Posterior Soft Tissues Research Articles

Biomechanical analysis of the effect of postero-latero-central tibial plateau fractures in the knee joint: Can posterior soft tissues prevent instability? A finite element study.

BackgroundAlmost 86 % of all tibial plateau fractures involves the failure of the postero-latero-central region of the tibial plateau. Surgical treatment of this region is technically demanding and in case of limited depression, it's occasionally chosen to leave them untreated. The aim of the study is to numerically check to what extent this choice can be accepted avoiding inferior outcomes (i.e. joint instability), and to analyze posterior soft tissues role in presence of this fractures. MethodsStarting from a previous validated finite element model with baseline structures, several configurations were developed by inserting posterior soft tissues and postero-latero-central fracture, with different articular depressions. Squat motion was numerically simulated and tibio-femoral kinematics were compared among configurations. FindingsAn increasing step-off led to a progressive joint instability, especially in the first 35°-40° of flexion. Posterior soft tissues showed to be beneficial in initial stabilization and early flexion. Tibial Axial Rotation didn't show any restorative effect of posterior soft tissues on knee kinematics. Tibial Antero-Posterior Translation is the most significant biomechanical parameter, showing posterior soft tissues restoring native antero-posterior translation, completely for 1-mm step-off fracture, only partially for 2-mm step-off fracture, and not sufficiently for 3-mm step-off fracture, at least in the first 30° of flexion. InterpretationThe results suggest that postero-latero-central fractures with step-off ≥2 mm should be treated to restore articular kinematic, whereas fractures with step-off <2 mm need a broad evaluation to assess the effective need of surgery. These information can be valuable for surgeons, to aid their decision to surgically operate or not.

Acute Effects of Handheld Vibration Massage on Posterior Shoulder Soft Tissues.

Interventions using vibration stimulation have been recognized for their potential for increasing range of motion (ROM) without compromising muscle strength. Handheld vibration massagers can efficiently deliver vibration therapy to the shoulder joint and may be a potential treatment. To evaluate the effects of vibration massage using a handheld device on the soft tissues of the posterior shoulder joint, particularly on internal rotation (IR) passive ROM and external rotation (ER) muscle strength. Crossover study design. A crossover study with a 5-min vibration massage and passive control condition was conducted in healthy male volunteers (mean age 20.5 ± 1.7 years). Vibration massage was applied to the posterior shoulder soft tissues of the dominant arm, with no intervention under control conditions. IR-ROM (vertebral level and in abduction) and strength of the external rotators (isometric and isokinetic) were measured before and immediately after the intervention. Vertebral levels were calculated as a ratio of lengths (ratio decreases with increased mobility). IR-ROM in abduction, the angle was measured. Statistical analysis was performed with two-way repeated measures ANOVA and paired t-test (Bonferroni correction). Vibration application decreased (improved) vertebral level IR ROM by -4.1% (p < 0.01, d = 0.445) and increased abduction position IR ROM by 11.4° (p < 0.01, d = 0.694). These changes exceeded the 95% confidence interval for the minimum detectable change. By contrast, the control condition produced no changes. IR-ROM (vertebral level and abduction) immediately after the intervention showed significant differences between the control and vibration conditions (p = 0.036, d = 0.273; p = 0.048, d = 0.483, respectively). Muscle strength did not show any interaction, time, or between-condition effects. A massage using a handheld vibration massager applied to the posterior shoulder soft tissues increased IR-ROM without negatively affecting muscle strength, suggesting its potential use as a means of warming up. Level 3.

Evaluation of arthrokinematics and posterior soft tissues of the ankle during ankle dorsiflexion using ultrasound

BackgroundArthrokinematics (caudal and posterior movements of the talus) and posterior soft tissues of the ankle during ankle dorsiflexion have not been objectively evaluated in detail. This study aimed to investigate the characteristics of arthrokinematics and posterior soft tissues of the ankle during ankle dorsiflexion using ultrasound. MethodsThirteen healthy adults participated in the study. Participants whose passive dorsiflexion range of motion (ROM) of the ankle joint was <35° were classified as the restricted group (n = 6), and participants whose passive ankle dorsiflexion ROM was ≥35° were classified as the control group (n = 7). Passive ankle dorsiflexion was performed to measure the ankle arthrokinematics. Strain elastography was performed to measure the elasticity of the flexor hallucis longus (FHL) and Kager's fat pad (KFP) at each dorsiflexion angle. ResultsA significant difference in the posterior movement of the talus at the ankle dorsiflexion of 30° was observed between the two groups (P = 0.04). The elasticity of the restricted group was increased at all angles in both FHL and KFP (P < 0.05). ConclusionThis study showed that it is possible to objectively evaluate the direction of ankle arthrokinematics and posterior ankle soft-tissue restrictions using ultrasound.

A Staged Protocol for Treatment of High-Energy Tongue-Type Calcaneus Fractures: Surgical Technique and Case Series.

Displaced tongue-type calcaneus fractures are frequently associated with severe soft tissue injuries, and urgent relief of the displaced tongue fragment on the posterior soft tissues is essential to preventing soft tissue complications. If there is a complex articular injury, the soft tissue envelope often needs time for swelling to resolve to allow for a safe open anatomic reduction because premature open reduction internal fixation is often associated with increased complications. We have found that in high-energy tongue-type calcaneus fractures with complex articular injuries, a staged protocol consisting of initial percutaneous reduction and fixation with later definitive reconstruction is soft tissue friendly, allows early restoration of calcaneal morphology, and affords extensile approaches for eventual reconstruction. The purpose of this study was to describe our protocol of staged treatment of high-energy tongue-type calcaneus fractures, along with postoperative surgical outcomes, in a case series of 53 patients.Our series of patients had a high rate of intra-articular injury with marked initial displacement (mean Bohler angle -8.4±20.8 degrees). They were treated initially with percutaneous reduction and fixation at median 1 day postinjury (interquartile range [IQR] 0-1) and definitively at median 16 days postinjury (IQR 10-33). In this series, 2 of 53 (3.8%) patients developed a deep wound infection.In high-energy tongue-type calcaneus fractures at risk for soft tissue compromise or with a significantly displaced tongue fragment without initial soft tissue compromise, we found that staged management represents a feasible management strategy to mitigate risk of soft tissue complications and therefore helps facilitate safe definitive open treatment.

Fixation-induced surgical segment’s high stiffness and the damage of posterior structures together trigger a higher risk of adjacent segment disease in patients with lumbar interbody fusion operations

BackgroundAdjacent segment disease (ASD) is a commonly reported complication after lumbar interbody fusion (LIF); changes in the mechanical environment play an essential role in the generation of ASD. Traditionally, fixation-induced high stiffness in the surgical segment was the main reason for ASD. However, with more attention paid to the biomechanical significance of posterior bony and soft structures, surgeons hypothesize that this factor may also play an important role in ASD.MethodsOblique and posterior LIF operations have been simulated in this study. The stand-alone OLIF and OLIF fixed by bilateral pedicle screw (BPS) system have been simulated. The spinal process (the attachment point of cranial ligamentum complex) was excised in the PLIF model; the BPS system has also been used in the PLIF model. Stress values related to ASD have been computed under physiological body positions, including flexion, extension, bending, and axial rotations.ResultsCompared to the stand-alone OLIF model, the OLIF model with BPS fixation suffers higher stress values under extension body position. However, there are no apparent differences under other loading conditions. Moreover, significant increases in stress values can be recorded in flexion and extension loading conditions in the PLIF model with posterior structures damage.ConclusionsFixation-induced surgical segment’s high stiffness and the damage of posterior soft tissues together trigger a higher risk of ASD in patients with LIF operations. Optimizing BPS fixation methods and pedicle screw designs and reducing the range of posterior structures excision may be an effective method to reduce the risk of ASD.

Artificial lamina after laminectomy: Progress, applications, and future perspectives.

In clinical practice, laminectomy is a commonly used procedure for spinal decompression in patients suffering from spinal disorders such as ossification of ligamentum flavum, lumbar stenosis, severe spinal fracture, and intraspinal tumors. However, the loss of posterior column bony support, the extensive proliferation of fibroblasts and scar formation after laminectomy, and other complications (such as postoperative epidural fibrosis and iatrogenic instability) may cause new symptoms requiring revision surgery. Implantation of an artificial lamina prosthesis is one of the most important methods to avoid post-laminectomy complications. Artificial lamina is a type of synthetic lamina tissue made of various materials and shapes designed to replace the resected autologous lamina. Artificial laminae can provide a barrier between the dural sac and posterior soft tissues to prevent postoperative epidural fibrosis and paravertebral muscle compression and provide mechanical support to maintain spinal alignment. In this paper, we briefly review the complications of laminectomy and the necessity of artificial lamina, then we review various artificial laminae from clinical practice and laboratory research perspectives. Based on a combination of additive manufacturing technology and finite element analysis for spine surgery, we propose a new designing perspective of artificial lamina for potential use in clinical practice.

Finite element analysis of lumbosacral soft tissue at sitting posture at desktop computer

ABSTRACT Aim: This study aims to numerically determine the biomechanical effect of von Mises stress, induced at different flexion angles of the spine while sitting at a desktop computer, on the soft tissues in the front and back of the lumbosacral region, as well as to contribute to determining the ideal sitting posture. Materials and Methods: Three-dimensional (3D) soft tissue models were created using Solidworks. Static structural analyses of the tissues were performed in ANSYS with the finite element method (FEM). Stress distribution and stress values occurring in the anterior and posterior sides of the lumbosacral region at 0, 15, 30, and 45 spine flexion angles were analyzed separately. The values of von Mises stress formed in the anterior and posterior soft tissues of the lumbosacral region gradually increased with the increase in the flexion angle. Furthermore, the stress values in the anterior and posterior soft tissues were compared with each other for the same spinal flexion angle. Results: The von Mises stress values were found to be higher in the posterior side only at 0 degrees, whereas at 15, 30, and 45 degrees, they were higher in the anterior side. As a result, the most suitable position for sitting at a computer was determined. Lower flexion angles of the spine, such as 0 and 15 degrees, create less stress on the anterior and posterior sides of the lumbosacral region. Conclusion: Sitting postures with a flexion angle of the spine higher than 0-15 degrees are not appropriate, and desktop users are not recommended to adopt such a posture. The results of the analysis could be used to better understand the effects of prolonged sitting on the lumbosacral area and to design interventions to reduce the risk of injury or discomfort.

A case of Streptococcus canis bacteremia, osteomyelitis, sacroiliitis, myositis, and abscess

BackgroundStreptococcus canis is a group G beta-hemolytic Streptococcus species which normally resides on the skin and mucosal surfaces of dogs. Although it rarely causes infection in humans, our case and review of relevant literature demonstrate that this multi-host pathogen may be responsible for metastatic infection. We present an appropriate management strategy in such cases.Case presentationA previously healthy 26-year-old male presented to the emergency department with a 2-day history of erythema, pain, and swelling of the left ankle and foot, consistent with acute cellulitis. The patient was initially discharged home with a plan to complete a course of IV cefazolin as an outpatient, but later recalled after two sets of blood cultures grew gram positive cocci. Blood cultures speciated as Streptococcus canis. This was performed by identifying beta hemolytic strep on blood agar, then typed as Lancefield group G, followed by MALDI-TOF which distinguished S. canis. History was unremarkable except for a 2-week history of lower back pain precipitated by a wrestling injury. There was no canine bite or scratch wound, although the patient lives with a dog. CT spine was obtained which demonstrated right piriformis myositis and S1 osteomyelitis. MRI additionally demonstrated right erector spinae myositis, right sacroiliitis, and multiple collections in the right posterior paraspinal soft tissues. Transthoracic echocardiogram did not demonstrate valvular vegetations. The S. canis isolate was pan-susceptible and the patient was ultimately discharged home and completed a 8-week course of IV penicillin G. After completion of therapy, his symptoms, repeat imaging, and biochemical markers suggested resolution of infection on follow-up.ConclusionsWe suggest that management of S. canis bacteremia should involve consideration of screening for metastatic infection and infectious diseases consultation. However, despite its potential for systemic involvement, S. canis is often susceptible to narrow spectrum antibiotics, and may be treated with penicillins.

S3549 A Peculiar Complication of Diabetic Ketoacidosis (DKA) Secondary to Pneumomediastinum: Spontaneous Pneumorrhachis

Introduction: Pneumorrhachis is the presence of free air surrounding the dura matter within the spinal canal. It was first reported by Gordon et al in 1977 and the actual term was coined in 1987 by Newbold et al. Spontaneous pneumorrhachis with extensive pneumomediastinum is a rare but self-limiting condition. We present a unique case of spontaneous pneumorrhachis secondary to pneumomediastinum. Case Description/Methods: A 20-year-old male with a history of Type 1 diabetes mellitus who presented with a two-day history of sudden onset of shortness of breath and retrosternal chest pain. He also reported nausea and multiple episodes of non-bloody, non-bilious emesis over the last two days prior to presentation. He denied fever, cough, trauma, or overt signs of GI bleed. He was tachycardiac and tachypneic on arrival. Exam consistent with anterior chest wall and neck subcutaneous emphysema. Labs were significant for blood glucose 450 with bicarbonate of 8 and an elevated anion gap. He was admitted to the ICU for the management of diabetic ketoacidosis. CXR showed extensive pneumomediastinum. CT chest showed pneumomediastinum with chest wall and neck subcutaneous emphysema. It also showed an important finding of pneumorrhachis. Barium esophagram showed no evidence of esophageal perforation in this patient with pneumomediastinum. No surgical intervention was warranted. Pt was monitored in the ICU, however unfortunately he left against medical advice prior to further investigation. He reported doing well on clinic follow up. Discussion: Pneumorrhachis represents an asymptomatic, radiological finding that is diagnosed with increasing prevalence due to the advancement in radiological techniques and modalities. Spontaneous pneumomediastinum (SPM) is a rare complication of DKA. Bouts of emesis and Kussmaul breathing in diabetic ketoacidosis have been postulated to cause alveolar rupture due to increased intra-alveolar pressure that eventually reaches the spinal canal. The most dangerous differential diagnosis of SPM is Boerhaave’s syndrome that should be excluded with contrast-swallow studies, especially in the setting of vomiting. Treatment is usually conservative since patients are asymptomatic and air is spontaneously resorbed. This case reflects the importance of keeping a differential of spontaneous pneumorrhacis as an important yet subtle complication of DKA.Figure 1.: Extensive pneumomediastinum in the anterior middle and posterior compartment with air extending to the spinal canal and posterior soft tissues.

Durability of transosseous repair of posterior soft tissues after primary total hip arthroplasty: a prospective randomized controlled trial.

Posterior soft tissue repair is one of the methods for preventing dislocation after total hip arthroplasty (THA). This study aimed to evaluate durability of two separate suture materials in THA patients who underwent posterior soft tissue repair. 42 THA patients were included in the study. The patients were randomly divided into two groups, where braided nonabsorbable suture was used in group A (n = 22), while braided absorbable suture was used in group B (n = 20). While repairing the posterior soft tissues, the piriformis and triceps coxae tendons together with the capsule were reattached to the greater trochanter via pull out sutures. Two hemoclips were attached as distance markers to both pull out sutures on the medial and lateal sides of the greater trochanter. Anteroposterior radiographs were taken one day, 15days, 3months and 6months after operation. Distances between the hemoclips medial and lateral to the greater trochanter were measured on the radiographs, and the closest distances were recorded. The repair was considered a failure if the difference of distances between the first and any of the follow-up measurements exceeded 15mm. No statistically significant difference was observed between the groups. In both groups, elongation magnitudes in all time intervals were statistically significant while the results obtained from measurements taken 15days after operation were more significant (p < 0.01). No dislocations were observed. We conclude that for transosseous posterior soft tissue repair in THA, both absorbable and nonabsorbable sutures are similarly durable and can be routinely performed.

Functional and clinical anatomy of the obturator externus muscle: Cadaveric studies and clinical findings for total hip arthroplasty in the posterior approach

Repairing released posterior soft tissues is important in preventing dislocation after total hip arthroplasty (THA) via the posterior approach. We clarify the functional and the clinical anatomy of obturator externus. We performed cadaveric studies and investigated clinically in primary THA cases. The location, trajectory, and size of the muscular tendon was recorded. The trajectory of the obturator externus ran orthogonal to the femoral axis with the hip in 90° flexion whereas that of the obturator internus muscle ran parallel. Because the trajectory of obturator externus and the obturator internus differ, their functions also differ.

Prevención, identificación y tratamiento de las recidivas en el pie equino varo congénito. Revisión de conceptos actuales

Recurrence is understood to be the progressive appearance of congenital clubfoot deformities usually along the first five years of the child's life. The main cause of recurrence is the improper use of the abduction splint which has the function of stretching the posterior and internal soft tissues of the leg and foot. Therefore, close communication between the doctor and the child's parents or guardians is essential in order to make them understand the relevance of abduction splint and to encourage them to use it as prescribed. Clinically, one should pay attention to the first sign of recurrence: the decrease in ankle dorsiflexion range of motion, usually early followed by the appearance of the other associated deformities as described widely for clubfoot. When the cavus deformity of the foot appears before the limitation for ankle dorsiflexion or the equine deformity, a neuromuscular etiology of clubfoot should be suspected. Treatment is performed by the application of the Ponseti method with correction of the deformity (s) with new casts, if necessary tenotomy and maintenance of the foot position with splints. In children aged over four years, it may be necessary to associate a surgical transfer of the anterior tibialis tendon to the third wedge. Regular use of the abduction splint is essential to prevent recurrence of deformities, so emphasis on its use constitutes an essential preventive measure.Evidence Level: IV.

Salvage of Failed Femoral Neck Fracture Fixation with Conversion Total Hip Arthroplasty Using the Direct Anterior Approach.

PurposeFailed femoral neck fracture (FNF) fixation with in situ pinning presents a surgical challenge. Osteoporotic bone, retained hardware, and a typically elderly population magnify the risks of surgery. Here, outcomes of conversion total hip arthroplasty (THA) using two separate incisions in these high-risk patients were examined.Materials and MethodsMedical records for 42 patients with a prior history of FNF fixation who underwent conversion THA with hardware removal between 2009 and 2019 were retrospectively reviewed. Surgery was performed by a single surgeon at a single institution. All patients underwent hardware removal followed by direct anterior approach (DAA) THA using two separate incisions. Clinical outcomes, radiographic findings, and perioperative morbidity and mortality are reported.ResultsClinically, there were no postoperative dislocations, periprosthetic fractures, or infections at follow-up. After a mean follow-up of 4 years, the mean hip disability and osteoarthritis outcome score, junior (HOOS, Jr) was 91. Radiographically, the mean postoperative cup abduction was 44 degrees and the mean cup anteversion was 21 degrees with an improvement in preoperative leg length discrepancy. Perioperative complications included one case of immediate foot drop and two readmissions for medical issues. One patient died one month after conversion THA.ConclusionSalvage of failed FNF treatment may be managed with conversion THA and DAA with a separate incision for hardware removal. Preservation of posterior soft tissues using a DAA and intraoperative fluoroscopy may mitigate well-known complications related to fracture and dislocation. While favorable clinical outcomes are possible, salvage surgery is still not without substantial surgical and medical risks.

Preventing postoperative prosthetic joint dislocation by repairing obturator externus in total hip arthroplasty performed via the posterior approach

BackgroundIn total hip arthroplasty performed via the posterior approach, repairing the posterior soft tissues is a conventional method for preventing postoperative prosthetic joint dislocation. The aim of this study was to verify whether obturator externus repair played the main role and what was the mechanism of the repair preventing the dislocation.MethodsIncluded were 188 patients who underwent primary cementless total hip arthroplasty via the posterior approach. The patients were divided into a repair group (n = 94) and a non-repair group (n = 94). Patients of repair group received additional obturator externus repair while patients of non-repair group did not. The range of motion of hip joint was assessed before and after operation. Data were compared between the two groups. A p value < 0.05 was considered statistically significant.ResultsBefore operation and under anesthesia, with regard to internal rotation of hip joint, the mean values of repair and non-repair groups were 24° ± 16/28° ± 15 (p = 0.2933). The mean values of the groups were 13° ± 8/15° ± 9 immediately after repair (p = 0.5672). Range of internal rotation 1 year after operation were 15° ± 8/19° ± 9 (p = 0.0139). Specifically, the values in repair group were lower than those in non-repair group. During a 5-year period of postoperative follow-up, hip joint dislocation occurred in one patient of non-repair group. No dislocation was observed in repair group.ConclusionWhen THA is performed via the posterior approach, repairing the obturator externus may decrease the risk of postoperative prosthetic joint dislocation by reinforcing the posterior soft tissues of the hip joint.Level of evidenceTherapeutic study, Level IVa.

S3345 “Having a Sweet Tooth”: Case of Oral Flora Found Within a Pancreatic Abscess

INTRODUCTION: This is a case of a patient presenting with a cystic lesion on the head of the pancreas, leading to pancreatic malignancy like symptoms, to be found growing oral flora in the aspirate culture. CASE DESCRIPTION/METHODS: A 61-year-old Male with a history of GERD, hiatal hernia presented to the emergency department with epigastric and right upper quadrant abdominal pain associated with nausea. - His pain was on and off in the preceding 1 year, worse in the past 4 months. Pain worsened with eating, and at night. He had an associated 28-pound weight loss since onset of symptoms. Patient was a active cigarette smoker with 1 pack per day since the last 40 years and had poor dentition. - Work-up with a CT scan of the abdomen revealed a thick walled 7.7 × 8.1 × 12 cm cystic mass in the head of pancreas compressing the stomach and duodenum, causing a pseudo meningocele in the posterior lumbar soft tissues and enlarged portocaval and paraaortic lymph nodes. - Laboratory studies revealed a Total bilirubin of 1.25 and a lipase level of 326. CEA and CA 19-9 were not elevated. - Esophago-gastro-duodenoscopy with endoscopic ultrasound were performed for biopsy of the mass. Thick pus was aspirated which was sent for culture. - He underwent absesso-gastrostomy with double pigtail stent into the abscess. - Aspirate from the pancreatic cyst grew oral flora with-Hemophilus Influenzae, Streptococcus (Viridans and Beta-hemolytic), Actinomyces Odontolyticus and Rothia Dentocarioa - Amylase in the fluid was >10,000. Cytology of the fluid showed no malignant cells. - Considering the microbiology of the aspirate, it was thought that the patient had a gastric ulcer with erosion to the pancreas causing the pancreatic abscess and peripancreatic findings. - Follow up CT scan in 2 days showed decompression of the fluid collection. - He was recommended treatment with Augmentin for one year. DISCUSSION: - Pancreatic pseudocysts are extra-pancreatic fluid collections lined with fibrous tissue without an epithelium. - Pancreatic cysts are cystic collections found as incidental findings in 2% of the population. Many pancreatic serous and mucinous neoplasms present as such. - Size of the cyst >3cm, thick and irregular wall, solid components to the cyst are features of likely malignancy. - This is a rare presentation of a patient presenting with malignancy like symptoms, having an infective cyst that when cultured grew oral flora.Figure 1.: Pancreatic cystic structure seen on the CT scan, compressing the stomach.

Posterior Glenoid Augmentation With Extra-articular Iliac Crest Autograft for Recurrent Posterior Shoulder Instability

Several techniques have been described for bone block augmentation as a treatment for posterior shoulder instability, including intra-articular distal tibial allograft and extra-articular iliac crest autograft. Although indications are not yet well defined, these bone augmentation procedures are considered in patients with glenoid bone loss, increased glenoid retroversion, previous failed posterior soft-tissue repair, and insufficient posterior capsulolabral tissue. In patients with posterior glenoid bone loss, the senior author (P.J.M.) recommends intra-articular glenoid reconstruction with a fresh distal tibial osteoarticular allograft. In patients with insufficient posterior capsulolabral tissue, the senior author prefers an extra-articular iliac crest autograft to buttress the posterior soft-tissue restraints. This technique guide outlines extra-articular iliac crest autograft treatment for recurrent posterior shoulder instability in patients with insufficient posterior soft tissues due to prior failed surgery. After an open capsulolabral repair is performed using suture anchors, the bone block is placed extra-articularly on the posterior glenoid neck.

POSTERO-MEDIAL TIBIAL PLATEAU (MOORE’S TYPE) FRACTURE AND THE IMPORTANCE OF COMPUTER TOMOGRAPHY IN DIAGNOSIS: A CASE REPORT

Moore type I posteromedial split fracturedislocation of proximal tibia are relatively uncommon. It is a specific fracture pattern that is not well described by the AO (41B2.2/B3.2) or Schatzker (IV) classification system because these systems do not differentiate when the medial fragment is primarily posterior and associated with a dislocation as the Moore system does. 1The additional use of computed tomography scans in the assessment of tibial plateau fracture may improve surgeon’s agreement that lead to the final decision and optimization of treatment. 2Galla and Lobenhoffer described a direct posteromedial approach for managing Moore type I tibial plateau fracture1.Report:A 48 years old malay gentlemen was alleged motor-vehicle accident, sustained closed fracture tibial plateau of right knee. Initially patient was diagnosed with right tibial fracture schatzker IV based on right knee anterior-posterior and lateral view xray. But CT scan had done, show the proximal tibial fracture transversing medial aspect with coronal spliting. Patient was treated with posteromedial locking compression plate with Lobenhoffer approach. Intraoperatively, diagnosis was confirmed with Hohl & Moore classification type I, there is coronal split fracture extending to posteromedially. The importance of computerised tomography scans when dealing with intra-articular fracture of tibial plateau may improve regarding localisation of fracture lines, depression zone, comminution, and the surgical treatment plan. 2Alexander et al. reported after addition of computerised tomography scans significantly improved to “good” in all classification. The features of Moore’s type I fracture which is coronal split fracture dominantly posterior column, coronal view from CT scans is more useful compare than sagital view. Galla and Lobenhoffer have introduce a direct postero-medial approach that minimizes soft tissue injury while allowing excellent fracture visualization, reduction, and fixations. 1This technique protect the neurovascular bundle and requires only suboeriosteal elevation of the popliteus to obtain full exposure. Furthermore, because of the protecting posterior soft tissues, skin closure and wound healing are reliable.Conclusion:Moore’s type I fracture managed with postero-medial approach has better post operative outcome, improved reliability and shows good reproducibility when classified with computerised tomography scans.

Biportal endoscopic spinal surgery for lumbar spinal stenosis

Lumbar spinal stenosis is a common disease in the elderly (over 60 years old). Common surgical options for treating lumbar stenosis include open decompression laminectomy, foraminotomy, and spinal fusion. Currently, the gold standard for treating lumbar stenosis that is resistant to conservative treatment is laminectomy with facet preservation.The purpose is to conduct a comparative assessment of the results of studies of the effectiveness and advantages of unilateral biportal endoscopy (UBE) in comparison with other methods of decompression of lumbar spinal stenosis based on the literature data.Results. A meta-analysis of the studies showed that the advantage of UBE is the possibility of preventing atrophy of the paraspinal muscles due to a decrease in muscle dissection and retraction compared to open decompression. This technique allows reducing the trauma of the nerve structures since it is possible to carry out manipulations finely and accurately due to significantly enlarged images. Also, due to the wide viewing angle through the endoscope, decompression of the contralateral side is relatively simple.Conclusions. The UBE technique has several advantages compared to other minimally invasive methods, namely, reduction of damage to the posterior ligamentous apparatus and soft tissues, complete decompression of damaged structures and lower risk of infection.

26. Posterior ligamentous reinforcement does not prevent proximal junctional kyphosis in adult spinal deformity

BACKGROUND CONTEXT Violation of the posterior soft tissues is believed to contribute to the development of proximal junctional kyphosis (PJK). Clinical and biomechanical studies have suggested that augmentation of the posterior ligamentous structures (PLS) may help prevent PJK. PURPOSE To determine whether augmentation of the PLS from the UIV-1 to UIV+1 prevents PJK. STUDY DESIGN/SETTING Single-surgeon retrospective cohort study. PATIENT SAMPLE One hundred fifty adult spinal deformity patients. OUTCOME MEASURES PJK (defined as a proximal junctional angle ≥20°) at final follow-up. METHODS We conducted a retrospective cohort study of 150 adult spinal deformity patients who underwent ≥5 level fusions to the pelvis by a single surgeon between 2014 and 2017. Exclusion criteria included neuromuscular or congenital scoliosis (18 patients), or follow-up less than 1 year (24 patients), leaving 108 patients available for final analysis. Patients were divided into two groups: PLS+ patients had reconstruction of the PLS between UIV+1 and UIV-1 with a surgical nylon tape while PLS- patients did not. Demographics, surgical data, and sagittal alignment parameters were compared between the cohorts. The primary outcome of interest was the development of PJK at final follow-up (1 or 2 years). A subgroup propensity match and backward stepwise logistic regression model were utilized to control for surgical and radiographic differences in the cohorts. RESULTS Thirty-one patients (28.7%) were PLS+. There were no differences with regard to preoperative or final sagittal alignment parameters, number of levels fused (10.7±3.8 vs 9.7±3.8, p=0.331), and BMI (24.9±5.2 vs 27.0±6.9 kg/m2, p=0.143), though the PLS+ cohort was older (64.1±10.4 vs 51.3±21.4 years, p=0.002) and had greater 6-week corrections in sacral slope (SS), pelvic tilt (PT), pelvic incidence-lumbar lordosis (PI-LL), C7-S1 sagittal vertical axis (C7 SVA), and T1 pelvic angle (T1PA), p 0.05 for 6-week changes in SS, PT, LL, PI-LL, C7 SVA, T1PA, thoracic kyphosis, thoracolumbar kyphosis, and cervical lordosis), PLS augmentation was still not associated with a lower rate of PJK (29% PLS+ vs 38.7% PLS-, p=0.367). In our multivariate analysis, only increased sagittal malalignment and failure to restore sagittal balance were retained as having independent associations with PJK, while PLS+ was not retained in the model. CONCLUSIONS Even after controlling for relevant variables such as age, preoperative alignment, and degree of correction, PLS reinforcement at the UIV+1 did not reduce the incidence of PJK at 1 year. Our findings emphasize the multifactorial nature of PJK and the difficulty of preventing PJK with a single surgical technique FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Posterior Ligamentous Reinforcement of the Upper Instrumented Vertebrae +1 Does Not Decrease Proximal Junctional Kyphosis in Adult Spinal Deformity.

Study Design:Retrospective cohort study.Objectives:Violation of the posterior soft tissues is believed to contribute to the development of proximal junctional kyphosis (PJK). Biomechanical and clinical studies suggest that augmentation of the posterior ligamentous structures (PLS) may help prevent PJK. The purpose of this study was to evaluate the effect of PLS augmentation on the rate of PJK at 1 year.Methods:A retrospective single-surgeon cohort study was performed of 108 adult spinal deformity patients who underwent 5 level fusions to the pelvis. Patients were divided into 2 groups: PLS+ patients had reconstruction of the PLS between upper instrumented vertebrae +1 (UIV+1) and UIV−1 with a surgical nylon tape while PLS− patients did not. Demographics, surgical data, and sagittal alignment parameters were compared between the cohorts. The primary outcome of interest was the development of PJK at final follow-up. A subgroup propensity match and logistic regression model were utilized to control for differences in the cohorts.Results:A total of 108 patients met final criteria, 31 patients (28.7%) were PLS+. There were no differences with regard to preoperative or final sagittal alignment parameters, number of levels fused, rates of 3-column osteotomies, and body mass index (P > .05), though the PLS+ cohort was older and had larger initial sagittal corrections (P < .05). The rates of PJK for PLS+ (27.3%) and PLS− (28.6%) were similar (P = .827). After controlling for sagittal correction via propensity matching, PLS+ had no impact on PJK (29% vs 38.7%, P = .367). In our multivariate analysis, only increased sagittal malalignment and failure to restore sagittal balance were retained as significant predictors of PJK.Conclusion:Even after controlling for extent of correction and preoperative sagittal alignment, PLS reinforcement at UIV+1 using a hand-tensioned nylon tape does not reduce the incidence of PJK at 1 year.