Perforation Of Cortex Research Articles

Evaluation of Unilateral Transmigration of Cuspid Tooth in Mandibular Arch using 3D Imaging

Transmigration, where an impacted tooth crosses the midline, is a rare anomaly occurring in less than 1% of cases. Described initially by Nodine and Thoma and later termed by Ando et al. in 1964, it is more common in the mandibular arch and linked with malocclusion, impacted teeth, over-retained primary teeth, and supernumerary teeth. This case series examines seven instances of transmigrated mandibular canines using Cone Beam Computed Tomography (CBCT). The evaluated cases included Type I and Type II variations, with canines showing coronal and medio-lateral oblique placements. These placements led to complications such as labial cortex perforation, internal root resorption, and cortical thinning. CBCT was crucial for precise localization and visualization, aiding in accurate diagnosis and treatment planning. Transmigrated canines affected adjacent structures, causing cortical thinning and perforation. The superior imaging of CBCT was essential in identifying root resorption, often missed by traditional radiographs. Early diagnosis through CBCT enhances treatment planning, whether for orthodontic intervention or surgical removal, particularly when symptomatic or associated with other dental anomalies. This case series underscores the need for meticulous evaluation of transmigrated mandibular canines due to their potential impact on adjacent teeth and structures. The enhanced diagnostic capabilities of CBCT facilitate accurate assessment and improved treatment outcomes. Early detection and regular monitoring are crucial to prevent complications and maintain dental health. This study highlights the importance of CBCT in managing transmigrated canines and calls for increased clinician awareness for timely intervention.

Suprascapular nerve injury after reverse total shoulder arthroplasty. Correlation with screw out of vault penetration and functional situation. Prospective study.

Baseplate screws have been suggested as a possible cause of suprascapular neuropathy after reverse total shoulder arthroplasty (RTSA). This study aims to investigate the association between screw penetration out of the vault, electromyographic study and the clinical outcomes. 31 patients who underwent RTSA for cuff tear arthropathy were prospectively enrolled. They were followed up for a minimum of 24 months. All underwent computed tomography 6 months postoperatively in order to determine the extraosseous position of the screws (perforation of the second bone cortex and protrusion into the supra or infraspinatus fossa). Electrodiagnostic evaluation was performed preoperatively and postoperatively to stablish any relation between cortex perforation of the screw and SSN injury. Clinical outcomes pre and postoperatively (Constant score, ranges of motion, and VAS) of patients with and without documented injury were recorded. 14 patients (45.2%) had abnormal preoperative SSN electrodiagnostic study (chronic or disuse injuries) and 6 patients (19.4%) abnormal postoperative study (acute injury. Of these last 6 patients: 2 cases appeared over the pre-existing lesion and 4 appeared over an intact preoperative nerve, all of them affecting the infraspinatus branch of the SSN. Perforation of the second cortex was detected for 60% of superior screws and 40% of posterior screws. The mean lengths of the superior and posterior screws were 30 and 18.2 mm, respectively. Patients with screw perforation of the second cortex were assessed as having a high risk of nerve injury (40% vs. 9.5%). Preoperative SSN injuries do not have a significant clinical impact and do not predispose to an acute postoperative SSN lesion. The Constant Score and VAS scale for patients with acute SSN injuries were not statistically different than those without SSN injury. Extraosseous position of the screw increases the probability of a SSN injury to 31%. This risk is higher with the posterior screw, which leads us to question whether it is really necessary to use it.

How many anchors to use in arthroscopic Bankart repairs? A biomechanical study of postage-stamp glenoid fractures.

Deciding how many anchors to use in a Bankart repair is challenging because of the desire to enhance stability while avoiding a postage-stamp fracture of the glenoid rim. This controlled laboratory study investigated load to fracture of the anterior glenoid rim after drilling holes of varying number and diameter and inserting anchors of 2 different types and sizes, with and without perforation of the medial cortex of the glenoid, creating postage-stamp fractures using a metallic humeral head that was compressed against the anterior glenoid rim. A destructive model with a servohydraulic load frame was used to test 46 synthetic scapulae with compressive strength and elastic modulus similar to that of a human glenoid. Load to fracture of the intact glenoid was compared with groups with a varying number of anchor holes of different diameters, with anchors of different sizes and types, and with anchors perforating or not perforating the glenoid medial cortex. The percentage of force to fracture an intact specimen was used to identify relative risk of fracture: low risk >75%, moderate risk 75%-50%, and high risk <50% of intact load. The load to fracture of intact glenoids was 1276±42 N. Loads decreased linearly as the number of holes drilled on the glenoid rim increased. Compared with the 1.6-mm group, the 3.0-mm group had significantly lower glenoid rim strength in specimens with 4, 5, and 7 holes (P=.013, .032, and .045, respectively). All-suture anchors in 1.6-mm holes did not alter the glenoid rim strength, and up to 5 anchors were associated with low risk of fracture. Load to fracture was significantly higher with 3.0-mm rigid core bioabsorbable anchors with 4 anchors (1081±6 N) compared with the 4-hole condition (838±107 N; P=.033). Perforating the glenoid medial cortex with five 1.6-mm anchors significantly weakened the glenoid rim to 58% of intact (P=.012). Perforating the medial cortex weakened the glenoid rim to 52% and 42% (P<.001 for both) of intact in the 3.0-mm 4-anchor and 5-anchor constructions, constituting moderate and high risk of fracture, respectively. Up to five 1.6-mm all-suture anchors and four 3.0-mm bioabsorbable rigid-core anchors were associated with low risk of fracture of the glenoid rim. Smaller diameter all-suture anchors best preserved structural integrity of the glenoid rim, whereas tunnel enlargement and perforation of the glenoid medial cortex were associated with moderate or high risk of a postage-stamp fracture.

387 A Multidisciplinary Approach to the Sequelae of Dental Trauma in a Child: A Radicular Cyst

Abstract Background A radicular cyst is an inflammatory cyst of odontogenic nature, formed by cells of Malassez in the periodontal ligament, which are stimulated and proliferate, following insults such as dental trauma. First stage treatment is commonly orthograde root canal treatment (RCT), followed by apicectomy or extraction and enucleation of the lesion +/- bone grafting and replacement tooth. Presenting problem This case illustrates the sequelae of a repeated dental trauma to a LR1 in a child, which was endodontically treated and obturated with Mineral Trioxide Aggregate (MTA). After a second dental trauma, a painful intra-oral swelling developed with mobility and tenderness of adjacent teeth. The swelling increased after extraction of the LR1, leading to enucleation by the Oral and Maxillofacial Surgery Surgeon (OMFS). Investigations Plain radiographic films, cone beam CT (CBCT) imaging revealing a radiolucent area extending from LR3 to LL3, 2 x 1.1 x 1.9cm, with buccal perforation and thinning of the lingual cortex. Clinical management Across a 6-year period restoration and orthograde RCT was completed LR1. A second dental trauma 4 years later necessitated extraction of LR1. Subsequent acute swelling and pain lead to further radiological assessment which was consistent with a giant cell lesion. Following enucleation, histopathology confirmed a radicular cyst, with pulse granuloma and reactive changes. Bony infill was noted and the LR1 was replaced with a resin-retained bridge. Discussion This case aims to raise awareness of the sequelae of dental trauma in children and the multidisciplinary approach to their care.

Prevalence of Pre-Existing Lingual Cortex Perforation Prior to Extraction of Mandibular Third Molars

The research aims to determine the relationship between the mandibular third molars and the nearby lingual cortical bone as well as to determine the frequency of lingual cortex perforation.The analysis was carried out by “CBCTs (cone beam computed tomographic scans)” of 18-65 years old patients. Lingual cortex fenestration at both root tips was observed. Almost three-quarters of radiographs showed the majority of the lingual area on the upper portion of a root (51.2% and 52.8%). The most lingual region and the area surrounding the root tip were both 1.25 mm thick. Mandibular third molars and perforated across both base levels were shown to be significantly related (P value.001). More than 50% of patients had lingual cortical perforation brought on by mandible third-molar teeth. The likelihood of lingual cortical rupture following extraction of the mandibular third molars is a sign of a prior problem rather than surgery.

The design method of the digital sequential tooth-sectioning guide for the extraction of mandibular impacted third molars

Objective: To explore a method for digitally designing and fabricating a sequential tooth-sectioning guide that can assist in the extraction of mandibular horizontal impacted third molars, preliminarily evaluate its feasibility and provide a reference for clinical application. Methods: Twenty patients with mandibular low level impacted third molars who visited the Department of General Dentistry, Peking University School and Hospital of Stomatology from March 2021 to January 2022 were selected. Cone-beam CT showed direct contact between the roots and mandibular canal, and full range impressions of the patients' intraoral teeth were taken and optical scans of the dental model were performed. The patients' cone-beam CT data and optical scan data were reconstructed in three dimensions, anatomical structure extraction, registration fusion, and the design of the structure of the guide (including crown-sectioning guide and root-sectioning guide) by Mimics 24.0, Geomagic Wrap 2021, and Magics 21.0 software, and then the titanium guide was three dimension printed, and the guide was tried on the dental model. After confirmation, the guide was used to assist the dentist in the operation. We observed whether the guide was in place, the number of tooth splitting, the matching of tooth splitting with the preoperative design, the operation time, and whether there were any complications. Results: In this study, 20 sectioning guides were successfully printed, all of them were well fitted in the patients' mouth, the average number of section was 3.4 times, the tooth parts was better matched with the preoperative design, and the average operative time of the guides was (29.2±9.8) minutes without complications such as perforation of the bone cortex. Conclusions: The use of sequential sectioning guides to assist in the extraction of mandibular impacted third molars was initially validated to accurately replicate the preoperative sectioning design, and is expected to provide a digital solution to improve surgical precision and ensure safety. Further studies with larger sample sizes are needed to evaluate its accuracy and safety.

Lumbar Pedicle Morphometry of Dry Vertebral Columns in Relation to Transpedicular Fixation: A Cross-Sectional Study From Central India.

The lumbar vertebrae are the largest vertebrae of the vertebral column, which support the maximum body weight. There has been an increased focus on transpedicular spinal fixation for addressing various lumbar spine pathology. However, its safety and efficacy require precise knowledge of the lumbar pedicle anatomy. Mismatched size of screw and pedicle may lead to failure of instrumentation. It may result in cortex perforation or pedicle fracture and loosening of the pedicle screw. The oversizing of the pedicle screw can result in dural tears, leakage of the cerebrospinal fluid, and injuries to the nerve root. As the racial variations in the anatomy of a pedicle are well known, this study was performed to assess the morphological parameters of the lumbar vertebrae pedicles in the Central Indian population so that the appropriate sizes of pedicular implants can be selected. The present study was conducted at a tertiary-level hospital and medical college on dry lumbar vertebrae specimens available in the department of anatomy. The measurement of morphometric parameters of the lumbar vertebrae pedicles was performed in 20 dry lumbar specimens using vernier calipers and a standard goniometer. The morphometric parameters included in the study are pedicle transverse external diameter (pedicle width), pedicle sagittal external diameter (pedicle height), transverse angle of the pedicle, and sagittal angle of the pedicle.Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) system version 25 (Chicago, IL: SPSS Inc.). The broadest external transverse diameter was at the L5 level, with a mean of (17.54±1.6 mm) in the lumbar vertebrae. The broadest external sagittal pedicle diameter was at the L1 level (13.7±0.88 mm). The maximum transverse angle of the pedicle was at L5 with a mean of 25.39±3.10°. The maximum sagittal angle was at L1 with a mean of 5.44±0.71°. The increased concern regarding the internal fixation of the spine with pedicle screw systems created the need to have almost accurate anatomical knowledge of lumbar pedicles. Due to the dynamic nature of the lumbar spine and the body's load, maximum degeneration occurs at this spine segment, making it the most commonly operated region of the vertebral column. In our study, pedicle dimensions are comparable to populations of other Asian countries. However, the pedicle dimension of our population is lower than the White American population. This morphological variation of pedicle anatomy will help surgeons choose appropriate size screws and optimum angulations to insert the implant, decreasing complications.

FEMORAL SHAFT-NAIL RADIUS OF CURVATURE DISCREPANCY: PREOPERATIVE ANALYSIS OF FEMORAL SHAFT ANTERIOR RADIUS OF CURVATURE USING IMAGING AND ITS ASSOCIATION WITH ANTERIOR CORTICAL IMPINGEMENT DURING FIXATION OF FEMORAL PATHOLOGY

Long femoral nails for neck of femur fractures and prophylactic fixation have a risk of anterior cortex perforation. Previous studies have demonstrated the radius of curvature (ROC) of a femoral nail influencing the finishing point of a nail and the risk of anterior cortex perforation. This study aims to calculate a patients femoral ROC using preoperative XR and CT and therefore nail finishing position.We conducted a retrospective study review of patients with long femoral cephalomedullary nailing for proximal femur fractures (OTA/AO 31(A) and OTA/AO 32) or impending pathological fractures at a level 1 trauma centre between January 1, 2015 and December 31, 2020 with both full length lateral X-ray and CT imaging. Femoral ROC was calculated on both imaging modalities. Outcomes measured including nail finishing position, anterior cortex encroachment and impingement. The mean femoral ROC was 1026mm on CT and 1244mm on XR. CT femoral ROC strongly correlated with nail finishing point with a spearmans coefficient of 0.77. Additionally, femurs with a ROC &lt;1000mm were associated with a higher risk of anterior encroachment (OR 6.12) and femurs with a ROC &lt;900mm were associated with a higher risk of anterior cortex impingement (OR 6.47).To our knowledge this is the first study to compare a measured femoral ROC to nail finishing position. The use of CT to measure femoral ROC and to a lesser extent XR was able to predict both nail finishing position and risk of anterior cortex encroachment. Preoperative XRs and CTs were able to identify patients with a small femoral ROC. This predicted patients at risk of anterior cortex impingement, anterior cortex encroachment and nail finishing position. We may be able to select femoral nails that resemble the native femoral ROC and mitigate the risk of anterior cortex perforation.

Use of a Retrograde Guidewire to Direct an Antegrade Femoral Nail.

Antegrade intramedullary nailing for the treatment of diaphyseal femur fractures may present challenges in obtaining appropriate positioning of the distal tip of the nail. Known mismatch between the radius of curvature of commonly used nails and the anatomic bow of the femur may result in impingement or perforation of the anterior cortex of the distal femur. Additionally, some unique scenarios may arise that complicate traditional antegrade wire passage. We report our surgical technique and clinical experience using a retrograde guidewire to direct an antegrade femoral nail to aid in obtaining a desired central location of the distal nail tip. [Orthopedics. 2023;46(2):e132-e135.].

Prospective study on functional and radiological outcome of suprapatellar approach for intramedullary nailing using semi extended knee position in tibial shaft fractures

Fractures of the tibia are one of the most common orthopedic injuries occurring most often in younger patients. Tibial fractures are frequently associated with high energy trauma mechanisms. Intramedullary nailing is one amongst the preferred treatment modalities for mid shaft tibial fractures. Standard Tibial nailing entry portals used are the infrapatellar and parapatellar approaches. Suprapatellar tibial nailing is a recent advance in the surgical technique for treatment of tibial shaft fractures. This method has shown reduced operative and fluoroscopy time and lesser pain incidence in previous studies. The semi extended position of the knee also allows for countering the deforming effect of the musculature pull of the quadriceps mechanism and also easier fluoroscopy imaging. The suprapatellar technique decreases the risk of perforation of posterior cortex by placing the starting point in line with the medullary canal. This technique also helps to reduce Varus and Valgus deformity by using the femoral trochlear groove as a guide to the starting point which maintains the mechanical axis of the lower extremity.Objectives of the study: To assess Functional outcomes of suprapatellar approach in mid shaft tibial fractures by Lower extremity functional score (LEFS).To assess Radiological outcomes of suprapatellar approach in mid shaft tibial fractures by the Radiological Union in Tibia Score (RUST).Study design: Prospective interventional studyStudy period: October 2019 to May 2021Source of data: Patients admitted with closed mid shaft tibial fractures as an inpatient in the Department of Orthopaedics, Victoria hospital and Bowring and Lady Curzon hospitals attached to BMCRI were included in the study satisfying the inclusion and exclusion criteriaMethodology: 20 patients with closed or open (type 1 and 2) mid shaft tibial fractures were treated using the suprapatellar approach. Functional outcome was measured using the Lower extremity functional score and radiological outcome was measured using the Radiological union in tibia score at immediate and last follow up intervals.Results: Our study group comprised of 20 patients between the ages 20 to 60 years. LEFS showed a statistically significant improvement from 23.35 at 6 weeks to 69.25 at 12 months. In our study analysis out of 20 patients, 11 patients had excellent LEFS score, 7 patients had good LEFS score and 2 patients had fair LEFS score. Also in our study 100% patients achieved union by 20 weeks with a mean RUST score of 7.4 at 6 weeks compared to a mean RUST score of 14.15 at 12 months.Conclusion: Suprapatellar nailing has shown shorter fluoroscopy less manoeuvrability and operative time, excellent to fair functional outcome of lower limb and reduced incidence of valgus and varus malalignment postoperatively. Suprapatellar nailing is a promising technique of tibial fracture fixation with satisfactory radiological and functional outcomes postoperatively.

Mylohyoid Ridge as a Predictor of Available Bone for Implant Placement: A Cone-Beam Computed Tomography (CBCT) Retrospective Observational Study.

Introduction: The posterior mandibular region, due to the presence of vital structures, poses a high risk during implant placement because of its susceptibility to neurovascular injury and perforation of the lingual cortex. A breach in implant length and available bone height may lead to serious intraoperative and postoperative complications. Prediction of the exact location of the inferior alveolar nerve and submandibular fossa anatomy is a prerequisite for ideal implant placement, which is always not possible with conventional radiographic and clinical techniques.Materials and methods: One hundred ten cone-beam computed tomographies (CBCTs) of patients were acquired from the radiological archives of a radiological center in Chennai. DICOM files from CBCT were exported to Bly Sky Plan software. Cross-sections of the second molar and first molar were extracted following the inclusion criteria. The linear dimension between the mandibular canal and mylohyoid ridge and anatomic variables of the submandibular fossa were measured digitally on the left and right sides using software measuring tools. Descriptive statistics were done. The unilateral and bilateral site and gender differences were evaluated. Bone height superior to the mandibular canal was correlated with the submandibular fossa parameters; depth of undercut in the vertical and horizontal directions; and angle of the undercut.Results: The mandibular canal was on average 5.5 mm and 4 mm inferior to the Mylohyoid ridge in the second molar region and first molar region, respectively, with the right and left sides showing no statistically significant difference. The depth of fossa undercut in vertical and horizontal dimensions was higher in the second molar region compared to the first molar region. The height of the deepest point of the undercut in the vertical dimensions showed a positive correlation with the bone available between the mandibular canal and the mylohyoid ridge.Conclusion: Keeping 2 mm of safety factor in consideration, implants can be safely placed up to the mylohyoid ridge in 100% of cases and 2 mm below the mylohyoid ridge in 78.9% of cases in the mandibular second molar region. In keeping with a safety factor of 2 mm, implants can be safely placed up to the mylohyoid ridge in 82.6% of cases and 2 mm below the mylohyoid ridge in 43.1% of cases in the first molar region. A more pronounced undercut was seen in the second molar region than in the first molar region. Deeper fossa undercuts in vertical dimension are associated with more inferior positioning of the mandibular canal.

A Simple Method to Improve Detection of Femoral Nail Abutment in the Distal Femur: A Computer Modeling Study.

Proximal femur fractures are more frequently treated with long femoral nails. Lateral radiographs are used to assess the nail position in the distal femur. However, because of the asymmetric shape of the distal femur, standard lateral radiographs alone are suboptimal for assessing anteriorly positioned nails in the distal femur. Consequently, instances of nail abutment or even perforation might be missed intraoperatively. Using a three-dimensional (3D) modelling approach, we asked: When the nail is in the anterior fifth of the canal, will rotating the femur to align the simulated x-ray beam with the anterior femoral condyles instead of the posterior femoral condyles increase the diagnostic accuracy of detecting nail perforation of the anterior cortex? 3D models of 42 unilateral femora from a population sample representative of patients with hip fractures (mean age of 76 ± 7 years, 10 males and 32 females, and 16 left and 26 right femora) were used. The patients had a mean height of 158 ± 9 cm; 27 femora were from Asians and 15 were from Caucasians. Clinically appropriately sized nails had already been virtually implanted previously as part of a quantitative nail fit assessment study. In a preliminary step, the mean angles of inclination of the distal anterior supracondylar region were quantified using four axial sections of the distal femur. For the femora with the nail tip in the anterior fifth of the canal, projections representing a lateral radiograph were generated along with rotated projections at mean angle (5°, 8°) rotations, with the anterior femoral condyles aligned, and anterior femoral condyle alignment followed by internal and external rotation to detect maximum nail perforation. The distance from the nail to the distal anterior cortex was measured for each rotational projection and used to detect anterior nail perforation. The accuracy of detection was assessed using the area under the curve (AUC) of the receiver operating characteristic (ROC) analysis. Rotating the 3D models by aligning the x-ray beam with the anterior femoral condyles improves the diagnostic ability of detecting anterior nail perforation compared with standard lateral radiographs. The AUC increased with rotation from 0.50 (95% confidence interval 0.50 to 0.50) on the lateral projection to 0.73 (95% CI 0.57 to 0.88, difference = -0.23; p = 0.004) at 5° of rotation, 0.77 (95% CI 0.62 to 0.93, difference = -0.27; p = 0.001) at both 8° of rotation and with the anterior femoral condyles aligned, and to 0.82 (95% CI 0.67 to 0.97, difference = -0.32; p < 0.001) with internal/external rotations past the anterior femoral condyles. There were no differences in accuracy between the four methods of rotation. This study shows that rotating the femur to align the anterior femoral condyles on a lateral radiograph and then internally/externally rotating it, improves the accuracy assessed via the AUC of detecting anterior perforation when long nails are positioned in the anterior fifth of the distal femur. This approach can easily be used in a clinical setting. Intraoperatively, the image intensifier can be rotated around the leg to produce an image with the anterior femoral condyle aligned, providing surgeons with an opportunity to identify and improve the nail's position or exchange the nail while the patient is still under anesthesia.

Moderate tibial loading and treadmill running, but not overloading, protect adult murine bone from destruction by metastasized breast cancer

Osteolytic bone lesions, which develop in many metastatic breast cancer patients, impair bone integrity and lead to adverse skeletal related events that are difficult to treat and sometimes fatal. Moderate mechanical loading has been shown to suppress osteolysis in young mice with breast cancer. In this study, we aimed to investigate the dose-dependent effects of mechanical loading on protecting the integrity of adult skeletons with breast cancer. Localized tibial loading and aerobic treadmill running with three levels of varying intensity were tested in a syngeneic mammary tumor bone metastasis model. Adult C57BL/6J female mice (14-week-old, N=88 mice) received intra-tibial injections of Py8119 triple-negative murine breast cancer cells or PBS and underwent 4 to 5weeks of exercise or acted as sedentary/non-loaded controls. The bone structure was monitored longitudinally with weekly in vivo micro-computed tomography imaging, while the cellular responses in bone and marrow were examined using immunohistochemistry. Moderate treadmill running (16m/min, 50min/day, 5days/week, and 5weeks) and tibial loading (4.5N, 630 με, 4Hz, 300cycles/day, 5days/week, and 4weeks) suppressed tumor-induced bone destruction, as evaluated by full-thickness perforation of tibial cortex and the volume of osteolytic lesions in the cortex. In contrast, tibial loading at higher magnitude (8N, 1100 με) induced woven bone and accelerated bone destruction, compared with the non-loaded controls. The three exercise regimens differentially affected osteocyte apoptosis, osteocyte hypoxia, osteoclast activity, bone marrow vasculature, and tumor proliferation. In conclusion, the relationship between exercise intensity and the risk of breast cancer-induced osteolysis was found to follow a J-shaped curve in a preclinical model, suggesting the need to optimize exercise parameters in order to harness the skeletal benefits of exercise in metastatic breast cancers.

Pedicle screw accuracy in thoracolumbar fractures- is routine postoperative CT scan necessary?

BackgroundWhile several studies report on accuracy rates of pedicle screws, risk factors associated with inaccurate pedicle screw positioning in patients with thoracolumbar fractures are reported rarely. CT scan as a routine postoperative control is advocated by various authors, however its necessity remains unclear.MethodsTwo hundred forty-five patients were included in this retrospective study. Percutaneous dorsal instrumentation was most commonly performed (n = 201). Classification of Zdichavsky et al. and Rao et al. were used to classify screw misplacement and anterior perforation was further evaluated according to the extent of perforation (< 2 mm; > 2 mm). Multivariate analysis was performed to identify risk factors for misplacement of screws.ResultsOne thousand sixty-eight pedicle screws were inserted in 245 patients. Misplacement was found in 51 screws (4.8%) in 42 patients (17.1%) according to the classification of Zdichavsky et al. and in 75 screws (7.0%) in 64 patients (26.1%) according to the classification of Rao et al.. An anterior perforation of the vertebral cortex was found in 56 screws (5.2%). Multivariate analysis showed fracture location in the upper thoracic (p = 0.048) and lumbar spine (p = 0.013) to be the only independent predictors for screw misplacement. In addition a significant correlation between pedicle diameter and the occurrence of screw malposition was found (p = 0.003). No consequences were drawn from postoperative routine CT in asymptomatic patients.ConclusionAn overall low rate of screw misplacement was found with fracture location in the upper thoracic and lumbar spine being the only factors independently associated with the risk of screw misplacement. No consequences were drawn from postoperative routine CT in asymptomatic patients. Therefore its use has to be discussed critically.

The Wagner Modular (S2) Prosthesis for Proximal Femur Bone Loss ; Prospective Study of 19 Cases

Background: Wagner proximal femur prosthesis is the versatile modular implant. Study Design: Prospective study Setting: Department of Orthopaedic Surgery Dow University of Health Sciences / Civil Hospital Karachi, from January 2013 to December 2019. Methodology: Total 19 patients of both genders with proximal femur bone loss due to tumor, implant failure for proximal femur fixation, comminuted intertrochanteric fracture, and failed arthroplasty included in the study. After taking written informed consent, detailed demographics including age, gender, indication of wagner prosthesis, and wagner stem type were recorded. Among all the patients 11 patients received total hip replacement and 8 patients received bipolar. Complications associated with procedure were recorded. Outcomes were assessed by Merle D Aubgine scale. Results: Total 19 patients were included in the study who were operated with wagner prosthesis for proximal femur bone deficit problems. 7 (37%) patients were male and 12 (67%) were female , between age of 16 to 70. 13 (68%) patient have proximal femur problem on right side and 6(32%) patient on left side .10 Patient have proximal femur fixation problems and 9 with proximal femur tumor. Modular wagner prosthesis used in all patients . Per-operative one (5%) patient have perforation of cortex and One (5%)patient posterior hip dislocation on next day . Two (11%) patient had per-operative fracture . Maximum follow-up is from 6.3 years to minimum 6 months. One patient with metastasis died within four weeks of surgery. Outcome measured with modified Merle D Aubgine scale showed no excellent , good in 15(79%) , fair 3 (16%), poor 1(5%). Conclusion: Wagner proximal femur modular implant is a versatile implant for proximal femur fixation failure and after proximal femur resection in tumor patients. It is modular with variable options to make stable hip joint. It is cheap as comparative to proximal femur replacement implant for tumor. Keywords: Implant failure, Proximal femur, Tumor, Wagner implant.

Fixation of Displaced Midshaft Clavicular Fracture in Adult by Intramedullary Elastic Rod

Background: Intramedullary elastic rod fixation of midshaft clavicular fracture results in rapid free movement of the shoulder and an earlier return to daily activities than the conservative treatment. In comparison with plate fixation, the procedure is less invasive, with no loss of fracture haematoma, rapid union, and less infection. No major surgery for removal with less injury to surrounded neurovascular structures. A smaller incision is required with superior cosmesis. Objective: To study the short-term results of treatment of displaced fractures of the middle third of the clavicle using percutaneous elastic intramedullary nails Patient and Methods: This prospective study was carried out on twenty patients with displaced fractures of the middle third of the clavicle presented to the Hospital and treated by percutaneous elastic intramedullary rod between November 2019 and May 2020. Results: At the end of the follow-up period, the mean score was 89.70 ± 13.55 ranging from 48 to 100 according to the modified Constant and Murley shoulder score. Fourteen patients (70%) had excellent results, four patients (20%) had good results, one patient (5%) had a fair result, and one patient (5%) had a poor result. Conclusion: Elastic stable intramedullary nailing (ESIN) is an image dependant procedure indicated best for young medically free patients with acute simple 2 part middle third clavicle fracture. Delay in surgery may necessitate open reduction. Hammering is not recommended to avoid dorsolateral cortex perforation.

A new technique for cement plug removal in hip and knee arthoplasty exchange

Removal of cement and especially the distal cement plug during cemented arthroplasty replacements is key to the success of the surgery, but can be challenging for the surgeon. The methods employed for this step can be very varied, ranging from removal with the aid of rasps, drills, ultrasonic techniques, to bone windows for direct access to the plug. These techniques can sometimes lead to perforation of the bone cortex and even to the production of uncontrolled fractures that prevent safe implantation of the new implant.The aim of this study is to review the different cement removal techniques and to evaluate the efficacy of a new technique, which allows the cement plug to be removed in a safe and controlled manner, avoiding the need for osteotomies. A customised guide is used for this purpose. This allows an effective and leak-free re-cementing of the new implants.We present 3 cases of distal cement removal using a customised guide that allows the cement plug to be broached. In all 3 cases, after cement removal, the implantation of longer stems with correct cementation was achieved.It should be noted that the target population in all cases is an elderly Spanish population, a population of short stature with curved femurs and poor bone quality; these characteristics make perforation and intraoperative fractures much more likely. However, in our two patients there were no cortical perforations. The mean time for plug removal was 22min. ConclusionThe use of customised guides for cement plug removal during cemented hip and knee arthroplasty replacement is safe and effective.

Functional Outcomes of Pediatric Both Bone Fractures Fixed with Titanium Elastic Nails: : A Hospital Based Study

Background: Successful treatment of both bone fractures depends on the restoration of normal alignment and full recovery of range of motion that can be achieved by either closed reduction and casting or surgical intervention. Number of surgical treatment modalities have been mentioned for unstable pediatric both bone fractures that includes Kirschner wire fixation, plating, external fixation and elastic intramedullary nailing&#x0D; Methods: This was descriptive cross-sectional study performed from January 2016 to December 2019. A total of 85 diaphyseal pediatric forearm fractures were treated surgically with TENs during this period. Functional outcomes and complications were analysed 6 months after surgery.&#x0D; Results: The mean age of patients in our study was 10.67±1.88. There were 50 (64.1%) male and 28 (35.9%) female. Incidence of fracture is higher in left side 47 (60.2%) in comparison to right side 31 (39.8%). Thirteen (16.7%) fractures were in proximal third, 50 (64.1%) in middle third and 15 (19.2%) in distal third of both bone forearm.There were excellent outcomes in 91%, good outcomes in 6.4% and fair results in only 2.6% of patients.Seven different types of complications were noted including skin irritation 8 (10.2%), cortex perforation in 2 (2.5%) and iatrogenic fracture in 1 (1.3%) case.&#x0D; Conclusions: Titanium elastic nailing is excellent treatment option for displaced unstable pediatric both bone fractures especially in elderly children. This is technically easy, minimally invasive procedure where bone healing is relatively fast, implant removal is easy with excellent cosmesis of skin without long ugly scar in forearm.

Una nueva técnica para la retirada del tapón de cemento en recambios de artroplastia de rodilla y cadera

Removal of cement and especially the distal cement plug during cemented arthroplasty replacements is key to the success of the surgery, but can be challenging for the surgeon. The methods employed for this step can be very varied, ranging from removal with the aid of rasps, drills, ultrasonic techniques, to bone windows for direct access to the plug. These techniques can sometimes lead to perforation of the bone cortex and even to the production of uncontrolled fractures that prevent safe implantation of the new implant.The aim of this study is to review the different cement removal techniques and to evaluate the efficacy of a new technique, which allows the cement plug to be removed in a safe and controlled manner, avoiding the need for osteotomies. A customised guide is used for this purpose. This allows an effective and leak-free re-cementing of the new implants.We present 3 cases of distal cement removal using a customised guide that allows the cement plug to be broached. In all 3 cases, after cement removal, the implantation of longer stems with correct cementation was achieved.It should be noted that the target population in all cases is an elderly Spanish population, a population of short stature with curved femurs and poor bone quality; these characteristics make perforation and intraoperative fractures much more likely. However, in our two patients there were no cortical perforations. The mean time for plug removal was 22 minutes. ConclusiónThe use of customised guides for cement plug removal during cemented hip and knee arthroplasty replacement is safe and effective.A new technique for the removal of the cement plug in knee and hip arthroplasty replacements

Clinical Outcome of Percutaneous IntramedullaryFixationfor Midshaft ClavicularFractures Using Elastic Stable Nails.

This study investigated the clinical outcomes of fixation of displaced middle-third clavicular fractures using percutaneous elastic stable intramedullary nails. This study included sixty patients with a mean age of 26.40 ± 8.91 years (16-53 years) presented with a displaced middle third fracture of the clavicle. According to the Robinson classification, 48 cases (80%) were type 2B1, 9 cases (15%) type 2B2 and 3 case (5%) 2A1. All cases were treated by elastic intramedullary nails and followed up for at least 12 months. At the end of the twelve months' follow-up period, the mean Constant Shoulder score was 95.70 ± 13.55, ranging from 48 to 100. 54 patients (90%) had excellent results, 3 patients (5%) had an adequate result and 3 patients (5%) had a poor result. There was a statistically significant relationship between the final score and age and associated medical conditions. 1. Elastic Stable Intramedullary Nailing is an image-dependent procedure indicated best for young medically free athletes with simple 2-part middle third clavicle fracture. 2. Hammering is not recommended to avoid dorsolateral cortex perforation. 3. The most common complication is medial skin irritation because of the subcutaneous position of the clavicle as well as the sharp end of the cut nail.