony fusion during follow‐up. No incision infection or internal fixation failure was observed in the two groups, and complications including cerebrospinal fluid and chylous leakage and hemothorax were resolved.ConclusionsThe quadrant positioning method can shorten operation time, reduce blood loss, and accelerate postoperative recovery. The technique provides an effective method for screw insertion for double screw–rod instrumentation fixation in the treatment of thoracolumbar fracture via the anterior approach.

Decision-making and technical choice in instrumental fixation for neurologically uncomplicated isolated burst fractures of the thoracic and lumbar vertebrae

Objective.To substantiate the principles of context-based optimal decision-making and technical choice in instrumental fixation of the spine in trauma patients with neurologically uncomplicated isolated burst fractures of the thoracic and lumbar vertebrae.Material and Methods.A comparative retrospective analysis of treatment outcomes of 206 trauma patients was performed. Patients of Group 1 (n = 17) underwent anterior spinal fusion with anterior instrumental fixation through isolated open anterior approach, those of Group 2 (n = 80) – open pedicle screw fixation, of Group 3 (n = 70) – posterior mini-invasive percutaneous pedicle screw fixation, of Group 4 (n = 20) – open pedicle screw fixation with the extended laminectomy and reconstruction of the anterior column, and of Group 5 (n = 19) – open pedicle screw fixation and anterior fusion through an open approach. Non-parametric statistical methods were used.Results.Open or minimally invasive posterior instrumental fixation of the spine with instrumentation systems including 6 screws for incomplete burst fractures and 8–10 screws for complete burst fractures should be considered the best operative option in the immediate post-traumatic period (up to 7 days) both from the point of view of convenience and safety of the patient and from the standpoint of maximally effective use of any hospital resources. The use of open anterior approaches for the reconstruction of the anterior spinal column can be justified only when the time from injury exceeds 7 days, as a part of combined procedure, primarily in combination with minimally invasive posterior pedicle screw fixation.Conclusion.To date, decision-making and technical choice in instrumental fixation for neurologically uncomplicated isolated burst fractures of the thoracic and lumbar vertebrae should be context-based. The decision-making algorithm should be built on the basis of the experience of the operating surgeon, the time from injury, the trauma patient’s state of health, as well as the administrative and logistical context of provision of the specialized medical care.

Pars Repair in Isthmic Spondylolysis in the Young Adults

Abstract Background Data: Spondylolysis is the main identifiable cause of low back pain in children and adolescents. The fifth lumbar vertebra (L5) is the most common site for spondylolysis. The cause of spondylolysis in these patients is attributed to repetitive stress of the pars interarticularis with subsequent microfracture;it is believed that an inherited genetic pars weakness can make an individual more susceptible to spondylolysis.There are varieties of surgical techniques in the treatment of spondylolisthesis whether the traditional surgical fusion and instrumental fixation or the direct pars repair if no evident slippage, disc degeneration or canal stenosis. Purpose: Evaluations of the efficacy of pars repair as regard bony fusion, preservation of motion segment with no adjacent level disease. Patients and Methods: our study was conducted on10 patients with diagnosed isthmic spondylolysis.Three males and seven females were operated (between 2016- 2018) by direct pars repair using smile face shaped rod technique (V shaped rod technique) with insertion of iliac crest bone graft at the site of the defect bilaterally to enhance bony fusion at the fracture site. Age less than 30years, Weight less than 80kg, back pain not responding to conservative treatment. No slippage or less than 2mm, healthy disc space not degenerated, no disc herniation or canal stenosis, no previous disc operation, preserved sagittal balance and lumber lordosis. Results: All cases were assessed clinically and radiologically over one year to assess the improvement in back pain using RMQ and to assess bony fusion radiologically through PXR and CT lumbosacral spine. Good outcome was achieved in seven cases (70% of patients) with significant improvement in back pain and RMQ. Two cases (20% of patients) had fair outcome with occasional back pain occur with sports and strenuous activities. 1 case (10% of patients) had poor out come as the patient exposed to back trauma that lead to fracture of the L5 screw and operated again for traditional surgery with 4 screws, 2 rods and cage placemen. Par bony fusion was sound in all cases except one patient that was subjected to direct back trauma 3 months following surgery and had one screw fracture, that required redo surgery with formal fixation using 4 screws, 2 rods and intervertebral cage Conclusion: Direct pars repair can provide good functional outcomes in young adult patients with isthmic spondylolysis.

Classifications of Non-Specific Hematogenous Vertebral Osteomyelitis. Critical Review and Suggestions for Clinical Use

For a long time classification of V.Ya. Fischenko published in 1983 and being solely descriptive was the main classification of vertebral osteomyelitis in the countries of the former ussr. In recent years some versions of tactical classifications appeared in the literature which were dedicated to standardization of tactics and methods of treatment. However, those classifications did not reflect distribution according to affection type, destruction degree, biomechanical instability and presence of neurological deficit and did not embrace all scenarios of disease progress.Purpose of the study — to compare existing classifications and to offer an adapted Russian language version of tactical classification for hematogenous vertebral osteomyelitis.Materials and Methods. The study included 209 patients with non-specific vertebral osteomyelitis treated in the period from 2006 till 2017. All cases of vertebral osteomyelitis were distributed in accordance with known classifications. The authors conducted the analysis of treatment tactics used in the clinic and by the authors of given classifications. The authors revealed a group of patients which is not classified in known literature.Results. Full match of treatment tactics with standardized approaches suggested by authors of new classifications was 61,5% (n = 126), partial match (applied treatment tactics does not contradict to suggested) — 20,0% (n = 41), which overall was 81,5% (n = 167). The authors refer to patients who underwent ventral sanation or reconstructive procedures. The majority of patients had the septic form of disease. Four out of 209 patients were not classified while three patients features isolated injury of vertebral processes and one patient — injury of CI-CII.Conclusion. Modern suggested classifications of hematogenous vertebral osteomyelitis are applicable in clinical practice and allow to standardize treatment algorithms. Tactics is determined not only by degree of destruction, involvement of paravertebral tissues, biomechanical instability of affected spine segment and neurological deficit, but by a presence of systemic inflammation response syndrome (SIRS). Considering the above it would be useful to introduce some additional subtypes which would characterize septic process of disease and determine the indications for sanation and reconstructive ventral procedures, which can be supplemented by instrumental fixation after stabilization of the patient.

Clinical efficacy of laminectomy with instrumented fixation in treatment of adjacent segmental disease following ACCF surgery: a retrospective observational study of 48 patients

This study was designed to investigate the clinical efficacy of laminectomy with instrumented fixation in treatment of adjacent segmental diseases following anterior cervical corpectomy and fusion (ACCF) surgery. Between January 2008 and December 2015, 48 patients who underwent laminectomy with instrumented fixation to treat adjacent segmental diseases following ACCF surgery, were enrolled into this study. The patients were followed up at least 2 years. Pain assessment was determined by visual analogue scale (VAS) score and Neck Disability Index (NDI) score; neurological impairment was evaluated by Japanese Orthopaedic Association (JOA) score; and radiographic parameters were also compared. All comparisons were determined by paired t test with appropriate Bonferronni correction. VAS score preoperatively and at last follow-up was 5.28 ± 2.35 vs 1.90 ± 1.06 (P < 0.001). JOA score preoperatively and at last follow-up was 8.2 ± 3.6 vs 14.5 ± 1.1 (P < 0.001). NDI score preoperatively and at last follow-up was 30.5 ± 12.2 vs 10.6 ± 5.8 (P < 0.001). Moreover, the losses of cervical lordosis and C2-C7 range of motion after laminectomy were significant (both P < 0.005), but not sagittal vertical axis distance. Postoperative complications were few or mild. In conclusion, clinical effectiveness and safety can be guaranteed when the patients undergo laminectomy with instrumented fixation to treat adjacent segmental diseases following ACCF surgery.

1065 NEW DIAGNOSIS OF OBSTRUCTIVE SLEEP APNEA FOLLOWING ANTERIOR CERVICAL DISCECTOMY AND FUSION, WORSENED BY RHEUMATOID ARTHRITIS

Onset of obstructive sleep apnea (OSA) following anterior cervical discectomy and fusion (ACDF) has been published in a retrospective study of 12 patients. Association of obstructive as well as central sleep apnea with Rheumatoid arthritis (RA) affecting the cervical vertebrae has also been observed. Here we present a case of new diagnosis of OSA following ACDF and subsequent worsening caused by RA and further instrumentalization affecting the cervical spine. A 66 yr old female with history of hypertension and rheumatoid arthritis and no prior diagnosis of OSA, underwent ACDF of C5-6 and C6-7 in 2012 due to progressive increase in pain, numbness and loss of grip strength in the right upper extremity. Postsurgically in recovery she was noted to have apneic episodes. Following discharge she underwent investigation with oximetry and subsequent polysomnography (PSG) and was diagnosed with mild OSA and placed of CPAP at 8cm H20. Two years later, her neurological symptoms worsened. Re Imaging showed pseudoarthrosis of C6-7 and autofusion of C3-5, likely from RA. She underwent C6-7 decompressive foraminotomy as well as C4-T2 posterior instrumented fixation. On recent followup with sleep medicine, her husband reported worsened snoring and increased apneic episodes. Since last PSG, she had lost 20-30lbs. On exam her Friedman score was 1. PSG demonstrated moderate OSA this time. Association of of OSA after ACDF has been investigated in the only retrospective study of 12 patients by Guilleminault. Development of positional dyspnea after ACDF was also reported by Zhang and associates. This case highlights, the need for prospective investigation to establish association between OSA and ACDF. It also highlights the association of RA and OSA, which have been reported in the past, due to reduced neck width, subluxation of C3-4 and compression of medulla by odontoid.

Анализ причин развития проксимального переходного кифоза после инструментальной фиксации на фоне дефицита минеральной плотности костной ткани

Анализ причин развития проксимального переходного кифоза после инструментальной фиксации на фоне дефицита минеральной плотности костной ткани

EN BLOCK RESECTION OF THE GIANT INVASIVE SCHWANNOMA IN THE THORACOLUMBAR SPINE

The paper presents a rare clinical case of surgical treatment of a patient with a giant invasive schwannoma of the thoracolumbar spine. A single-stage en block resection of the tumor through a combined posteroanterior approach was performed followed by replacement of post-resection interbody diastasis with a carbon implant and by posterior instrumental fixation of the spine. The pain syndrome regressed from VAS scores 7 and 8 (back, lower limbs) to scores 4 and 1, respectively. The follow-up examination was conducted at 6 and 12 months after surgery: there were no signs of relapse. Publications on giant invasive spinal schwannomas were analyzed.

Fusion surgery with instrumentation following carbon ion radiotherapy for primary lumbar tumors: A case series

Carbon-ion radiotherapy (CIRT) is a useful modality for treatment of primary spinal sarcoma, but osteonecrosis after CIRT may cause pseudoarthrosis that can make subsequent reconstruction surgery difficult. The patients were a 68-year-old man (case 1), a 30-year-old woman (case 2), and a 49-year-old man (case 3) with lumbar lesions. After CIRT, cases 1 and 3 were treated with instrumented spondylectomy and case 2 underwent posterior decompression and instrumentation surgery. Cases 1 and 2 required several salvage procedures because of failure of instrumentation (rod breakage) before bone union was achieved. After multiple revision surgeries, these cases did achieve bone union without tumor recurrence. In contrast, in case 3, only spondylectomy using a pedicle screw system at 20 months after CIRT was required for fusion. At follow-up 11 years postoperatively, CT showed bone union with invasion of autograft bone from the iliac crest into adjacent vertebra. Collapse or a finding of viable tumor cells after CIRT requires surgery such as spondylectomy with reconstruction. Instrumented fixation following CIRT for a lumbar primary tumor should be performed with multilevel anterior support using a sufficient amount of bone graft in posterior fusion levels.

Comparison of synthetic bone graft ABM/P-15 and allograft on uninstrumented posterior lumbar spine fusion in sheep

BackgroundSpinal fusion is a commonly used procedure in spinal surgery. To ensure stable fusion, bone graft materials are used. ABM/P-15 (commercial name i-Factor™ Flex) is an available synthetic bone graft material that has CE approval in Europe. This peptide has been shown to improve bone formation when used in devices with fixation or on bone defects. However, the lack of external stability and large graft size make posterolateral lumbar fusion (PLF) a most challenging grafting procedure. This prospective randomized study was designed to evaluate early spinal fusion rates using an anorganic bovine-derived hydroxyapatite matrix (ABM) combined with a synthetic 15 amino acid sequence (P-15)–ABM/P-15 bone graft, and compared with allograft in an uninstrumented PLF model in sheep. The objective of this study was to assess fusion rates when using ABM/P-15 in uninstrumented posterolateral fusion in sheep.MethodsTwelve Texas/Gotland mixed breed sheep underwent open PLF at 2 levels L2/L3 and L4/L5 without fixation instruments. The levels were randomized so that sheep received an ABM graft either with or without P15 coating. Sheep were euthanized after 4.5 months and levels were harvested and evaluated with a micro-CT scanner and qualitative histology. Fusion rates were assessed by 2D sections and 3D reconstruction images and fusion was defined as intertransverse bridging.ResultsThere was 68% fusion rate in the allograft group and an extensive migration of graft material was noticed with a fusion rate of just 37% in the ABM/P-15 group. Qualitative histology showed positive osteointegration of the material and good correlation to scanning results.ConclusionsIn this PLF fusion model, ABM/P15 demonstrated the ability to migrate when lacking external stability. Due to this migration, reported fusion rates were significantly lower than in the allograft group. The use of ABM/P15 as i-Factor™ Flex may be limited to devices with fixation and bone defects.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Evaluation and Treatment of Patients With Thoracolumbar Spine Trauma: Novel Surgical Strategies

Treatment of thoracolumbar burst fractures has traditionally involved spinal instrumentation with fusion performed with standard open surgical techniques. Novel surgical strategies, including instrumentation without fusion and percutaneous instrumentation alone, have been considered less invasive and more efficient treatments. To review the current literature and determine the role of fusion in instrumented fixation, as well as the role of percutaneous instrumentation, in the treatment of patients with thoracolumbar burst fractures. The task force members identified search terms/parameters and a medical librarian implemented the literature search, consistent with the literature search protocol (see Appendix I), using the National Library of Medicine PubMed database and the Cochrane Library for the period from January 1, 1946 to March 31, 2015. A total of 906 articles were identified and 38 were selected for full-text review. Of these articles, 12 articles met criteria for inclusion in this systematic review. There is grade A evidence for the omission of fusion in instrumented fixation for thoracolumbar burst fractures. There is grade B evidence that percutaneous instrumentation is as effective as open instrumentation for thoracolumbar burst fractures. Does the addition of arthrodesis to instrumented fixation improve outcomes in patients with thoracic and lumbar burst fractures? It is recommended that in the surgical treatment of patients with thoracolumbar burst fractures, surgeons should understand that the addition of arthrodesis to instrumented stabilization has not been shown to impact clinical or radiological outcomes, and adds to increased blood loss and operative time. Strength of Recommendation: Grade A. How does the use of minimally invasive techniques (including percutaneous instrumentation) affect outcomes in patients undergoing surgery for thoracic and lumbar fractures compared to conventional open techniques? Stabilization using both open and percutaneous pedicle screws may be considered in the treatment of thoracolumbar burst fractures as the evidence suggests equivalent clinical outcomes. Strength of Recommendation: Grade B The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_12.

Biomechanical Evaluation of Internal Fixation of Pauwels Type III Femoral Neck Fractures: A Systematic Review of Various Fixation Methods.

BackgroundThe purpose of this systematic review was to investigate various fixation methods or implants used in the treatment of Pauwels type III femoral neck fractures.MethodsPubMed Central, OVID Medline, Cochrane Collaboration Library, Web of Science, Embase, and AHRQ databases were searched to identify relevant studies published until August 2017 with English language restriction. Studies were selected on the basis of the following inclusion criteria: biomechanical study of Pauwels type III femoral neck fractures and the use of dynamic hip screw (DHS) or multiple screw fixation or other devices for fixation of the fracture.ResultsA total of 15 studies were included in the systematic review. Eight studies were conducted using cadavers, six studies using sawbones, and one using a finite element model. During the mechanical testing, each study measured mechanical stiffness, failure to cyclic loading, failure to vertical loading of each fixation device. DHS was included in 11 studies, multiple screw fixation in 10 studies, and other devices in six studies. Baitner et al. and Samsami et al. reported that the mechanical stiffness of DHS was superior to three inverted triangular screw fixation. Hawks et al. and Gumustas et al. reported that using a transverse calcar screw can withstand vertical loading better than three inverted triangular screw fixation. In addition, there were some studies where instruments such as Intertan nail, locking plate or other devices showed excellent biomechanical properties.ConclusionsThere are a variety of methods and instruments for fixation of the Pauwels type III fractures. However, it is difficult to conclude that any method is more desirable because there are advantages and disadvantages to each method. Therefore, we should pay attention to the implant choice and consider adequate weight bearing affecting the stiffness of the implant.

Surgical Treatment of Spine Deformations after Neonatal Sepsis (The Analysis of Clinical Series)

Background. Neonatal sepsis presents one of the current issues in modern pediatrics. The orthopedic outcomes of such a state and the possibility of treatment, in particular by surgical spinal reconstruction, are rarely analyzed. Objective. To analyze pathology features and treatment outcomes in infants with vertebral complications resulted from neonatal sepsis.Material and Methods. The analysis of observation and treatment of 15 infants, who have undergone neonatal sepsis which led to vertebral lesion with subsequent gross kyphotic deformity formation, is presented.Results. Average age of infants was 2.5 months when spinal pathology was diagnosed. In 7 of the 15 observations, a local angular kyphosis was revealed when the acute phase of disease was already passed („cured“). The thoracic vertebrae were most often affected, mainly Th 7-8 vertebral bodies. Average kyphosis was 53°. All infants were operated on during the period from 2006 to 2017. Each had two-stage spinal reconstruction including the anterior spinal fusion using a titanium mesh cage filled with bone autografts, or an autogenous bone graft only. At the second stage, the instrumental correction and fixation of the spine with a multi-support laminar structure were performed. Average age of patients at the time of surgery was 14 months. Average value of kyphosis correction was 27°. Further correction and anterior spinal fusion were achieved when performing the incorporation of a titanium mesh cage with bone autografts. The histological and bacteriological examination of the surgical material did not reveal any signs of infection or inflammation. Correction of deformity and restoration of the supporting strength of anterior vertebral column as a result of surgery were achieved in all cases. Various complications in the early and late followup period were reported in a total of 7 cases. Repeated interventions were required in two patients: in one case in the early period (dislocation of the structure supporting hook) and in one case in the long-term period (graft resorption and kyphotic deformity relapse).Conclusion. One of the complications of neonatal sepsis is severe multilevel thoracic spondylitis, the outcome of which is the formation of severe kyphosis against the background of subtotal bone vertebral destruction. The principal possibility of radical spine reconstruction in infants with achievement of good anatomical and functional results is shown.

Méthode « Stepwise » de réduction arthroscopique et de fixation par plaque des fractures intra-articulaires du radius distal — évolution de la technique et de l’instrumentation

Arthroscopic visualisation of articular fractures of the distal radius can allow accurate reconstruction of the articular surface whilst minimising disruption of the dorsal capsular structures. In minimising the iatrogenic injury, this may lead to improved outcomes, though this remains unproven. Technically, one of the most challenging problems is how to hold the reduction while definitive fixation is employed. Where a volar locking plate is used, typically the plate is applied with proximal fixation, prior to the arthroscopy and articular manipulation. Two technical difficulties often ensue. Firstly maintaining accurate reduction of volar fragments after applying traction. Secondly, inserting distal locking fixation whilst holding the articular reduction under arthroscopic visualisation with the wrist in traction. It is difficult to simultaneously maintain traction for arthroscopy, and retraction to allow safe introduction of the drill and screws. The stepwise technique and the newly evolved fixation are presented. A trans FCR approach is used. The volar cortex is reduced under direct vision. The plate is fixed proximally with screws. Interference K-wire sleeves are then applied to the distal locking screw holes. K-wires are then introduced only as far as the volar fragments, using II. The dorsal fragments remain free. Traction is applied, dry arthroscopy performed using 1 2, 3 4 and 6R ports. The articular surface is reduced by the surgeon and provisionally fixed by advancing the wires. Traction is removed, correct wire length assessed with II. Using the cannulated system, peg length is calculated, the sleeve removed, the wire overdrilled, and cannulated locking pegs inserted over the wires. Some cases will be briefly presented to illustrate the technique. The technique may bring this technically challenging method into the repertoire of most capable wrist arthroscopists. As each step of the surgery is completed, the articular surface is brought closer to anatomical alignment, with increasing stability. The chance of a backwards step is minimised, decreasing frustration and optimising the result. An evolution of surgical technique and instrumentation for arthroscopic reduction and stable fixation of exploded articular fractures of the distal radius is presented.

Data analysis of 8 113 cases of limb deformities corrected by external fixation

To analyze the data of external fixation instruments (including Ilizarov instruments) used by QIN Sihe orthopaedic surgical team in the treatment of limb deformities in the past 30 years, and to explore the indications for the application of modern external fixation techniques in the correction of limb deformities and individual device configuration selection strategy. According to QIN Sihe orthopaedic surgical team, the use of external fixator between January 1988 and December 2017 was analyzed retrospectively. The total use of external fixation and the proportion of different external fixators were analyzed in gender, different operation time, different age, different parts, and different diseases. External fixators were used in 8 113 patients, 69 of them were used simultaneously in both lower extremity surgery, so 8 182 external fixators were used. Among them, there were 4 725 (57.74%) combined external fixators, 3 388 (41.41%) Ilizarov circle fixators, 64 (0.78%) single arm external fixators (including Orthofix), 5 (0.06%) Taylor space external fixators. There were 4 487 males (55.31%) and 3 626 females (44.69%). According to the analysis of different time periods, the number of external fixators increased year by year, and the number of applications increased after 2000. The main age of the patients was 11-30 years old, of which 1 819 sets (22.23%) were used at the age of 21-25 years. The use of the external fixator covered almost all parts of the limbs, with the ankle and toe areas being the most common, reaching 4 664 sets (57.00%), and the upper extremities the least, with 152 sets (1.86%). The 8 113 cases covered more than a dozen disciplines and more than 150 kinds of diseases. The top 5 diseases were poliomyelitis sequelae, cerebral palsy, deformity of lower extremity after spina bifida, traumatic sequelae, and congenital equinovarus foot. Ilizarov technique has been widely used in extremity deformity, disability, and complicated orthopedic diseases caused by vascular, lymphoid, nerve, skin, endocrine, and other diseases. The indication of operation is far beyond the scope of orthopedics. The domestic external fixator and its mounting tools can basically meet the requirements of various treatments. The technique of external fixation has entered a new era of tension tissue regeneration under stress control, natural repair of tissue trauma and deformity, and reconstruction of limb function.

SURGICAL TREATMENT OF ELDERLY AND SENILE PATIENTS WITH DEGENERATIVE CENTRAL LUMBAR SPINAL STENOSIS

Objective. To analyze the results of surgical treatment of patients of the older age group with central spinal stenosis at the lumbar level. Material and Methods. A total of 107 patients of elderly and senile age with clinically significant degenerative central stenosis of the spinal canal were treated. They were divided into two groups: patients in Group 1 underwent bilateral decompression of nerve roots through unilateral approach; those in Group 2 - nerve root decompression supplemented with interbody fusion and transpedicular fixation. Results. The surgery resulted in statistically significant reduction in pain, improvement of the quality of life, enlargement of spinal canal dimension parameters, and increase in the distance of walking. Statistical difference in the quality of life between Groups 1 and 2 was revealed for the indicator characterizing the psychological component of the SF-36 questionnaire (p = 0.03); there were no statistical differences for the remaining indicators. The key parameter for assessing central stenosis is the cross-sectional area of the dural sac. Conclusion. Preoperative examination of patients of the older age group should be comprehensive and include CT myelography with 3D reconstruction. The cause of nerve root compression in central stenosis is a combination of various factors in 41.9 % of cases. Differential surgical tactics provides an improvement in the quality of life in 80 % of cases. Excessive decompression does not improve the quality of life of patients. Instrumental fixation does not improve the outcome of surgical intervention and should be used only for clinically significant instability of the spinal motion segment.