Proximal Fixation Research Articles

Proximal and Distal Failure Site Analysis in Percutaneous Achilles Tendon Rupture Repair

Category:AnkleIntroduction/Purpose:Different techniques have been described for Achilles Tendon Rupture repair, but no biomechanical evaluation have been performed separately for proximal and distal suturing techniques.The purpose of this study was to biomechanically analyze 3 proximal and 2 distal suture configurations during a simulated cyclic load and load to failure. It was hypothesized that proximal suturing technique was stronger than the distal one and that the modified double suturing technique was the strongest of all techniques.Methods:A simulated, mid-substance rupture was created 6 cm proximal to the calcaneal insertion in 15 fresh-frozen cadaveric Achilles tendons, obtaining 15 proximal and 12 distal samples. Specimens were tested independently and randomly allocated to different suture techniques: proximal fixation site groups: (A1) classic Dresden technique, (A2) modified Dresden, (A3) double modified Dresden; distal fixation groups: (B1) classic distal suture and (B2) modified distal suture. Repairs were subjected to a cyclic testing (1000 cycles of 50-200 N) and load to failure. Load to failure, cause of failure and tendon elongation was evaluated. Fischer’s test was used as statistical analysis.Results:None of the proximal tendon and 7/12 of the distal samples failed in cyclic testing. The proximal fixation groups demonstrated significantly more strength than the distal groups (p< 0.05) with average failure loads of 598 N, 587 N and 710 N for groups A1, A2 and A3 respectively (A3 stronger than A1 and A2, p=0,035). Groups B1 and B2 failed on average at 416 N and 351 N respectively, p=0.24. The majority of all repairs failed in the suture- tendon interphase.Regarding elongation, no significant differences were found between groups (p=0.57).Conclusion:The distal fixation site in the Dresden percutaneous Achilles tendon repair is weaker than the proximal fixation site. A proximal modified suture configuration increased resistance to cyclic loading and load to failure significantly. A modification in the proximal and distal fixation sites can be suggested to improve repair strength and hopefully achieve a better outcome.

Curative effect of surgery within 48 hours after hip fracture in elderly patients

Objective To compare the clinical effects of surgery within and over 48 hours for hip fractures in elderly patients. Methods From May 2017 to April 2018, 47 patients over 75 years old with hip fracture were operated in our hospital and met with inclusion criteria. The patients were divided into two groups: within 48-hour group and over 48-hour group according to study design. In the within 48-hour group, there were 22 patients including 5 males and 17 females, aged from 76 to 97 years, with an average age of 83.6±5.0 years, and there were 10 femoral neck fractures (3 total hip arthroplasty, 7 hemiarthroplasty) and 12 femoral intertrochanteric fractures (proximal femoral intramedullary nail fixation). There were 25 patients (7 males and 18 females) in the over 48-hour group, aged from 76 to 98 years, with an average age of 83.8±5.8 years, and there were 10 femoral neck fractures (2 total hip arthroplasty, 8 hemiarthroplasty) and 15 femoral intertrochanteric fractures (proximal femoral intramedullary nail fixation). At the end of the follow-up period, the clinical data of the two groups were compared. The differences in the length of stay, cost of stay (excluding implants), postoperative complications within 1 month, hip function score (Harris score) within 1 month and 3 months, and mortality within 3 months and at the end of follow-up were analyzed. Results Both groups were followed up for 12 to 24 months, with an average of 17.7 months. The hospitalization time (7.9±3.0 d), hospitalization expenses (16 627.5±6 428.8 yuan), the incidence of early complications after operation (59.1%) and Harris score (80.9±8.6) in the within 48-hour group were significantly better than those in the over 48-hour group (12.3±4.1 d, 23 799.0±9 785.3 yuan, 88.0%, 71.1±9.2, respectively). At 3 months after operation, there was no significant difference in Harris score between the two groups (83.9±7.3 in within 48-hour group and 82.3±8.9 in over 48-hour group; t=0.668, P=0.507). Within 3 months, there was no death inwithin 48-hour group, but 2 in over 48-hour group; and 1 in within 48-hour group at the last follow-up. Conclusion Elderly patients with hip fracture benefit significantly from surgery within 48 hours after admission. Key words: Aged; Hip; Fractures, bone

Proximal and Distal Failure Site Analysis in Percutaneous Achilles Tendon Rupture Repair.

Different techniques have been described for percutaneous Achilles tendon rupture repair, but no biomechanical evaluation has been performed separately for proximal and distal suturing techniques. The purpose of this study was to biomechanically analyze proximal versus distal percutaneous Achilles suture configurations during cyclic loading and load to failure. A simulated, midsubstance rupture was created 6 cm proximal to the calcaneal insertion in fresh-frozen cadaveric Achilles tendons. Fifteen proximal specimens were divided into 3 groups: (A1) triple locking technique, (A2) Bunnell-type technique, and (A3) double Bunnell-type technique. Twelve distal specimens were divided into 2 groups: (B1) triple nonlocking technique and (B2) oblique technique. Repairs were subjected to cyclic testing and load to failure. Load to failure, cause of failure, and tendon elongation were evaluated. None of the proximal specimens and 7/12 of the distal ones failed in cyclic testing. The proximal fixation groups demonstrated significantly more strength than the distal groups (P = .001), achieving up to 710 N of failure load in Group A3. Groups B1and B2 failed on average at 380 N with no difference between them (P > .05). The majority of all repairs failed in the suture-tendon interface. Distal groups had more elongation during cyclic testing (13.7 mm) than proximal groups (9.4 mm) (P = .02). The distal fixation site in this Achilles tendon repair was significantly weaker than the proximal fixation site. A proximal modified suture configuration increased resistance to cyclic loading and load to failure significantly. A modification can be suggested to improve strength of the Achilles repair.

Cementless Total Hip Arthroplasty After an Iatrogenic Subtrochanteric Fracture due to Hardware Removal: A Case Report

Introduction: Total hip arthroplasty (THA) after proximal femoral fixation is a challenging procedure due to possible hardware-related complications. Case presentation: A 78-year-old female with hip osteoarthritis had a proximal femoral osteotomy fixed using a blade plate in the same femur 41 years ago. A two-step approach was planned. After a challenging hardware removal, an iatrogenic subtrochanteric fracture below the degenerated hip occurred after three months. THA with a tapered long stem was successfully performed with no need for additional osteosynthesis, and good results were seen two years later. Discussion: THAs in subtrochanteric fractures are technically demanding but feasible in selected cases. Hardware removal before THA implantation may carry important risks, and the surgical team should be prepared to perform arthroplasty in case of complications. Conclusion: THA in a subtrochanteric fracture below hip osteoarthritis is a feasible option in selected cases.

Suprarenal Aortic Remodeling after Endovascular Aortic Aneurysm Repair among Three Endografts with Different Types of Proximal Fixation System

Remodeling of suprarenal aorta after endovascular aortic aneurysm repair (EVAR) in relation to different endograft designs has not been thoroughly investigated. The aim of this study is to assess the anatomical configuration of the suprarenal aorta after using endografts with different proximal fixation during the first post-EVAR year. A retrospective study including EVAR patients using 3 types of endografts with different proximal fixation systems according to Instructions for Use was undertaken (50: Ovation, Endologix, Irvin, CA; 25: Endurant IIs, Medtronic, Santa Rosa, CA; 25: Excluder C3, W. L. Gore & Associates, Flagstaff, AZ). Comorbidities were recorded. Anatomic variables of the supra-aortic anatomy, abdominal aortic aneurysm (AAA) maximum diameter, and neck angulation were analyzed. Computed tomography angiography was obtained preoperatively at 1 and 12months post-EVAR, while a duplex scan was undertaken at 6months. Comorbidities were not different across the 3 groups. Presence and amount of neck calcification (P=0.139) and thrombus (P=0.116) was similar among groups. Maximum aortic diameter showed significant reduction from preoperative measurements to 12-month postoperative ones, for all groups. (Ovation: 56.5 to 53mm, P<0.001; Endurant: 57 to 51mm, P<0.001; Excluder: 55 to 50mm, P<0.001). Suprarenal angulation was decreased significantly in the Ovation (P<0.001) and Excluder groups (P=0.05), while the infrarenal angulation was decreased in all groups. Among endografts, the decrease in AAA maximum diameter was similar (P=0.99), while the suprarenal aortic diameter was significantly increased in Ovation patients in comparison to the other 2 endografts at the level of 5mm (P=0.02) and 25mm (P=0.01). Suprarenal angulation reduction was similar (P=0.7), while infrarenal angulation was significantly more decreased in Ovation endograft than the other 2 systems (P<0.001). Proximal endograft configuration appears to have different impact on supra-aortic anatomy. Longer follow-up is needed to clarify future remodeling and clinical impact of these observations.

A comparative study between DHS and PFN for the treatment of IT fractures

Background: Intertrochanteric fractures are one of the common fractures. Intertrochanteric and per trochanteric are generic terms for per trochanteric fractures. The incidence of intertrochanteric fractures is gender and race dependent and varies from country to country. Ninety percent of intertrochanteric fractures in the elderly result from a simple fall & Intertrochanteric fractures in younger individuals are usually the result of a high-energy injury. Implants for fixation for intertronchateic factures are broadly broadly be divided into 1. Extramedullary devices, ex-: Dynamic hip Screw (DHS) 2. Intramedullary devices ex: - proximal femoral nail (PFN). Now a controversy has arised about the ideal implant for fixation of intertrochanteric fractures i.e DHS or PFN. In view of these conditions, this study is taken up to compare the results of DHS and PFN in the management of intertrochanteric fracture.Aims & ObjectivesTo determine the rate of union, complications, operative risks and functional outcomes in intertrochanteric fractures treated with DHS and PFN.To compare the results obtained between DHS and PFN. Patients and Methods: The present STUDY has been conducted at king George hospital, Visakhapatnam during the period between September 2013 and august 2015.Thirty patients with intertrochanteric fractures treated with dynamic HIP SCREW & PROXIMAL FEMORAL NAILING fixation were selected for the present study.Observation and Results: The patients are evaluated based on intra operative and post operqative complications, duration of surgery, post-operative functional and anatomical results and time of complete weight bearing.Conclusion: From the study, we consider PFN as better alternative to DHS in the treatment of intertrochanteric fractures but is technically difficult procedure and requires more expertise compared to DHS. With experience gained from each case operative time, radiation exposure, blood loss and intraoperative complications can be reduced in case of PFN.

Biomechanical Assessment of a Distally Fixed Lateral Extra-articular Augmentation Procedure in the Treatment of Anterolateral Rotational Laxity of the Knee

Background: Most lateral extra-articular tenodesis (LET) procedures rely on passing a strip of the iliotibial band (ITB) under the fibular (lateral) collateral ligament and fixing it proximally to the femur. The Ellison procedure is a distally fixed lateral extra-articular augmentation procedure with no proximal fixation of the ITB. It has the potential advantages of maintaining a dynamic element of control of knee rotation and avoiding the possibility of overconstraint. Hypothesis: The modified Ellison procedure would restore native knee kinematics after sectioning of the anterolateral capsule, and closure of the ITB defect would decrease rotational laxity of the knee. Study Design: Controlled laboratory study. Methods: Twelve fresh-frozen cadaveric knees were tested in a 6 degrees of freedom robotic system through 0° to 90° of knee flexion to assess anteroposterior, internal rotation (IR), and external rotation laxities. A simulated pivot shift (SPS) was performed at 0°, 15°, 30°, and 45° of flexion. Kinematic testing was performed in the intact knee and anterolateral capsule–injured knee and after the modified Ellison procedure, with and without closure of the ITB defect. A novel pulley system was used to load the ITB at 30 N for all testing states. Statistical analysis used repeated measures analyses of variance and paired t tests with Bonferroni adjustments. Results: Sectioning of the anterolateral capsule increased anterior drawer and IR during isolated displacement and with the SPS (mean increase, 2° of IR; P < .05). The modified Ellison procedure reduced both isolated and coupled IR as compared with the sectioned state (P < .05). During isolated testing, IR was reduced close to that of the intact state with the modified Ellison procedure, except at 30° of knee flexion, when it was slightly overconstrained. During the SPS, IR with the closed modified Ellison was less than that in the intact state at 15° and 30° of flexion. No significant differences in knee kinematics were seen between the ITB defect open and closed. Conclusion: A distally fixed lateral augmentation procedure can closely restore knee laxities to native values in an anterolateral capsule–sectioned knee. Although the modified Ellison did result in overconstraint to isolated IR and coupled IR during SPS, this occurred only in the early range of knee flexion. Closure of the ITB defect had no effect on knee kinematics. Clinical Relevance: A distally fixed lateral extra-articular augmentation procedure provides an alternative to a proximally fixed LET and can reduce anterolateral laxity in the anterolateral capsule–injured knee and restore kinematics close to the intact state.

Sternal Muscle: A Case Report

Introduction The sternal muscle is an anatomical variation found in the anterior region of the thorax. Objective To report the anatomical characteristics of a new type of sternal muscle. Case Report This was a dissection study in which the sternal muscle found was unilateral and long. Discussion Proximal fixation differs from the classification adopted for these cases. Documentation of sternal muscle variations can improve the theoretical database in anatomy as well as aid diagnoses, reducing the probability of the unexpected during clinical and/or surgical thorax-related investigations.

Biomechnical stability of proximal humeral fracture fixated by a locking plate plus different fibular allografts

Objective To investigate the ability of locking plate construct plus fibular autograft that varies in way of augmentation to withstand varus stresses in a model of proximal humeral fracture. Methods Wedge osteotomy was conducted in the humeral surgical necks of 12 shoulders from 6 cadaveric specimens to create models of proximal humeral fracture. There were 3 males and 3 females; their average age at death was 83 years (from 75 to 87 years). The 12 left and right cadaveric humeri were randomly divided into equal groups A and B (n=6) for autogenous iliac bone graft. All the fibular autografts were harvested without distinction from the thinnest and even part of the fibular shaft. A fibular autograft of 8 cm was placed vertically in group A while a fibular autograft of 6 cm was placed slantly in group B. After the fractures were fixated with the proximal humerus internal fixation locking system (PHILOS), varus stress was repeatedly applied to the proximal humerus until the internal fixation failed in the fracture model. The 2 groups were compared in terms of number of compression, number of compression leading to 1 mm deformation, and average shape variable after each press. Results Cut-out of the lateral cortex of the humeral head by the humeral screw and plate loosening to different extents were observed in both groups. The number of compression leading to internal fixation failure was 31,338±5,994 for group A and 30,608±8,015 for group B; the number of compression leading to 1 mm deformation was 2,808±1,501 for group A and 3,153±2,024 for group B; the average shape variable after each press was 0.52±0.39 μm/time for group A and 0.53±0.47 μm/time for group B. All the above comparisons between the 2 groups showed no significant differences (P>0.05). Conclusion As locking plate construct plus slant fibular autograft augmentation provides no more strength to withstand repetitive varus stresses than locking plate construct plus vertical fibular autograft augmentation, it is not necessary to adopt the former way of augmentation in clinic practice for proximal humeral fracture. Key words: Shoulder joint; Bone plates; Transplantation, heterotopic; Biomechanics; Proximal humeral fracture

Proximal, Distal, and Combined Fixation Within the Tibial Tunnel in Transtibial Posterior Cruciate Ligament Reconstruction: A Time-Zero Biomechanical Study In Vitro

To compare the time-zero biomechanical properties of 3 graft fixation techniques (proximal, distal, and combined fixation) within the tibial tunnel in transtibial posterior cruciate ligament (PCL) reconstruction. Porcine tibias and bovine extensor tendons were used to simulate a transtibial PCL reconstruction invitro. Load-to-failure testing was carried out in 3 groups: distal fixation alone (group I, n= 10), proximal fixation alone (group II, n= 10), and combined fixation (group III, n= 10). The load-elongation curve, tensile stiffness (in newtons per millimeter), ultimate load (in newtons), yield load (in newtons), energy absorbed to failure (in joules), and failure mode were recorded. All graft-tibia complexes failed because the grafts slipped past the interference screws. The tensile stiffness, yield load, and energy absorption in group I were significantly lower than those in group II and group III (tensile stiffness, 19.25 ± 9.68N/mm in group I vs 34.92 ± 16.48N/mm in group II [P= .016] and 32.31 ± 13.79N/mm in group III [P= .041]; yield load, 265.36 ± 144.52N in group I vs 398.23 ± 57.04N in group II [P= .006] and 424.94 ± 74.00N in group III [P= .001]; and energy absorption, 5.16 ± 2.35J in group I vs 19.95 ± 3.48J in group II [P < .001] and 21.09 ± 4.29J in group III [P < .001]). No statistically significant differences in biomechanical properties were found between group II and group III (P > .05). Compared with distal fixation in transtibial PCL reconstruction, proximal fixation and combined fixation showed superior time-zero biomechanical properties. Proximal fixation and combined fixation produced superior biomechanical properties to distal fixation in transtibial PCL reconstruction.

Biomechanical Comparison of Two Pediatric Blade Plate Designs in Proximal Femoral Osteotomies

Blade plates are frequently used for internal fixation following proximal femoral varus rotational osteotomy to treat hip dysplasia in children with cerebral palsy. Recently, cannulated blade plates with the option for a proximal locking screw have demonstrated ease of insertion and low complication rates. Although there are two commonly used blade plates with a proximal screw option, no comparison of their biomechanical profiles has been undertaken. Our study sought to compare the structural properties under axial loading, as well as the biomechanical contribution of a proximal screw, of two different 90° cannulated blade plates designed for pediatric proximal femurs. Plate A has a hole distal to the blade designed to attach a plate inserter, through which a 3.5-mm non-locking cortical screw could be placed. Plate B has a threaded hole distal to the blade designed to accept a 3.5-mm locking screw. Plate A and plate B were inserted into 33 left pediatric synthetic proximal femurs. Axial loading to failure of plate A with and without a proximal screw was compared to that of plate B with and without a proximal screw. An additional 10 samples using plate B, with and without a proximal locking screw, were tested in tension to quantify the effect of the proximal screw on pullout strength. Plate B failed at a higher axial load than plate A. The addition of a proximal screw did not affect the axial load to failure for either plate. Pullout testing revealed that blade plates fixed with the proximal screw failed in tension at a significantly higher load (856.3 ± 120.9N) than those without proximal fixation (68.1 ± 9.3N, p < 0.001). Plate B failed at a higher axial load in biomechanical testing, likely related to differences in its design. The addition of a proximal screw did not increase the axial loading properties of the blade plate construct but did increase the pullout strength by a factor of 12. These results may be used to influence implant selection and post-operative rehabilitation following proximal femoral osteotomies in children.

Implant cut-out following cephalomedullary nailing of intertrochanteric femur fractures: Are helical blades to blame?

IntroductionImplant cut-out remains a common cause of cephalomedullary nail (CMN) failure and patient morbidity following surgical treatment of intertrochanteric femur fractures. Recent studies have suggested an increased rate of CMN cut-out with helical blades as opposed to lag screws. We compared rates of overall cut-out between helical blades and lag screws and used bivariate and multivariate analysis to determine the role of proximal fixation method among other variables on risk for cut-out. Subgroup analysis was performed on the basis of failure mechanism; superior migration (Fig. 2) versus medial perforation (Fig. 3). MethodsThree-hundred and thirteen patient charts were retrospectively reviewed over an 8-year period; 245 patients were treated with helical blades and 68 with lag screws. Radiographs were reviewed for fracture pattern, Tip-Apex Distance (TAD), Parker’s Ratio (PR) and reduction quality. Rate of implant cut-out was compared between groups and multiple logistic regression was used to analyze the ability of several independent variables to predict implant cut-out. ResultsTwenty cut-outs occurred; 15 with helical blades and 5 with lag screws. No difference in the rate of cut-out was observed between the two groups (p = 0.45). Poor fracture reduction was found to be a significant predictor of implant failure via bivariate and multiple logistic regression analysis (p = <0.01, OR 23.573). Helical blade fixation, fracture instability, TAD ≥ 25, and PR ≥ 0.45 were not predictive of implant cut-out during multivariate analysis. Similarly, patient smoking status and surgeon trauma fellowship training did not significantly increase the odds of implant cut-out. Failure by medial perforation occurred in 12 instances, all involving helical blades. Failure by superior migration occurred at a significantly higher rate with lag screws than helical blades (p = 0.02). ConclusionCMN cutout is likely multifactorial. A direct association between helical blade fixation and implant cut-out was not observed in our study. Amongst modifiable risk factors for implant failure, poorer fracture reduction was predictive of failure by cut-out. Subgroup analysis highlights differing modes of failure between lag screws and helical blades which warrants further investigation. Ideal TAD during helical blade fixation remains unknown.

Optimal tether configurations and preload tensioning to prevent proximal junctional kyphosis: a finite element analysis.

Proximal junctional kyphosis (PJK) is, in part, due to altered segmental biomechanics at the junction of rigid instrumented spine and relatively hypermobile non-instrumented adjacent segments. Proper application of posteriorly anchored polyethylene tethers (i.e., optimal configuration and tension) may mitigate adjacent-segment stress and help prevent PJK. The purpose of this study was to investigate the impact of different tether configurations and tensioning (preloading) on junctional range-of-motion (ROM) and other biomechanical indices for PJK in long instrumented spine constructs. Using a validated finite element model of a T7-L5 spine segment, testing was performed on intact spine, a multilevel posterior screw-rod construct (PS construct; T11-L5) without tether, and 15 PS constructs with different tether configurations that varied according to 1) proximal tether fixation of upper instrumented vertebra +1 (UIV+1) and/or UIV+2; 2) distal tether fixation to UIV, to UIV-1, or to rods; and 3) use of a loop (single proximal fixation) or weave (UIV and/or UIV+1 fixation in addition to UIV+1 and/or UIV+2 proximal attachment) of the tether. Segmental ROM, intradiscal pressure (IDP), inter- and supraspinous ligament (ISL/SSL) forces, and screw loads were assessed under variable tether preload. PS construct junctional ROM increased abruptly from 10% (T11-12) to 99% (T10-11) of baseline. After tethers were grouped by most cranial proximal fixation (UIV+1 vs UIV+2) and use of loop versus weave, UIV+2 Loop and/or Weave most effectively dampened junctional ROM and adjacent-segment stress. Different distal fixation and use of loop versus weave had minimal effect. The mean segmental ROM at T11-12, T10-11, and T9-10, respectively, was 6%, 40%, and 99% for UIV+1 Loop; 6%, 44%, and 99% for UIV+1 Weave; 5%, 23%, and 26% for UIV+2 Loop; and 5%, 24%, and 31% for UIV+2 Weave.Tethers shared loads with posterior ligaments; consequently, increasing tether preload tension reduced ISL/SSL forces, but screw loads increased. Further attenuation of junctional ROM and IDP reversed above approximately 100 N tether preload, suggesting diminished benefit for biomechanical PJK prophylaxis at higher preload tensioning. In this study, finite element analysis demonstrated UIV+2 Loop and/or Weave tether configurations most effectively mitigated adjacent-segment stress in long instrumented spine constructs. Tether preload dampened ligament forces at the expense of screw loads, and an inflection point (approximately 100 N) was demonstrated above which junctional ROM and IDP worsened (i.e., avoid over-tightening tethers). Results suggest tether configuration and tension influence PJK biomechanics and further clinical research is warranted.

Effectiveness analysis of Lenke type 1 adolescent idiopathic scoliosis with different proximal fixation vertebra

To investigate the short-term effectiveness of proximal fixation of one vertebra above to the upper end vertebra and the upper end vertebra in the treatment of Lenke type 1 adolescent idiopathic scoliosis (AIS) patients with preoperative right higher shoulder. The clinical data of 37 Lenke type 1 AIS patients treated with posterior correction between January 2010 and December 2015 were retrospectively analysed. According to proximal fixation vertebra, the patients were divided into 2 groups: group A ( n=17), proximal fixation of one vertebra above to the upper end vertebra; group B ( n=20), proximal fixation of the upper end vertebra. There was no significant difference in gender, age, Risser stage, radiographic shoulder height (RSH), flexibility of proximal thoracic curve, flexibility of main thoracic curve, flexibility of thoracolumbar/lumbar curve between 2 groups ( P>0.05). The main thoracic curve Cobb angle, proximal thoracic curve Cobb angle, thoracolumbar/lumbar curve Cobb angle, apical vertebral translation (AVT), clavicle angle (CA), RSH, coronal trunk shift, sagittal trunk shift, thoracic kyphosis (TK), and lumbar lordosis (LL) were measured by X-ray film before operation, and at 1 month, 1 year, and 2 years after operation. The correction indexes of main thoracic curve were evaluated, including the correction degree and correction rate of main thoracic curve and AVT correction at 1 month after operation, the loss degree and the loss rate of the correction of main thoracic curve at 2 years after operation. The operation time and intraoperation blood loss in group A were significantly greater than those in group B ( P<0.05). All the patients were followed up, and the follow-up time was 2-4 years (mean, 2.8 years) in group A and 2-3.5 years (mean, 2.6 years) in group B. No serious complication such as nerve damage occurred during perioperative period and follow-up period. No complication such as failure of fusion, loosening and rupture of internal fixator, adjacent segment degeneration, and proximal junctional kyphosis occurred. There was no significant difference between 2 groups in the correction degree and correction rate of main thoracic curve and AVT correction at 1 month after operation, the loss degree and the loss rate of the correction of main thoracic curve at 2 years after operation ( P>0.05). Comparison within the two groups: except for LL had no significant difference between pre- and post-operation ( P>0.05), the other indicators were significantly improved after operation ( P<0.05) in the two groups. There were significant differences in RSH, CA, proximal thoracic curve Cobb angle, and thoracolumbar/lumbar curve Cobb angle at each time point after operation ( P<0.05), and there were spontaneous correction during follow-up; however, there was no significant difference in main thoracic curve Cobb angle, AVT, TK, LL, trunk shift at each time point after operation ( P>0.05), and there was no significant loss during follow-up. Comparison between the two groups: there was no significant difference in all the radiographic indexes at pre- and post-operation ( P>0.05). For Lenke type 1 AIS patients with preoperative right high shoulder, proximal fixation vertebra be fixed to the upper end vertebral can obtain satisfactory short-term orthopedic effectiveness and reduce blood loss and operation time.

Internal fixation for the treatment of multiple physeal tibial fractures in a growing dog

This case report describes pinning fixation for the treatment of three tibial physeal fractures in a 3-month old mixed-breed dog. The radiographic study revealed a severe proximal dislocation of the tibial diaphysis along with multiple, closed fractures of the proximal and distal tibial physes, distal femoral physis and the fibula. Open reduction and internal fixation (ORIF) were performed using crossed Kirschner wires for proximal and distal tibial physeal fixation and a tension band to manage the tibial tuberosity avulsion fracture. Postoperative radiographs showed proper fracture reduction, tibial alignment and correct implant positioning. Clinical and radiographic checks documented progressive limb weight-bearing, gradual resolution of distal limb oedema and fracture healing. The described open surgical treatment had a satisfactory clinical outcome with restoration of tibial anatomy, preservation of joint function and an early return to normal motor activity at 45 days of follow-up.

Internal Rotation Stress Testing Improves Radiographic Outcomes of Type 3 Supracondylar Humerus Fractures.

The purpose of this study was to determine if routine use of an intraoperative internal rotation stress test (IRST) for type 3 supracondylar humerus fractures will safely improve maintenance of reduction. An intraoperative protocol for type 3 supracondylar humerus fractures was adopted at our institution, consisting of fracture reduction, placement of 2 laterally based divergent pins, and then an IRST to determine the need for additional fixation with a medial column pin placed through a small open approach. Fractures treated with the prospective IRST protocol were compared with a retrospective cohort before adoption of the protocol (pre-IRST). The primary outcomes were differences in Baumann's angle, lateral humerocapitellar angle, and the rotation index between final intraoperative fluoroscopic images and radiographs at final follow-up. Secondary outcomes were complications such as iatrogenic nerve injury, loss of fixation, or need for reoperation. There were 78 fractures in the retrospective cohort (pre-IRST) and 49 in the prospective cohort (IRST). Overall rotational loss of reduction (>6%), measured by lateral rotation percentage, and major rotational loss of reduction (>12%) were less common in the IRST cohort (6/49 vs. 27/78, P=0.007 overall; 0/49 vs. 8/78, P=0.02 major loss). There were no major losses of reduction for Baumann's angle (>12 degrees) in either cohort. There were 5 subjects in the pre-IRST cohort (6.4%) with a major loss of reduction of the humerocapitellar angle (>12 degrees) and none in the IRST cohort (P=0.16) Loss of proximal fixation with need for reoperation occurred in 3 fractures in the pre-IRST cohort, and none in the IRST cohort (P=0.28). There were no postoperative nerve injuries in either group. Intraoperative IRST after placement of 2 lateral pins assists with the decision for additional fixation in type 3 supracondylar humerus fractures. This method improved the final radiographic rotational alignment, and was safely performed using a mini-open approach for medial pin placement. Level III-prospective cohort compared with a retrospective cohort.

Proximal fixation devices in endovascular repair of abdominal aortic aneyrysm with unfavourable proximal neck anatomy

Abdominal aortic aneurysm is a common vascular disease requiring surgical treatment. Currently, endovascular aortic repair is a good alternative to open surgery. However, high incidence of unfavorable anatomical variants of the proximal landing zone limit the use of endovascular aortic repair in these patients. Additional techniques can increase applicability of endovascular procedure with optimal results. Two patients with unfavorable proximal neck anatomy undergoing endovascular aortic repair with anchor type of proximal fixation devices are reported in the article.

Distal Radius Fractures in the Elderly: Use of the Volar Bearing Plate.

Distal radius fractures represent some of the most common injuries to the upper extremity, yet current evidence demonstrates great variability in the management of this injury. Elderly patients, in particular, stand to benefit from the early mobilization provided by operative fixation with a volar bearing plate. We conducted a retrospective chart review on all patients 65 years or older who underwent unilateral open reduction internal fixation of distal radius fractures using a volar bearing plate at a single institution between January 2014 and January 2016. We excluded patients with bilateral injuries, multiple fractures, and major injuries to the same extremity. Fifty-five patients met criteria for this study. By AO classification, we repaired 17 type A, 24 type B, and 14 type C fractures. At final radiographic measurements, average radial height compared with ulna measured -0.31 mm, average radial inclination measured 20.45 degrees, and average volar tilt measured 7.11 degrees. On discharge, 36 patients had wrist range-of-motion data consistent with a functional wrist. Four patients had limitations in the flexion/extension plane, 8 with radial-ulnar deviation, and 7 had limitations in both planes. Distal radius fractures in the elderly may successfully be treated with a volar bearing plate. Useful strategies include supraperiosteal dissection of the radius from the pronator quadratus, use of a longer plate for stronger proximal fixation in osteoporotic bone, and regional block. This methodology allows for a safe procedure facilitating the early return of hand and wrist function.

Invited commentary

Invited commentary

Dynamic intraligamentary stabilization for ACL repair: a systematic review.

It was the aim to assess all published original research dealing with dynamic repair of the anterior cruciate ligament (ACL) and to provide a semi-quantitative analysis of clinical outcome reports. Both OVIS and MEDLINE databases were utilized for allocation of articles. All preclinical and clinical studies related to dynamic intraligamentary stabilization (DIS) were identified. Results were tabulated and semi-quantitative analysis performed. Twenty-three articles related to DIS were identified. The predominant level of evidence ranged between II and IV, with only one level I study. Reported failure rates ranged between 4% and 13.6%. Most clinical studies only reported revision rates without referring to failure of restoring stability. Highest success was achieved with proximal ACL ruptures. Both the level of physical activity and patient age have been found to influence the risk of failure. There is sufficient evidence to support that DIS repair may be an effective modality forthe treatment of acute proximal tears of the ACL. However, comparative studies are lacking. Upcoming studies should compare the technique to ACL reconstruction with failure as an endpoint. Comparison to rigid methods of proximal fixation is also necessary to justify the need for dynamic fixation. Overall, there is evidence to suggest the potential space for ACL repair in the decision tree for individualized treatment planning. The best outcome will be in the hands of the best patient selectors. IV.