Postoperative Angulation Research Articles

Forearm diaphyseal fractures in children: Intramedullary Kirschner's wire fixation treatment

IntroductionDiaphyseal fractures of the forearm comprise 6%–10% of all fractures in children. The treatment depends on the age and type of displacement, and conservative and surgical management with fixation of intramedullary nails, among other techniques, is valid. The aim is to show the radiological and functional outcomes, and complications of intramedullary fixation with Kirschner nails in children. Materials and methodsA retrospective descriptive case series of patients treated with intramedullary fixation of forearm fractures. The radiological and functional results, and complications are correlated. ResultsOf the 117 patients operated, 59 met the inclusion criteria. The average age was 10 years. Eighty-four point seven percent were males and the left side was the most affected (62.7%). In 88.1% both bones were fractured and 11 cases had open fractures. An open reduction was performed in 72.8% of the cases, the main indications for this being instability, failed reduction and refracture. There were 52 excellent outcomes, 2 good, and 4 regular and 1 bad. There were 13.5% minor complications. DiscussionThis study shows that intramedullary fixation with Kirschner nails in radius and ulna diaphysis fractures in children is a safe, low-cost procedure and offers adequate short and medium term functional outcomes, with a low prevalence of serious complications with only 6 cases of non-consolidation and refracture. Larger preoperative angulations in the anteroposterior and lateral planes, and lateral postoperative angulations, could be considered predictors of less satisfactory functional results.

Ultrasonography-guided reduction of pediatric radial neck fractures

BackgroundTreatment of displaced and angulated radial neck fractures in children is controversial and challenging. Numerous studies have been conducted regarding treatment algorithms and surgical techniques that use fluoroscopy. However, ultrasonography (US)-guided reduction of pediatric radial neck fractures has not been reported yet. We aimed to determine the safety and efficacy of US-guided reduction and fixation of radial neck fractures in children.MethodsAmong 28 cases of radial neck fracture from 2014 to 2016, 12 were classified as type III or IV according to the Judet classification. All 12 patients underwent US-guided reduction and percutaneous fixation with Kirschner wire and follow-up for more than 6 months. US was used primarily to monitor the angulation and reduction of the radial neck. Fluoroscopy was applied to confirm the fixation with Kirschner wire. Dose area product (DAP; mGy/cm2) was measured to assess per-procedure radiation dose. Radiological and clinical results were evaluated at 6 months after the surgery by using the Metaizeau criteria.ResultsOf the patients, 4 were boys and 8 were girls, with a mean age of 7.7 years (range, 5–11 years). Judet type III fractures accounted for 83% of all injuries. The mean preoperative radial angulation was 62.5° (range: 46°–76°). The mean postoperative radial angulation was 5.6° (range: 2°–9°). The mean fluoroscopy time was 31 s (range: 10–73 s), and the mean DAP was 10.7 mGy/cm2 (range: 7.2–18.7 mGy/cm2). The mean follow-up period was 18.3 months (range, 8–24 months). According to the Metaizeau criteria, 10 cases were excellent and 2 cases were good at the last follow-up.ConclusionsUS-guided reduction and percutaneous fixation is safe and reliable option to treat displaced radial neck fractures in children.

Do We have an Aimer to put the Tibial and Femoral Tunnels in the Same Line to reduce Mechanical Strain in Reconstructed Anterior Cruciate Ligament?

AbstractThe strain between the ACL graft tissue and the osteochondral tissue at the tunnel entrances would lead to postoperative deviation of the femoral and/or tibial insertion of the ACL graft. Postoperative changes of the 3D orientation of the ACL graft affect its physiometry leading to failure of graft tension. A conception of an aimer is suggested to insure straightening of the intraosseous (tibial and femoral) and intra-articular parts of the graft at the tunnel entry point to overcome the postoperative angulation of intraosseous and intra-articular graft parts

Fracturas diafisarias del antebrazo en niños: tratamiento con fijación intramedular con clavos de Kirschner

IntroductionDiaphyseal fractures of the forearm comprise 6%-10% of all fractures in children. The treatment depends on the age and type of displacement, and conservative and surgical management with fixation of intramedullary nails, among other techniques, is valid. The aim is to show the radiological and functional outcomes, and complications of intramedullary fixation with Kirschner nails in children. Materials and methodsA retrospective descriptive case series of patients treated with intramedullary fixation of forearm fractures. The radiological and functional results, and complications are correlated. ResultsOf the 117 patients operated, 59 met the inclusion criteria. The average age was 10 years. Eighty-four point seven percent were males and the left side was the most affected (62.7%). In 88.1% both bones were fractured and 11 cases had open fractures. An open reduction was performed in 72.8% of the cases, the main indications for this being instability, failed reduction and refracture. There were 52 excellent outcomes, 2 good, and 4 regular and 1 bad. There were 13.5% minor complications. DiscussionThis study shows that intramedullary fixation with Kirschner nails in radius and ulna diaphysis fractures in children is a safe, low-cost procedure and offers adequate short and medium term functional outcomes, with a low prevalence of serious complications with only 6 cases of non-consolidation and refracture. Larger preoperative angulations in the anteroposterior and lateral planes, and lateral postoperative angulations, could be considered predictors of less satisfactory functional results.

Evaluation of Correction of Radiologic Parameters (Angulation and Displacement) and Accuracy of C2 Pedicle Screw Placement in Unstable Hangman's Fracture with Intraoperative Computed Tomography-Based Navigation.

Opinions vary regarding optimal treatment of unstable hangman's fractures, including rigid orthosis and internal fixation. The anatomy of upper cervical spine is complex. The advent of intraoperative 3-dimensional navigation systems facilitates safe and accurateinstrumentation. To evaluate radiologic parameters of fracture morphology in unstable hangman's fracture in preoperative and postoperative period and accuracy of inserting axis pedicle screws by using intraoperative computed tomography-based navigation. Fifteen patients with unstable hangman's fractures with age ranging from 17 years to 81 years were operated using computed tomography-based navigation from September 2011 to march 2016. Patient's age, sex, mechanism of injury, associated injuries, and neurologic status were noted. Clinical outcome, accuracy of screw insertion, preoperative and postoperative displacement, and angulation of C2 over C3 and bony fusion were assessed. Overall, 76 screws were inserted including 30 screws in C2 pedicle with 2 (2/60; 6.7%) malplaced screws in C2 pedicle. Mean follow-up period was 34 ± 18 months (range 7-80 months). Mean hospital stay was 12.8 ± 2.4 days. Mean preoperative and postoperative displacements were 4.09 mm ± 1.78 mm and 1.82 mm ± 1.14 mm respectively with a mean reduction of 2.27 mm ± 1.49 mm. Mean preoperative angulation was 7.23° ± 11.96° and postoperative angulation was 2.32° ± 4.77° with a mean reduction of 5.11° ± 11.96°. Bony fusion was achieved and rotation was preserved at C1-C2 joint in all cases. Intraoperative O-arm-based navigation is a safe, accurate, and effective tool for screw placement in patients with unstable hangman fracture and achieves good anatomical reduction.

Result of intramedullary interlock nailing in fracture proximal third tibia in rural hospital

Aim: Tibia is one of the most commonly fractured bone. Proximal third tibial fracture account for 5% to 11% of tibial shaft fracture. Treatment of proximal third fracture tibia is complex and problematic. Techniques include plate fixation, external fixation and intramedullary nailing. Purpose of this paper is to review and compare IM Interlock nailing technique in treatment of fracture proximal third tibia with other available techniques. Materials and Methods: Study involved 33 patients (24 male and 9 females) operated between year 2012 and 2016 in SRTR Medical College and rural hospital, Ambajogai. An age between 18-70 year was selected for the study. Male to female ratio was 3:1. There were 27 simple fractures and six had open injury (4 with gustillo1 and 2 with gustillo 2). Fractures were classified on basis of fracture pattern as simple undisplaced, displaced, comminuted, and segmental. Fractures extending into articular surface were excluded from our study. Patient was in supine position with knee in figure of four posture. A 4 cm vertical midline incision was taken on patellar tendon. Patellar tendon was retracted medially. Entry made just in front of inter meniscus ligament with curved awl, after removal of piece of infrapatellar pad. Entry point was much higher than techniques described in other interlocking nailing. Tibia IM interlock nail of suitable size was inserted with manual rotation and proximal and distal locking done with locking screw. Polar screw and reaming was not used in our cases. In the case of nonunion, broken implants were removed and nail used, bone graft was done. In the case of hypertrophic nonunion IM nail was used and 1cm fibula excision. Post operatively patients were ambulated with crutches NWB and later PWB to FWB as per the pain threshold of the patient. Follow-up of patients were done at regular intervals and final angulations in four planes were studied. Reduction greater than 5 degree in any plane was considered as mal reduction Results: The average hospital stay was 3-7 days. There was only one postoperative superficial infection, which healed with antibiotics and dressing. No patient had deep infection, neurovascular injury, implant failure or screw loosening. Union time was average 16 weeks with union rate of 94%. Majority of the patient with fractures (88%) shows painless wt bearing and radiological evidence of healing between 12-16 weeks. About 91% pt. showed more than 120-degree knee range of motion at final follow up. The nonunion cases took 16-20 wks for union. Postoperative angulations were within five degree in all planes, and no secondary procedure was required to achieve union or correct malunion. Conclusion: Tibia IM intramedullary nailing is a safe and effective technique of fixation with good outcome. Alignment can be well maintained despite short proximal segment because the interlock IM nail, triple diameter screw that provides better stiffness and stability in axial and rotatory plane.

Dynamic Intraspinous Stabilization reduces Spinal Mobility After Bilateral Laminotomy

Dynamic stabilization devices were developed to reduce spinal hypermobility while preserving a certain degree of physiological motion. Our goal was to assess radiographic and clinical outcomes of patients treated with surgical decompression and stabilization with the LimiflexTM implant. We investigated the effect of LimiFlex implantation on post-operative translation and angulation in 36 patients with spinal stenosis and degenerative spondylolisthesis Meyerding Grade I treated with decompression and dynamic stabilization. Significant improvements following lumbar decompression were observed. The average Oswestry Disability Index (ODI) score fell from 45.9 Pre-operatively to 29.6 at dismissal and 26.5 at first follow up. The average visual analog scale (VAS) score fell from 7 Pre-operatively to 3 at dismissal and 3 at follow up. Pre-operatively the median translation within the operated segment was 2.0 mm. Post-operatively the translation was reduced to 0.7 mm (p=0.006, Student’s t-test). Pre-operatively the median rotation within the operated segment was 4.6°. Post-operatively the rotation was reduced to 3.5° (p=0.08, Student’s t-test). The re-operation rate was 6 out of 36 (16.7%). Here we provide evidence suggesting that the dynamic paraspinous stabilization implant LimiflexTM is well tolerated in patients with degenerative spondylolisthesis and lumbar spinal canal stenosis. Our data show that within 3 months after the operation it limits hypermobility in the operated segment. This might be well suited in cases such as spinal stenosis with Grade I degenerative spondylolisthesis, where instability at the operated segment is likely to happen, but a patient is not indicated for a spinal fusion.

Wilkie's syndrome with duodenojejunal diverticulosis: A rare combination causing duodenal obstruction

Wilkie's syndrome is an unusual cause of proximal intestinal obstruction. It is a clinical entity characterized by compression of the third or transverse portion of the duodenum between the aorta and superior mesenteric artery (SMA). This results in chronic, intermittent, or acute complete or partial duodenal obstruction. We present the case of a 40-year-old lady who presented with postprandial abdominal pain at the epigastric region, colic type, without radiation accompanied by nausea, postprandial vomiting, and weight loss. She was evaluated and diagnosed with SMA syndrome with duodenojejunal diverticulosis. She was taken for surgery due to chronic malnutrition that did not improve with conservative management. Duodenojejunostomy with transgastric feeding jejunostomy was done. To alleviate postoperative refractive gastroparesis, kinking, and angulation as is our previous few cases, transgastric feeding jejunostomy was done in contrast to modified Witzel's technique. The patient was free of symptoms and recurrence during follow-up. Wilkie's syndrome is an unusual cause of intestinal obstruction. Prompt diagnosis and appropriate surgical intervention are associated with good outcome.

Immediate Change in Suprarenal Neck Angulation After Endovascular Aneurysm Repair

Purpose: To compare the immediate suprarenal neck angulation change between the Ovation stent-graft, with its inflatable sealing rings, and a stent-graft with a conventional sealing mechanism. Methods: A case-control study was conducted in which 30 consecutive patients (mean age 67 years; all men) with abdominal aortic aneurysm (AAA) treated with the Ovation stent-graft (group O) were retrospectively compared with 24 patients (mean age 77 years; all men) contemporaneously treated with the Endurant stent-graft (group E) at 3 high-volume tertiary vascular centers. The variables recorded were the aortic neck length, preoperative and postoperative angulation, minimum and maximum diameters of the infrarenal neck, as well as the maximum AAA diameter. All patients had undergone preoperative and postoperative (within 30 days) computed tomographic angiography. Multiple regression analysis compared the relative contribution to neck angulation change of each geometric parameter and the type of endograft. Data are presented as the mean ± standard deviation. Results: The mean preoperative suprarenal neck angulation in group O was 23.2°±18.0° compared with 23.8°±22.9° in group E (t test, p=0.91). The neck lengths were 29.2±14.6 and 23.2±11.0 mm in groups O and E, respectively (p=0.1). Similarly, the minimum and maximum neck diameters were 22.4±2.6 and 25±3.5 mm, respectively, in group O vs 23.3±3.6 mm and 27.0±5.7 mm, respectively, in group E (p=0.3 and 0.12, respectively). The maximum transverse diameters of the AAA in the 2 groups were comparable, that is, 57.0±9.0 mm in group O vs 53.2±11.1 mm in group E (p=0.17). The Ovation stent-graft caused greater decrease in the aortic neck angulation postoperatively compared with the Endurant device (13.2°±16.1° vs 6.1°±5.9°, p=0.04). Multiple regression analysis revealed that preoperative neck angulation (β coefficient 0.37, p<0.001) and the type of endograft (β coefficient −7.91, p=0.01) had significant influence on the postoperative neck angulation change. The intraclass correlation coefficient ranged from 0.951 to 0.990 for the preoperative measurements and from 0.911 to 0.999 for the postoperative measurements for each examiner or the total of estimates at the measurement time points. Conclusion: The Ovation stent-graft induces greater postoperative reduction in the AAA neck angulation compared to an endograft with stent-supported graft seal. Expanded research to infrarenal angle as well to greater angles and correlation to clinical events is justified.

Residual angulation of distal tibial diaphyseal fractures in children younger than ten years.

BackgroundThe purpose of this study was to evaluate the factors that influence residual angulation after treating pediatric distal tibial diaphyseal fractures.MethodsWe retrospectively reviewed the records of 75 children under the age of ten who were treated at two referral centers for distal tibial diaphyseal fractures. The mean patient age was 6.8 ± 2.3 years, and the mean follow-up duration was 4.1 ± 1.3 years (range, 3 to 6 years). Early postoperative and late follow-up radiographs were used to measure angulation.ResultsTwenty-four patients had valgus angulations >5° at the final follow-up. There was no varus, or anteroposterior residual angulations >5°. There was more residual valgus angulation when the postoperative angulation was >5° (p = 0.006) and when intramedullary nail and external fixators were applied for treatment (p = 0.004). Multivariate logistic regression analysis showed that postoperative angulation (adjusted odds ratio (OR) 4.33, 95% confidence interval (CI) 1.07–17.53) and treatment methods (intramedullary nail: adjusted OR 7.33, 95% CI 1.31–41.07; external fixator: adjusted OR 11.35, 95% CI 1.91–67.40 compared with the cast group) were associated with residual deformity.ConclusionsValgus angulation after pediatric distal tibial fractures persisted in this study sample. Accurate reduction should be performed to prevent residual deformity.

Primary surgical management by reduction and fixation of unstable hangman's fractures with discoligamentous instability or combined fractures

Several controversial issues arise in the management of unstable hangman's fractures. Some surgeons perform external reduction and immobilize the patient's neck in a halo vest, while others perform surgical reduction and internal fixation. The nonsurgical treatments with rigid collar or halo vest immobilization present problems, including nonunion, pseudarthrosis, skull fracture, and scalp laceration and may also fail to achieve anatomical realignment of the local C2-3 kyphosis. With recent advances in surgical technique and technology, surgical intervention is increasingly performed as the primary treatment in high cervical fractures. The outcomes of such surgeries are often superior to those of conservative treatment. The authors propose that surgical intervention as a primary management for hangman's fracture may avoid risks inherent in conservative management when severe circumferential discoligamentous instability is present and may reduce the risk of catastrophic results at the fracture site. The purposes of this study were to assess fracture healing following expedient reduction and surgical fixation and to propose a guideline for treatment of unstable hangman's fractures. From April 2006 to December 2011, the authors treated 105 patients with high cervical fractures. This study included 23 (21.9%) of these patients (15 men and 8 women; mean age 46.4 years) with Type II, IIa, and III hangman's fractures according to the Levine and Edwards classification. The patient's age, sex, mechanism of injury, associated injuries, neurological status, and complications were ascertained. The authors retrospectively assessed the clinical outcome (Neck Disability Index), radiological findings (disc height, translation, and angulation), and bony healing. The average follow-up period was 28.9 months (range 12-63.2 months). The overall average Neck Disability Index score at the time of this study was 6.6 ± 2.3. The average duration of hospitalization was 20.3 days, and fusion was achieved in all cases by 14.8 ± 1.6 weeks after surgery, as demonstrated on dynamic radiographs and cervical 3D CT scans. The mean pretreatment translation was 6.9 ± 3.2 mm, and the mean postoperative translation was 1.6 ± 1.8 mm (mean reduction 5.2 ± 3.1 mm). The initial angulation was 4.7° ± 5.3° and the postoperative angulation was 2.5° ± 1.8° (mean reduction 6.1° ± 5.3°). The preoperative and postoperative values for translation and angulation differed significantly (p < 0.05). The overall C2-3 disc height was 6.7 ± 1.2 mm preoperatively, whereas 3 months after surgery it was 6.4 ± 1.1 mm. These values did not differ significantly (p = 0.0963). The authors observed effective reduction and bony healing in cases of unstable hangman's fractures after fixation, and all patients experienced favorable clinical outcomes with neck pain improvement. The protocols allowed for physiological reconstruction of the fractured deformities and avoided external fixation. The authors suggest that posterior reduction and screw fixation should be used as a primary treatment to promote stability of hangman's fracture in the presence of discoligamentous instability or combined fractures.

Change of postoperative lateral angulation with different incision level in anterior approach for thoracolumbar fractures

Objective To analyze the relationship of the lateral angulation with the incision level after anterior approach operation for thoracolumbar fractures by evaluating the Cobb' s angle at different approach levels.Methods A retrospective study was done on 154 patients with thoracolumbar fractures treated consecutively with anterior operation from May 2004 to January 2008.The preoperative,postoperative and follow-up angle of coronal Cobb and the postoperative angle between screws and endplates on the anteroposterior radiograph were measured.According to the relationship between the injury vertebrae and the incision level,the patients were divided into two groups,ie,incision level ≥2 vertebrae group and incision level ≤ 1 vertebra group.Results All patients were followed up for 6-47 months(mean 37 months),which showed significant postoperative lateral angulation(P ＜ 0.01)especially at follow-up (P ＞ 0.05).The coronal Cobb' s angle showed insignificant difference before operation between two groups but it was increased after operation and during the follow-up(P ＜0.01).The screws A or B were more parallel to the endplate in two groups(P ＜ 0.01),while the parallel of the screws C or D to the endplate showed no statistical difference(P ＞ 0.05).Conclusions Compared with the operation with incision level ≥2 vertebrae,the operation with incision level ≤ 1 vertebra can more easily induce postoperative lateral angulation and exert a significant impact on implantation orientation of the vertebral screws A and B,which may indirectly lead to postoperative lateral angulation. Key words: Spinal fractures; Thoracic vertebrae; Lumbar vertebrae; Complication; Lateral angulation

A New Technique of Locked, Flexible Intramedullary Nailing of Spiral and Comminuted Fractures of the Metacarpals: A Series of 21 Cases

Spiral and comminuted fractures of the metacarpals are rotationally and axially unstable fractures with a tendency to shorten, which in turn causes significant extensor lag and loss of grip strength. We have designed a new, cheap and locally developed method of locked intramedullary nailing of these metacarpal fractures. We are presenting the results of our first 21 patients with 22 fractures treated by closed, fluoroscopically assisted, intramedullary K-wiring with proximal locking done by a specially designed locking pin. This was a retrospective, observational cohort study of all patients with spiral and comminuted fractures of metacarpals with minimum of 1year of follow-up and average follow-up of 14months (range, 12 to 26months). The patients were evaluated clinico-radiologically using range of motion, extensor lag, time to healing, amount of collapse, angulation and rotation and complications. All fractures had healed uneventfully with average time to union being 8weeks. Average metacarpal shortening was 2.04 ± 0.95mm, while the average post-operative angulation of the fracture was 4.81° ± 1.7. The metacarpophalangeal range-of-motion recovered almost fully with the average extensor lag being only 5.22° ± 2.42. Other than extensor tendinitis in two patients, there were no other complications. This method is cosmetically appealing, provides stable fixation, avoids periosteal stripping associated with open reduction and is associated with very low complication rate, and thus can be safely and effectively used for the treatment of these difficult fractures.

Association between anterior internal fixation systems and post-operative lateral angulation in thoracolumbar fractures

ObjectiveTo explore the effects of the anterior internal fixation systems on the post-operative lateral angulation in treatment of thoracolumbar fractures.Methods A retrospective study was done to analyze the 172 patients who had been consecutively treated by anterior internal fixation for thoracolumbar fractures between May 2004 and January 2008. They were 124 men and 48 women, with a man age of 39.0 years (from 15 through 70 years) . According to the internal fixation system, they were divided into 4 groups: Z-plate (63 cases), Antares (45 cases), Profile (50 cases) and Mono-screw-rod ( 14 cases).Radiographic scans were used to measure and compare the coronal Cobb angles between preoperation and postoperation as well as between the 4 groups.Results All the patients were followed up for 8 to 49 months (mean, 39 months) . The mean coronal Cobb angle was O. 8°±3.9° before operation, 3. 2°±4. 1°immediately after operation, and 3.5° ± 4. 2° at the final follow-up. In all the cases and the 4 groups, the postoperative lateral angulation was significantly larger compared to preoperation ( P ＜ 0. 05), but there was no significant difference between the last follow-up and postoperation ( P ＞ 0. 05). There were no significant differences in multiple comparison of postoperative coronal Cobb angles between the 4 internal fixation systems ( P ＞ O. 05) . There were no significant differences in ratio of postoperative lateral angulation between the 4internal fixation systems either ( P ＞ 0.05).Conclusion The current internal fixation systems are not associated with the postoperative lateral angulation in treatment of thoracolumbar fractures. Key words: Thoracic vertebrae; Lumbar vertebrae; Fractures; Fracture fixation, internal; Internal fixators

Pre-bend elastic stable intramedullary nail fixation for distal radial shaft fractures in children

Objective To investigate the functional and radiographic outcomes of pre-bent elastic stable intramedullary nail in treatment of distal radial shaft fractures in children. Methods From January 2006 to December 2008, 18 children with distal radial shaft fracture were treated by close reduction and internal fixation with a pre-bent elastic stable intramedullary nail. The age range was from 5 years to 15 years,with an average of 9 years and 8 months. All the cases were closed fractures, and followed up at least 12 months. The time interval from injury to surgery were 1 to 9 days. Fracture sites were located at the distal radial shaft. Among them, 15 cases suffered ipsilateral ulnar fracture, and the others for solitery radial fracture. Closed reductions were performed under C-arm fluoroscopy. All affected arms were immobilized in the functional position postoperatively by the plaster cast beyond elbows. Results The average time of fracture complete union was 5 months (ranged from 3 months to 7 months). The average preoperative angulation of the fractures: anteroposterior view 16.2±7.5 degrees, lateral view 26.2±13.1 degrees. The average postoperative angulation of the fractures: anteroposterior view 2.7±1.5 degrees, lateral view 1.4±1.2 degrees. All fractures maintained good alignment postoperatively, and 94.4% (17/18) of the patients regained a full range of rotation of the forearm. One patient suffered limitation of rotation in forearm less than 10°, and this had improved by final follow-up. Complications included soft tissue irritation at the site of nail insertion in one patient and transient scar hypersensitivity in another. Conclusion Fixation with a pre-bent elastic stable intramedullary nail is an effective, safe and convenient method for treating distal radial shaft fractures in children. Key words: Child; Radius fractures; Fracture fixation, intramedullary

Quantitative analysis of the variation in angles of the carpal arch after open and endoscopic carpal tunnel release

Previous studies have demonstrated that the volume of the carpal canal increases after open and endoscopic surgery in patients with carpal tunnel syndrome. There is some controversy regarding the contribution of the post operative widening of the carpal arch to the increment in carpal canal volume. The objectives of this study were to: 1) evaluate the degree of variation in the angles formed by the borders of the carpal arch following the surgical division of the transverse carpal ligament; and 2) determine if there are differences in the variation of these angles after the classical open surgery versus endoscopic carpal tunnel release.Methods. The authors prospectively studied 20 patients undergoing carpal tunnel syndrome surgery: 10 patients were treated via the standard open technique, and 10 underwent endoscopic carpal tunnel release. The angles of the carpal arch were measured on CT scans of the affected hand obtained before and immediately after the surgical procedures.Measurements were performed at the level of the pisiform-scaphoid hiatus and at the level of the hook of the hamate-trapezium hiatus. There was widening of the postoperative angles of the carpal arch after open and endoscopic division of the flexor retinaculum; however, the difference between pre- and postoperative angulations reached statistical significance only in those patients treated by means of the open procedure. The mean (+/- SD) values for the postoperative increase in the angles at the level of the pisiform-scaphoid hiatus were 5.1 +/- 0.4 degrees after open surgery and 2.5 +/- 0.3 degrees after the endoscopically assisted procedure (p < 0.05). At the level of the hook of the hamate-trapezium hiatus, the mean values for the widening of the angles were 6.2 +/- 0.6 degrees for the open surgery group and 1.2 +/- 0.4 degrees for those patients treated by means of the endoscopic technique (p < 0.05). The widening of the postoperative angles of the carpal arch is a phenomenon observed at the proximal and distal levels of the carpal canal, and it can be noted after both open and endoscopically assisted carpal tunnel release. The endoscopic procedure yielded less increase in these angles than the open surgery.

Esophageal angulation after hiatoplasty and fundoplication: a cause of dysphagia?

Hiatoplasty is generally considered an essential part of antireflux operations. Posterior closure of an enlarged hiatus may lead to anterior displacement of the esophagus and it may be contributory to postoperative dysphagia. The aims of this study were to (i) measure the normal esophageal anteroposterior angulation, (ii) evaluate the variation of the angulation after laparoscopic hiatoplasty and fundoplication, and (iii) correlate the angulation with postoperative dysphagia. Normal esophageal anteroposterior angle determined by barium preoperative barium esophagram was evaluated based on the study of 100 patients. Postoperative angulation was evaluated based on the study of 32 patients who underwent barium esophagram after laparoscopic hiatoplasty and fundoplication. The results showed that the normal esophageal anteroposterior angle was 150.4 +/- 10.7 (range 119-169) degrees. There was no correlation between the angle and gender (P = 0.6) or age (P = 0.1). Postoperative angle averaged 146.6 +/- 11.7 (range 122-170) degrees. Normal and post-operative angle were not different (P = 0.1). The difference between post- and preoperative angle averaged 0.7 +/- 8.9 (range -15-14). There was no statistically significant difference when pre- and post-operative angles were compared (P = 0.6). De novo dysphagia was present in 31% of the 32 postoperative patients. There was no statistically significant difference when the angles in patients with and without de novo dysphagia were compared (P = 0.2). We concluded that (i) laparoscopic hiatoplasty and fundoplication does not significantly change the esophageal anteroposterior angle; and (ii) de novo dysphagia is not with the esophageal anteroposterior angle.

THE MEASUREMENTS OF INTERVERTEBRAL FORAMINAL AREA AND ANGULATION OF CERVICAL VERTEBRA BEFORE AND AFTER ANTERIOR CERVICAL DISCECTOMY

Aim: There are two main problems after cervical discectomy without using bone graft or methalic instruments; angulation and foraminal stenosis. We evaluated these problems which occur after cervical discectomy. Methods: We viewed the control magnetic resonance images (MRI) of 13 patients who had been operated with simple anterior cervical discectomy, regarding the fact that at least one year had passed after operation. We measured the right and left side foraminal areas on the sagittal section of MRI. We also studied how the foraminal areas were affected from the postoperative angulation on the cervical vertebra. Results: In cases, where the intervertebral disc space had narrowed after the anterior cervical discectomy and where there was no appearance of forward angulation, the right and left side measurements revealed significant decrease (P≤0.05) (Wilcoxon) for the measurement of foraminal areas (patients 1-8). Clinically, all 8 cases had root irritation findings. Besides this situation, in the cases who had 100 or more forward angulation after the operation, there were significant increase (P≤0.05) (Wilcoxon) for the measurement of foraminal areas (patients 9-13). Clinically, these patients had muscular tension type headaches. Conclusion: It is well known that cervical spine arrangement is destroyed due to angulation and this causes chronic neck pains in the postoperative period. Despite this chronic pains, angulation is still a benefitial development for the patient because of the enlargement of the foraminal area. Although angulation is not an acceptable situtation for the arrangement of the spine, it may be preferable result when prognosis is concerned.

Congenital Sporadic Clinodactyly of the Index Finger

Congenital sporadic clinodactyly of the index finger is uncommon and has not been specifically investigated in previous reports. In this paper, we report on 10 cases with this deformity to investigate its clinical features and to document the results following a closing wedge osteotomy. The study demonstrated that clinodactyly of the index finger is a unique entity. It is unilateral, with male predominance. It is commonly associated with brachydactyly but is not associated with systemic anomalies or mental retardation. Finally, the study showed that the side of angulation of the index finger is consistently to the radial side. The closing wedge osteotomy technique obtained a satisfactory correction of the angulation in all patients (the mean preoperative angulation was 44 degrees and the mean postoperative angulation was 13 degrees). The cosmetic outcome was considered acceptable in 9 cases. In the remaining patient, the operated index finger appeared too short compared with the other fingers. We now believe that it was not appropriate to do a closing wedge osteotomy for all cases of sporadic clinodactyly of the index finger, and we have designed a new approach of management based on 3 factors: the severity of angulation, the age of the patient, and the relative degree of brachydactyly of the index finger compared with the adjacent middle finger.

Factors Associated with the Loss of Thickness of Polyethylene Tibial Bearings After Knee Arthroplasty

Wear of the polyethylene tibial bearing is a leading cause of failure of knee replacements done prior to the current decade. The objective of this study was to determine how patient-related factors, implant-related factors, and limb or tibial component alignment influenced the amount of thickness loss in polyethylene tibial bearings that were retrieved at the time of revision surgery or after the death of the patient. We retrieved polyethylene tibial bearings from eighty-one unicondylar and eighty-nine total knee replacements that had been performed because of osteoarthritis with varus deformity from 1984 to 1998. All of the polyethylene bearings had been sterilized with gamma radiation in air. Polyethylene loss was quantified as the change in the minimum bearing thickness per years in vivo (the mean time in vivo [and standard deviation] was 8 +/- 4 years). Multiple linear regression was used to assess whether polyethylene loss was associated with age, weight, gender, varus angle of the tibial component, postoperative hip-knee-ankle angle, initial thickness of the polyethylene, shelf age of the polyethylene, and either the type of polyethylene (for total knee replacements, which were of one posterior cruciate ligament-retaining design) or the manufacturer (for unicondylar knee replacements), and to determine the magnitude by which polyethylene loss would change if any of the significant risk factors were changed. The mean loss (and standard deviation) of polyethylene thickness in the medial compartment of total knee replacements (0.33 +/- 0.28 mm/yr) and that in medial unicompartmental knee replacements (0.49 +/- 0.40 mm/yr) were significantly (p < 0.05) associated with the same three variables: patient age, postoperative hip-knee-ankle angle, and shelf age of the polyethylene. A total knee bearing with a one-year increase in shelf age, a unicondylar knee bearing with a six-month increase in shelf age, a patient who was ten years younger at the time of operation, or a limb that was aligned in 5 degrees more varus (less valgus) had similar effects on the loss of polyethylene thickness in the medial compartment; the coefficients of the linear regression equations indicated that any one of these changes would increase polyethylene loss by 0.11 to 0.14 mm/yr. The wear-related loss of thickness in gamma-irradiated-in-air polyethylene bearings from unicondylar and total knee replacements implanted in osteoarthritic knees with varus deformity is influenced mainly by the shelf age of the polyethylene, the age of the patient, and the postoperative angulation of the knee in the coronal plane. Although polyethylene bearings have not been sterilized with gamma radiation in air since the end of the last decade, many arthroplasty patients have polyethylene bearings that were sterilized with use of this method. An understanding of the findings of this study may be of value as these patients return for follow-up care. Whether the study findings have relevance to bearings sterilized with other methods is unclear and will remain so for many years. Prognostic Level II.