Preoperative X-ray Research Articles

Preclinical Evaluation of a Novel 3D-Printed Movable Lumbar Vertebral Complex for Replacement: In Vivo and Biomechanical Evaluation of Goat Model.

Purpose This was an in vivo study to develop a novel movable lumbar artificial vertebral complex (MLVC) in a goat model. The purpose of this study was to evaluate clinical and biomechanical characteristics of MLVC and to provide preclinical data for a clinical trial in the future. Methods According to the preoperative X-ray and CT scan data of the lumbar vertebrae, 3D printing of a MLVC was designed and implanted in goats. The animals were randomly divided into three groups: intact, fusion, and nonfusion. In the intact group, only the lumbar vertebrae and intervertebral discs were exposed during surgery. Both the fusion and nonfusion groups underwent resection of the lumbar vertebral body and the adjacent intervertebral disc. Titanium cages and lateral plates were implanted in the fusion group. MLVC was implanted in the nonfusion group. All groups were evaluated by CT scan and micro-CT to observe the spinal fusion and tested using the mechanical tester at 6 months after operation. Results The imaging results showed that with the centrum, the artificial endplates of the titanium cage and MLVC formed compact bone trabeculae. In the in vitro biomechanical test, the average ROM of L3-4 and L4-5 for the nonfusion group was found to be similar to that of the intact group and significantly higher in comparison to that of the fusion group (P < 0.05). The average ROM of flexion, extension, lateral bending, and rotation in the L2-3 intervertebral space significantly increased in the fusion group compared with the intact group and the nonfusion group (P < 0.001). There were no significant differences in flexion, extension, lateral bending, and rotation between the nonfusion and intact groups (P > 0.05). The average ROM of flexion, extension, lateral bending, and rotation in the L2-5 intervertebral space was not significantly different between the intact group, the fusion group, and the nonfusion group, and there was no statistical significance (P > 0.05). HE staining results did not find any metal and polyethylene debris caused by abrasion. Conclusion In vivo MLVC can not only reconstruct the height and stability of the centrum of the operative segment but also retain the movement of the corresponding segment.

Glenoid Component Position Does Not Affect Short-Term Clinical and Radiologic Outcomes in Total Shoulder Arthroplasty.

Background: Malpositioning of the glenoid component in total shoulder arthroplasty (TSA) remains the primary source of loosening. The purpose of this study is firstly, to quantify postoperative glenoid component position in patients having a TSA and secondly, to explore whether glenoid component radiolucency is associated with glenoid position, clinical outcomes and patient-reported measures in the short-term (two year) follow-up period. Methods: This study was a sub-study of a larger clinical trial that included patients who underwent a TSA and who were randomized into two different glenoid types with a minimum two-year follow-up period. Post-operative radiographic assessments (six weeks and two years) were used to measure glenoid component position (version, inclination, offset) and humeral head centering anterior–posterior (AP) and superior–inferior (SI), and to assess glenoid component radiolucent scoring (modified Lazarus). Pre-operative X-rays were used to measure glenoid version, inclination and Walch classification. Patient-reported measures (PROMs) included the EQ-5D health slider and the Western Ontario Osteoarthritis (WOOS) and American Shoulder and Elbow Surgeons (ASES) score and were captured at baseline and two years postoperative. Clinical outcomes including range of motion and complications were also documented. Statistical analysis included t-tests and regression modeling. Results: Ninety-one patients with an average age of 69.9 ± 6.2 years were included in this study. Glenoid component position improved significantly in version (−19.4 ± 8.6° to −17.7 ± 8.5°; p < 0.045) and inclination (11.5 ± 7.1° to 5.9 ± 6.3°; p < 0.00001) from preoperative to six weeks postoperative. Glenoid component offset in SI and humeral head centering in AP remained unchanged throughout the follow-up. Radiolucency (Lazarus classification) was recorded in 21 cases (17.3%) with a Lazarus score of 1 (15 cases) and 2 (6 cases). The EQ-5D health slider, WOOS and ASES, and ROM confirmed continuous improvements from the preoperative scores to the two-year follow-up (p < 0.05). Regression models showed no correlation between glenoid component radiolucency at two years and the postoperative week six glenoid component position; however, female gender was a significant variable. Conclusion: Glenoid component changes from its original native glenoid were observed following TSA. Glenoid inclination was improved more than version from baseline, and the humeral head remained well-centered in AP and SI at two years. Radiolucency of the glenoid at two years is not negatively associated with PROMs or component position; however, female gender was identified as a significant predictor and warrants further investigation. Complications are not associated with glenoid position or radiolucency, but longer-term follow-up is required.

Clinical application of sacral alar screw fixation in surgical treatment of lumbosacral degenerative disease

Objective: To verify the safety and feasibility of sacral alar screw fixation and fusion surgery in lumbosacral area. Methods: The clinical and radiological data of patients receiving L5/S1 single-level cortical bone trajectory screw combined with sacral alar screw decompression fixation and fusion in Beijing Chaoyang Hospital due to lumbar spinal stenosis from January 2019 to January 2020 were retrospectively analyzed. The clinical data included operation duration, intraoperative blood loss, postoperative drainage, pain and function scores during follow-up. The radiological data included preoperative and postoperative follow-up X-rays and three-dimensional reconstruction of lumbar spine CT. The fusion status and complication of internal fixation, such as screw loosening and fixation failure were evaluated by the radiological examination. Results: According to the inclusion and exclusion criteria, a total of 16 patients (7 males and 9 females) were included, with an average age of (69.6±5.2) years. The patients were followed-up for (16.2±1.7) months. The average operation duration was (144±21) min, the intraoperative blood loss was (103±20) ml, and the postoperative drainage was (80±34) ml. The patient's low back pain visual analogue scale (VAS) score was 6.8±1.0 before surgery, and it was improved to 0.9±0.7 at the last follow-up; leg pain VAS score was 6.1±0.9 before the operation and it improved to 0.9±0.7 at the last follow-up; Oswestry disability index (ODI) function score was 66.2%±8.0% before the surgery and it decreased to 26.6%±7.2% at the last follow-up. No neurological complications, surgical site infection, screw loosening, internal fixation failure or cage displacement were observed during the follow-up. The fusion rate was 68.8% (11/16) at 6 months post operation. Conclusion: It is safe, feasible and effective to apply cortical screws combined with sacral alar screws in short-segment decompression, fixation and fusion surgery on the lumbosacral region to treat lumbosacral spinal stenosis.

Ganz osteotomy for treatment of hip dysplasia through intra-pelvic approach. Early results.

Ganz periacetabular osteotomy (PAO) is a technically demanding surgical procedure. It requires cutting around the acetabulum to mobilize it under fluoro- scopic control. The radiolucent table and good quality imaging are mandatory to perform this osteotomy in a safe way. Modification of Ganz osteotomy was developed a with minimal soft tissue exposure using intra-pelvic approach which allows direct visualization of the quadrilateral plate. The purpose of the present study was to review the early results in the initial group of patients who had this procedure. The Ganz PAO was performed on 8 cases painful dysplastic hips, using the intra-pelvic approach through the Pfannenstiel incision. All of the osteotomies were performed under fluoroscopic control and direct visualizing the osteotomy site from the same incision. The acetabular fragment was medialized and redirected anterolaterally then fixed with 3 screws. The pre-operative Harris hip score mean was 66.8 and improved to be 92.7 (p value <0.0005) and this was statistically significant. Radiologically the CEA improved in the pre-operative X-ray from mean of 13.12 degree to 28.37 degrees (p value <0.0005) and this was statistically significant. Painful dysplastic hips should be treated before function becomes seriously impaired. The Ganz osteotomy through an intra-pelvic approach, can be done with minimal exposure to radiation in a relatively short time.

Hanging radiograph in idiopathic scoliosis patients: significance as a preoperative stress X-ray.

Before corrective surgery for idiopathic scoliosis, the stress X-rays are indispensable to collect information regarding the reducibility of deformity, deciding fusion levels, and categorizing curve types and so on. The hanging radiograph has not been conducted preoperatively so far as known. The objective of this study was to investigate retrospectively the significance of the hanging radiograph for prediction of the curve correction with surgical procedure by comparing with the side-bending and the traction radiographs. The subjects enrolled in current study were 22 cases of idiopathic scoliosis who performed posterior instrumentation and fusion by ISOLA method between 2008 and 2014. They included 2 males and 20 females, with a mean age of 16 years and 8 months. The type of curves by Lenke classification were type 1 in 20 cases, type 2 in 1 case, and type 3 in 1 case. We investigated the correction rates of main thoracic curves in side-bending, traction, and hanging positions and compared them with that after surgery. In addition, correction indices were also calculated and compared among these stress X-rays. The correction rate after surgery was 65.9% that was statistically higher than those in side-bending (44.2%), traction (46.6%), and hanging (22.1%) positions. There were statistical correlations between the correction rates after surgery and in side-bending position (R=0.73) and those after surgery and in traction position (R=0.57). However, there was no statistical correlation between the correction rates after surgery and in hanging position (R=-0.01). With regard to the correction indices, that in hanging position (3.67) was statistically higher than those in side-bending (1.51) and traction (1.45) positions. The correction rates in side-bending and traction positions seem to be useful to estimate the amount of curve correction before surgery. Whereas, that in hanging position did not have any significance as preoperative evaluation.

Predictive Factors of Keloid Formation in Congenital Foot Syndactyly.

Background:Keloid formation after syndactyly division is a stressful situation for patients. In our experience, digital enlargement may be involved in keloid formation following syndactyly divisions. Therefore, we aimed to identify predictive factors and reference values for keloid formation.Methods:In this retrospective study, 11 keloid patients (seven children, four adults) and 11 nonkeloid patients after syndactyly division (control group) with the same sex, age, webspace division site, and operation were enrolled between 2008 and 2020. Using preoperative x-ray images, we compared bony width, length, area, and protruding index relative to the great toe between keloid and control groups. Additionally, reference values for keloid formation were obtained using receiver operating characteristic curves. Statistical analysis was performed using Spearman’s correlation test.Results:When compared with the same digit in the normal foot, distal phalanx (P3) bony base width, area, and protruding index on keloid foot were significantly different between keloid group and control group. The reference values for keloid formation after syndactyly release were 1.34 for the P3 area ratio and 1.61 for the P3 triangular area ratio (using the horizontal length of the P3 base and P3 vertical length). The reliability of reference values for the P3 area ratio and P3 triangular area ratio was excellent for all patients.Conclusions:If digital enlargement in distal phalanx is present when compared with adjacent toe in patients who had undergone primary foot syndactyly divisions, risk of keloid development should be communicated preoperatively, and preventive strategies for keloid development and close observations are required.

Trancatheter embolization of pulmonary artery pseudoaneurysm with detachable coils in association with non-adhesive liquid embolizing agent (Squid).

A nodular lesion at the lower left pulmonary lobe was detected in a 46 years old male during a preoperative chest X-Ray for appendicitis. To further characterise the nodule, a contrast enhanced computed tomography (CE-CT) was performed showing a 20 mm vascular lesion, which was suspected to be a pseudoaneurysm. The diagnostic angiography detected a flattening of the vascular wall with a voluminous pseudoaneurysm (PSA) in the distal portion of the tributary branch of the inferior left lobe. To treat the lesion, a 2.9F microcatheter was advanced into the sac and 4 detachable coils were placed (16-18mm Penumbra Inc) to pack the PSA. To block vascular supply to the lesion, the feeding artery was embolized with an ethylene vinyl alcohol copolymer agent (Squid Peri 18, Emboflu). The final angiographic control showed the exclusion of the pseudoaneurysmal sac which was confirmed by SEMAR™ reconstructed CE-CT scan after 40 days. Furthermore, no signs of pulmonary infarction were reported. (www.actabiomedica.it).

EP.TH.164Staging CXR preoperatively in invasive breast cancer, is it time it should be abandoned? A single-centre cohort review of its utility

Abstract Aim The use of preoperative chest x-rays (pCXR) for staging in invasive breast cancer has uncertain benefit. This review aimed to ascertain its utility in this cohort in a single centre. Methods Retrospective cohort review of consecutive patients with invasive breast cancer planned for surgery for 2018 was carried out. An 18-month follow-up allowed the identification of any subsequent lung pathology that may have potentially been seen on pCXR. Patients who had staging CT instead were excluded. Formal reports of pCXR and any subsequent imaging were reviewed. Results 244 patients with invasive breast cancer that was planned for surgery for 2018 were identified, 214 of whom had pCXR. 194 had no abnormalities reported. 16 had lung pathology; eight were indeterminate and were advised to have follow-up imaging. Of the six who had follow-up CTs, three had lung nodules; they were all subsequently discharged from follow-up as they were determined as benign. At 18 months, nine patients had new thoracic pathology: two had metastatic lung disease; six had lung nodules requiring follow-up. All nine patients’ pCXRs were reported as normal. Conclusions pCXR for invasive breast cancer has limited, if any, utility; it does not identify any management-altering pathology. Those that developed malignancy were not predicted by pCXR, but identified by post-operative symptoms, or on staging CT directed by post-operative nodal status. pCXR in this cohort, in the absence of respiratory symptoms, should therefore be discontinued. This would reduce cost, radiation exposure, hospital footfall, radiology reporting time, and likely improve patient satisfaction.

Surgical Outcomes in Pediatric Patients Testing Positive for SARS-CoV-2

Introduction: In this study we aimed to determine surgical outcomes of pediatric patients undergoing surgery with perioperative severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) diagnosis. Methods: We examined all patients 18 years old and younger who underwent surgery at a children's hospital and tested positive for SARS-CoV-2 within 1 week before or after their procedure. Age-matched control patients who underwent similar procedures over the past ten years were included in a 3:1 ratio. The primary outcome of our study was 7- and 30-day mortality rates. Secondary outcomes in our study were postoperative pulmonary complications, specifically unexpected ventilation, pneumonia, or acute respiratory distress syndrome. Other outcomes included postoperative hospital stay, ICU admission, and readmission for surgical complications. Results: Our study included 43 procedures performed on 39 patients who tested positive for SARS-CoV-2 and underwent surgery from March 1, 2020 to December 31, 2020. No 7- or 30-day mortality events were observed in any patients. Pulmonary complications were observed in 3 out of 43 (7%) surgeries performed on patients with perioperative SARS-CoV-2 diagnosis, and no pulmonary complications were observed in 124 surgeries performed on patients without SARS-CoV-2 diagnosis (p=.003). SARS-CoV-2 diagnosis did not affect length or occurrence of postoperative hospital stay, ICU admission, and readmission for surgical complications. Abnormal preoperative chest x-ray and preoperative blood pressure were also associated with pulmonary complications in additional analyses (p=.02 and.01, respectively). Conclusion: Our results indicate that pediatric patients undergoing surgery with perioperative SARS-CoV-2 diagnosis may be at increased risk for pulmonary complications.

Lumbar Stabilization with DSS-HPS® System: Radiological Outcomes and Correlation with Adjacent Segment Degeneration.

Arthrodesis has always been considered the main treatment of degenerative lumbar disease. Adjacent segment degeneration is one of the major topics related to fusion surgery. Non-fusion surgery may prevent this because of the protective effect of persisting segmental motion. The aims of the study were (1) to describe the radiological outcomes in the adjacent vertebral segment after lumbar stabilization with DSS-HPS® system and (2) to verify the hypothesis that this system prevents the degeneration of the adjacent segment. This is a retrospective monocentric analysis of twenty-seven patients affected by degenerative lumbar disease underwent spinal hybrid stabilization with the DSS-HPS® system between January 2016 and January 2019. All patients completed 1-year radiological follow-up. Preoperative X-rays and magnetic resonance images, as well as postoperative radiographs at 1, 6 and 12 months, were evaluated by one single observer. Pre- and post-operative anterior and posterior disc height at the dynamic (DL) and adjacent level (AL) were measured; segmental angle (SA) of the dynamized level were measured. There was a statistically significant decrease of both anterior (p = 0.0003 for the DL, p = 0.036 for the AL) and posterior disc height (p = 0.00000 for the DL, p = 0.00032 for the AL); there were a statistically significant variations of the segmental angle (p = 0.00000). Eleven cases (40.7%) of radiological progression of disc degeneration were found. The DSS-HPS® system does not seem to reduce progression of lumbar disc degeneration in a radiologic evaluation, both in the dynamized and adjacent level.

INTRAOPERATIVE MANAGEMENT OF A NEWBORN WITH COR TRIATRIUM DEXTRUM: A CHALLENGING CASE

Introduction Cor triatrium dextrum is an extremely rare cardiac condition with an incidence of Methods CASE REPORT: Informed parental consent was obtained to present this case. A 20-day-old term infant weighing 2.8 kg was admitted for progressive cyanosis and difficulties to thrive. At physical examination the newborn had a peripheral oxygen saturation of 75%. Preoperative chest X-ray showed a clog-shaped heart. Preoperative NT pro-BNP was 2311 ng/L. Repeated transthoracic echocardiography confirmed the diagnosis of cor triatrium dextrum and a R-to-L shunt through a patent foramen ovale. Distal pulmonary arteries were small for age. Surgery was scheduled. At the induction of anesthesia specific attention was paid to maintain normovolemia and a blood pressure and heart rate as compared to baseline values. Induction of anesthesia was performed with 2 mg Ketamine, 0.2 mg midazolam and 2 µg sufentanil. Tracheal intubation was facilitated with cisatracurium. Anesthesia was maintained with 1% Sevoflurane and a continuous infusion of sufentanil. Intraoperative transesophageal echocardiography (TEE) confirmed the diagnosis. The TEE 4 chamber view showed a membrane within the RA (Figure 1A) with a spinnaker movement in diastole when it was bulging into the TV (Figure 2). Laterally, there was an opening within the membrane permitting turbulent blood flow from the RA through the TV (Figure 1B). Resection of the membrane was uneventful and the foramen ovale was closed. Weaning from cardiopulmonary bypass (CPB) was facilitated with a continuous infusion of milrinone. Results Figures 1A and 1B: Intraoperative TEE view of the membrane. Discussion Cor triatrium dextrum being an extremely rare CHD, anesthesiologists may not be familiar with its clinical presentations. Depending on the degree of the RA obstruction, poor right ventricle (RV) filling and compromised pulmonary blood flow may occur. Neonatal cyanosis may appear due to streaming of the blood from the RA across the atrial septum to the left atrium. Intraoperative actions need to be taken in order to increase RV filling. In this case the opening from the RA to the RV resulted in turbulent flow but intraoperative hemodynamic optimization increased this forward flow and prevented any oxygen saturation concentrations LEARNING POINTS 1. Anesthesiologists need to be aware of intraoperative hemodynamic instability and cyanosis due to the obstructive membrane within RA in case of cor triatrium dextrum. 2. Pre CPB TEE should carefully evaluate the TV that may mimick an Ebstein anomaly as the membrane may bulge into the TV.

A CASE OF PLASTIC BRONCHITIS POST EBUS-TBNA

TOPIC: Lung Pathology TYPE: Medical Student/Resident Case Reports INTRODUCTION: Plastic bronchitis (PB) is a disorder in which intrapulmonary lymphatic overload or leakage causes retrograde thoracic lymphatic flow into lungs, forming mucofibrinous bronchial casts that can result in significant airway obstruction. PB is associated with congenital heart disease in children; in adults, etiology is less clear. Presentation is expectoration of thick, rubbery secretions with histopathology revealing cross-linked branching of mucin-containing, lymphocyte-predominant casts. However, without high clinical suspicion, this can be confused with mucous plugging or pneumonia. Here we present a case of plastic bronchitis in a patient after EBUS-TBNA for diagnosing and staging a lung nodule. CASE PRESENTATION: A 75-year-old woman with history of COPD and remote breast cancer with right mastectomy and radiation underwent EBUS with FNA of a right middle lobe lung mass found incidentally on a pre-operative chest x-ray. She was diagnosed with Stage III squamous cell carcinoma of the lung after EBUS-TBNA was done on stations 4R,7 and 11Rs. Shortly after EBUS she developed cough that progressed to acute dyspnea, wheezing and thick rubbery sputum production that did not improve with course of antibiotics and prednisone. Chest CT showed atelectasis of right upper and middle lobe with ground-glass opacification and interlobular septal thickening in right lower lobe. Bronchoscopy revealed an obstructive cast in the bronchus intermedius, extending into right middle and lower lobes, that was removed with Cryoprobe. Histopathology showed mucofibrinous material with lymphocytes & foamy macrophages consistent with Type II plastic bronchitis cast. She underwent IR lymphangiogram which showed proliferation of right mediastinal & intrapulmonary lymphatic channels with lobar/interlobar lymphadenopathy. She was treated with percutaneous embolization of thoracic duct and right mainstem peribronchial lymphatic channels, complicated by post-procedure pancreatitis. Symptoms slowly improved with aggressive chest physiotherapy and bronchodilators. No obstructive casts were seen on repeat bronchoscopy. One month later she was able to be discharged to begin chemo radiation. DISCUSSION: PB is likely more common than reported and most literature has focused on pediatric cases. PB can cause life-threatening events in 40 percent of cases, particularly if mis-diagnosed, and causative etiologies in adults are not fully understood. This patient's remote history of mastectomy with lymph node dissection and active malignancy may have put her at risk but the timing of symptoms raise concern that the EBUS itself may have been the trigger for development of PB. CONCLUSIONS: Our case illustrates that PB should be considered as a complication that can arise post EBUS in patients with impaired lymphatic drainage and previous radiation treatment. To the best of our knowledge this is the first reported case of PB post EBUS-TBNA. REFERENCE #1: Rubin B. Plastic Bronchitis. Clinics in Chest Medicine 2016; 37(3):405. REFERENCE #2: Coen M, Daniel L, Serratrice J. An adult case of plastic bronchitis: a rare and multifactorial disease. J Thorac Dis. 2018;10(1):E16-E19. REFERENCE #3: Madsen P, Shah SA, Rubin BK. Plastic bronchitis: new insights and a classification scheme. Paediatr Respir Rev 2005;6:292-300. DISCLOSURES: No relevant relationships by Edward Adams, source=Web Response No relevant relationships by Abduljabbar Dheyab, source=Web Response No relevant relationships by Shaun Toomey, source=Web Response

Morphological analysis of coronal femoral intertrochanteric fracture and its effect on reduction and internal fixation

To investigate the morphology of coronal femoral intertrochanteric fracture and its effect on reduction and internal fixation. The clinical and imaging data of 46 patients with femoral intertrochanteric fracture who met the selection criteria between August 2017 and October 2018 were reviewed. There were 15 males and 31 females; the age ranged from 62 to 91 years, with an average of 72.8 years. The causes of injury included walking falls in 35 cases, falling out of bed in 4 cases, and traffic accidents in 7 cases. The AO/Orthopaedic Trauma Association classification was type 31-A1 in 11 cases and type 31-A2 in 35 cases. All patients underwent closed reduction and internal fixation with intramedullary nails. During the operation, fracture reduction and fixation were performed according to the preoperative evaluation results. According to the patients' preoperative X-ray film and CT three-dimensional reconstruction images, the direction of the coronal fracture line of the femoral intertrochanter and the morphological characteristics of the fracture block were observed; and the coronal fracture discrimination analysis was carried out for the fractures of different AO/OTA types. The percentages of coronal femoral intertrochanteric fractures diagnosed by preoperative X-ray film and CT three-dimensional reconstruction were calculated and statistically analyzed. The fracture reduction, the position of internal fixation [measurement of tip-apex distance (TAD)]. and the reliability of internal fixation were observed after operation. X-ray film was not easy to identify coronary fracture, and the coronal fracture line and the shape of the fracture piece weree clearly visible in CT three-dimensional reconstruction images. The morphological characteristics of the coronary fracture block: in AO/OTA 31-A1 type, the fracture line extended obliquely backward from the anterior tip of the large rotor, above the small rotor with or without small rotor fracture; in AO/OTA 31-A2 type, fracture line extended obliquely backward from the anterior tip of the large rotor to below the small rotor. Thirteen cases (28.3%) of coronal fractures were found on preoperative X-ray films, and 35 cases (76.1%) were found by CT three-dimensional reconstruction, showing significant difference ( χ 2=21.083, P=0.000). In AO/OTA 31-A1 type patients, the proportion of coronal fractures found by X-ray film and CT three-dimensional reconstruction was 18.2% (2/11) and 54.5% (6/11), respectively, and that in AO/OTA 31-A2 type patients was 31.4% (11/35) and 82.9% (29/35), respectively, showing significant differences ( χ 2=3.143, P=0.000; χ 2=20.902, P=0.000). Among the 35 patients with coronal fractures, 6 cases (17.1%) of AO/OTA 31-A1 type, 29 cases (82.9%) of AO/OTA 31-A2 type. The operation time of the patient was 80-112 minutes, with an average of 95 minutes; the intraoperative blood loss was 180-450 mL, with an average of 360 mL. There was no complication such as infection, falling pneumonia, and deep vein thrombosis of the lower extremities. At 3 days after operation, the internal fixators were all in the proper position. The TAD was 0.9-1.8 cm, with an average of 1.4 cm. All patients were followed up 14-18 months, with an average of 16 months. All the fractures healed osseously, and there was no complication such as nonunion and loosening of internal fixation. CT three-dimensional reconstruction can better identify coronal femoral intertrochanteric fractures than X-ray films, and accurately recognize and analyze the incidence and morphological characteristics of coronal fractures, which can help formulate more effective surgical strategies to promote patient recovery.

Oligosymptomatic tumors – Traps for doctors and patients

Abstract Few patients are fortunate enough to get detected in the early stages of tumors whether benignant or malignant. This chance, with multiple hidden ethical issues, has pitfalls for both doctors and patients. We are presenting two cases, a male and a female with diagnosis problems successfully managed even if they are not convinced about the necessity of the surgery. The male, aged 63 years, non-smoker, with occupational exposure for 41 years, oligosymptomatic, during a preoperative routine X-ray and thorax CT for a left hydrocele operated in June 2020, was identified an acidophilic tumor formation, located in the anterior mediastinum. Additional investigations revealed a left vocal cord paresis and the transthoracic needle biopsy raised suspicion of thymoma with glandular areas and clear cells, also confirmed by surgery, an N0 stage. In the second case, a 42 years female with a recent history of SARS-COV-2 viral infection, mild clinical form, while performing a CT scan to assess COVID status, discovered a tumor mass located in the anterior mediastinum. ENT examination establishes the diagnoses of subacute laryngitis, dysphonic syndrome under etiological observation, and chronic rhinitis. The excision of the mediastinal formation is performed with favorable postoperative evolution. Histopathological examination highlighted changes that argue the diagnosis of mature intrathymic teratoma. Apparently, there were fortunate cases with curative resection, but being oligosymptomatic also involved substantial efforts to convince the patient and the caregivers about the need for urgent surgery.

Distal interphalangeal Joint Arthrodesis using only Kirschner Wires in small distal Phalanges.

To report the clinical and radiographic results of arthrodesis of relatively small-sized distal interphalangeal joints (DIPJs) using only K-wire fixation. Between January 2000 and December 2018 28 arthrodesis in 21 patients (9 males and 12 females with an average age of 52.1 years) with relatively small-sized DIPJs were performed using only K-wires. Data on patient's characteristics, such as age, sex, affected finger, and the number and size of the used k-wires were collected from the medical database. The narrowest diameter of the cortex and medulla of the distal phalanx was measured on preoperative plain radiographs. The time to union and the arthrodesis angle was determined using serial X-ray radiography follow-up. Preoperatively and at the latest follow-up examination, pain using the visual analogue scale (VAS) and the quick DASH score was registered. In addition, complications were investigated. Average follow-up period was 11.4 months. The small finger was mostly affected (n = 12; 42.9 %). The narrowest diameters of the distal phalanx cortex and the medulla measured on preoperative X-ray images were 2.8 mm (SD 0.5) and 1.2 mm (SD 0.4), respectively. Seven fusions were done with use of 1 K-wire, 20 with 2 (71.4 %), and 1 with 3 K-wires. The most common K-wire sizes were 1.1-inch (24 K-wires = 48 %), and 0.9 inch (21 K-wires = 42 %) The preoperative VAS score and quick DASH score improved from 6.1 (range: 0-9) and 25.8 (range: 2-38) to 0.4 (range: 0-2) and 3.4 (range: 0-10.2), respectively. 25 (89.3 %) out of 28 fingers achieved bony union in an average of 96.1 days (range: 58-114) with three non-union. Arthrodesis of small DIPJs with K-wire fixation has a high success rate. Therefore, we suggest K-wire fixation as an acceptable alternative for patients with a small phalanx which may be at risk of mismatch with bigger implants. However, concerns remain in terms of fusion delay with K-wire only fixation.

Evaluation of anteroposterior accelerometric change after bi-cruciate stabilized total knee arthroplasty and posterior stabilized total knee arthroplasty

BackgroundIn conventional total knee arthroplasty (TKA), the anterior cruciate ligament (ACL) is resected. ACL dysfunction causes knee instability and is regarded as one factor in poor TKA outcomes. In bi-cruciate stabilized (BCS) TKA, the implant reproduces ACL function and provides anterior stability. The objective of this study was to evaluate preoperative and postoperative X-rays and accelerometer gait measurements in patients who underwent BCS TKA and posterior-stabilized (PS) TKA to assess the postoperative acceleration changes of knees after these procedures and to compare them in terms of joint range of motion (ROM) and the New Knee Society Score (New KSS). MethodsThe subjects were 60 patients, 30 of whom underwent BCS TKA and 30 PS TKA. Joint ROM, New KSS, lateral X-rays of the standing extended knee, and accelerometer data were evaluated 12 months postoperatively. ResultsThere was no significant difference in joint ROM between the groups. Both had good New KSS results, but the functional activity score was significantly higher after BCS TKA than after PS TKA. X-rays showed a lower posterior offset ratio after BCS TKA than after PS TKA, with anteroposterior positioning closer to that of the normal knee.Accelerometer data showed that postoperative anteroposterior acceleration on the femoral side in the stance phase and swing phase was lower after BCS TKA than after PS TKA. ConclusionCompared with PS TKA, BCS TKA resulted in a higher functional activity score, closer positioning to that of the normal knee on lateral X-ray, and lower anteroposterior acceleration on the femoral side.

P82. Limited bend out of proximal thoracic curve is associated with add on phenomenon following posterior surgery for Lenke 1A curves

<h3>BACKGROUND CONTEXT</h3> Add-on phenomenon following posterior surgery for Lenke 1A curves has been studied and lowest instrumented vertebra (LIV) selection, skeletal immaturity, and L4 right vertebral tilt have been identified as risk factors. To minimize the risk, LIV has been recommended to be set at the last substantially touched vertebra (LSTV); however, add-on phenomenon has been observed even when LIV was set at LSTV and immediate postop X-rays showed minimal residual curve. To study the possible causes in this scenario, we can keep LIV consistently at or immediately adjacent to LSTV and compare characteristics between curves with and curves without add-on phenomenon. <h3>PURPOSE</h3> To study risk factors for add-on phenomenon while keeping LIV consistently at or immediately adjacent to LSTV. <h3>STUDY DESIGN/SETTING</h3> Case control study, single institution. <h3>PATIENT SAMPLE</h3> We identified 21 consecutive patients who had Lenke 1A curves, preop upper thoracic bending X-rays, and minimum of 2 year follow-up from patients who underwent posterior scoliosis surgery at a single institution from 2006 to 2017. <h3>METHODS</h3> We used billing records to identify patients who underwent posterior scoliosis surgery from 2006 to 2017 at a single institution. From the 21 patients who met our criteria, we obtained age at presentation and at time of surgery from medical records. The main thoracic curve (MT), proximal thoracic curve (PT), and PT bend out Cobb angle, % PT correction on bend out = (PT - PT on bend out)/PT, Risser stage, and L4 tilt were determined from preop X-rays. Upper instrumented vertebra (UIV) was either T3 or T4. LIV was at or immediately adjacent LSTV such that if LSTV was: a) T12, LIV was primarily L1 (LSTV+1); b) L1, LIV was L1; c) L2, LIV was L1 if L1 was neutral on bending xrays (LSTV-1) and L2 if not (LSTV); d) L3, LIV was L2 (LSTV -1). Residual curve, lowest instrumented vertebra adjacent disc angle (LIVDA), and lumbar curve were measured in first (avg 2 months) and last follow-up (avg. 40 months). Add-on phenomenon was defined as (1) an increase in the residual Cobb angle of at least 10°, (2) an increase in the lumbar curve of 5 ° (3) increase in LIVDA of greater than 5 °. <h3>RESULTS</h3> The residual curve progressed more than 10 ° in 3 patients between two follow-ups, 1/3 of whom had progression of LIVDA of greater than 5 ° and 2/3 of whom had progression of the lumbar curve of more than 5 °. These 3 patients were the add-on group (AG). None of the other 18 patients met any of the criteria for add-on phenomenon and were the non-add-on group (nAG). There were no significant differences between the two groups in the age at the time of presentation or surgery, Risser stage, preoperative MT and PT. One out of 3 patients in AG and 10/18 patients in nAG had L4 tilt to the right (p=0.59). LIV=LSTV-1 did not appear to be a risk factor (p=0.38); all 8 of those patients were in the nAG while 3 patients in AG had LIV either at LSTV or LSTV+1. PT bend out Cobb angles were statistically larger (25.7o +/- 2.1o, range 24 to 28, versus 10.8o +/- 5.5 °, range 0 to 21, p=0.0002) and the % PT correction with bend out was statistically lower (5.0 +/- 2.7%, range 3 to 8, versus 53 +/- 19%, range 25 to 100, p=0.0004) in the AG compared to the nAG. <h3>CONCLUSIONS</h3> We demonstrated an association between add-on phenomenon and limited correction of PT on bend out in Lenke 1A curves where the LIV was primarily at or immediately adjacent to LSTV. If % PT correction with bend out is less than 10%, the surgeon may consider treating the curve as a Lenke 2A curve and set UIV at T1 or T2. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

74. Novel artificial intelligence algorithm can accurately and independently measure spinopelvic parameters

<h3>BACKGROUND CONTEXT</h3> Preoperative and postoperative sagittal plane assessment is crucial in both spinal deformity and degenerative pathologies. Sagittal malalignment is a well-established cause of poor patient reported outcomes. There is a growing need for an automated analysis tool that measures pelvic parameters with speed, precision and reproducibility without relying on user identified landmarks. A new AI algorithm has been developed to measure important radiographic parameters independently. <h3>PURPOSE</h3> The analysis of sagittal alignment by measuring spinopelvic parameters has been widely adopted among spine surgeons globally. The currently available spine measurement software programs require users to identify several landmarks prior to calculating parameters, making them time consuming and more reliant upon user experience. This study evaluates and demonstrates that an algorithm based on artificial intelligence (AI) can independently determine spinopelvic parameters. This allows for precise radiographic measurement without time-intensive human input. We hypothesize that the novel, fully automatic method will have a high agreement with human measurements for lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT) and sacral slope (SS). <h3>STUDY DESIGN/SETTING</h3> Evaluation of the inter-rater reliability and mean error between radiographic measurements of the AI algorithm and expert human raters. Radiographs were retrospectively reviewed from a single site, multisurgeon center. <h3>PATIENT SAMPLE</h3> In this study, preoperative and postoperative X-rays were evaluated in 100 patients undergoing a lumbar fusion procedure. <h3>METHODS</h3> From a total of 200 lateral lumbar radiographs (preoperative and postoperative images from 100 patients undergoing fusion) 5 independent observers (4 spinal surgeons, 1 senior researcher) digitally measured LL, PI, PT and SS. Their parameters were compared with AI algorithm generated parameters. Mean error (95% confidence interval, standard deviation) and inter-rater reliability were assessed using 2-way mixed, single-measure intraclass correlation (ICC). ICC values larger than 0.75 were considered excellent. <h3>RESULTS</h3> The novel algorithm's spinopelvic parameter ICC values were excellent in 98% of preoperative and in 95% of postoperative radiographs (PreOp range: 0.85–0.92, PostOp range: 0.81–0.87). Exemplarily, mean errors are smallest for the PI (PreOp: -0.5° [95%-CI: -1.5°–0.6°]; PostOp: 0.0° [-1.1°–1.2°]) and largest for LL (1.3° [0.3°–2.4°]; 3.8° [2.5°–5.0°]). <h3>CONCLUSIONS</h3> Novel AI algorithm automated spinopelvic parameter measurements from spine radiographs have a high degree of accuracy comparable to digital measurements by experts. This algorithm can improve physician workflow efficiency and reduce inter-rater and intra-rater measurement errors <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Recurrence in infantile tibia vara (Blount disease) after high tibia and fibula osteotomy.

Infantile Tibia Vara (ITV or Blount disease) often recurs after surgical correction of the deformity. Vastly different recurrence rates have been reported in the literature. The main objective of this study was to identify any risk factors for the recurrence of ITV following high tibia and fibula valgus osteotomy. This was a retrospective cohort comparative study of 44 patients with ITV (16 with bilateral involvement) who underwent a total of 60 high tibia and fibula osteotomies. Demographics, family history, BMI, walking age and age at surgery were recorded. Pre-, post- and follow-up weight-bearing anatomic femorotibial angles, were measured from X-rays. The limbs were divided into Langenskiöld stages based on preoperative X-rays. The study found an overall recurrence rate of 63.3% for children who had a high tibia and fibula osteotomy for ITV. Surgery after the age of 4 years, advanced Langenskiöld stages (stages 3-5) and overcorrection of less than 15 degrees of valgus were identified as risk factors for recurrence. This study recommends performing a high tibia and fibula valgus osteotomy before the age of 4 years in ITV to avoid recurrence. Overcorrection of the high tibia and fibula osteotomy to 15 degrees of valgus should be considered in older patients with high Langenskiöld stages at time of presentation.

Acetabular volume and femoral coverage change following Dega-like osteotomy in treatment of developmental dysplasia of the hip.

Although Dega's acetabuloplasty has become a commonly used osteotomy, there is still an ongoing debate regarding its impact on the volume and depth of the acetabulum. The purpose of our study was to assess the postoperative images of the transverse acetabular plane and version obtained from developmental dysplasia of the hip (DDH) patients after a modified Dega osteotomy. We performed a retrospective study of the morphologic indices obtained from the pelvic X-rays and computer tomography (CT) scans of patients with DDH, who were operated in our institution between July 2005 and October 2013, using the modified Dega osteotomy. Preoperative and postoperative pelvic X-rays were used to measure the acetabular index and the acetabular (ACM) angle. The postoperative CT scans were used to measure the acetabular anteversion angle (AAA), acetabular depth and depth of acetabular coverage [total acetabular index (TAI)]. The contralateral unaffected hips served as control. The postoperative acetabular indices and ACMs showed a significant improvement, with near-normal values measured 1 year after the surgery. Comparing the CT scan parameters (AAA, TAI and the depth of acetabulum) showed that TAI and the depth of acetabulum were not significantly different between the groups (TAI: P = 0.423; depth of acetabulum: P = 0.132), whereas AAA comparison implied a slight advantage of the DDH hips (17.6° DDH vs. 13.3° contralateral, P = 0.001). On the basis of images set of acetabular morphometric parameters, our study substantiates previous reports on an increase of acetabular volume and a significant improvement of femoral head coverage for patients with DDH who underwent Dega acetabuloplasty. Level of evidence: Level III - retrospective comparative study.