Resection Of Ligament Research Articles

Posterior cruciate ligament resection increases intraoperative lateral and medial flexion laxity during total knee arthroplasty.

This study reports the relationship between posterior cruciate ligament (PCL) retention vs resection and soft tissue laxity and balance throughout flexion using a robotically controlled ligament tensioner. 55 robotic-assisted TKAs (Total knee arthroplasty) were retrospectively reviewe. The robotic ligament tensioner collected laxity data both before and after PCL resection. Medial and lateral coronal laxity were compared before and after PCL resection at 10°, 45°, and 90° flexion. Gap opening was compared between pre-operative coronal hip-knee-ankle groups. Lateral laxity was greater after PCL resection at 60° (12.7 ± 2 vs 11.5 ± 3mm), 75° (13.2 ± 2 vs 11.8 ± 3mm), and 90° (13.7 ± 2 vs 12.1 ± 3mm). Medial laxity was significantly greater after PCL resection at 90° (10.1 ± 2 vs 9 ± 2mm). After PCL resection, laxity in valgus knees increased more compared to neutral/varus knees laterally at 30° (1.2 ± 1 vs 0.3 ± 1mm), 45° (1.6 ± 1 vs 0.6 ± 1mm), and 60° (2.1 ± 2 vs 1 ± 1mm). A similar, but non-significant trend was observed at 90° (2.7 ± 2 vs 1.5 ± 1mm, p = 0.09). PCL resection increases flexion laxity laterally by up to 1.6mm and medially by 1.1mm on average, with valgus knees increasing more than neutral/varus knees. The findings emphasize that surgeons should consider the interplay between PCL resection and coronal deformity when planning and executing TKA procedures.

Impact of Pulmonary Ligament Resection in Upper Lobectomies: A Multicenter Matched Cohort Study.

Background: Division of the pulmonary ligament is standard in lower lobectomies, but its application in upper lobectomies remains controversial due to potential complications like atelectasis and bronchial kinking. This retrospective matched cohort study aimed to evaluate the efficacy and safety of ligament resection in upper lobectomies for oncological purposes. Methods: From January 2015 to December 2020, 988 patients who underwent minimally invasive upper lobectomies across multiple centers were identified. They were categorized into ligament resection and no ligament resection groups, with propensity score matching (PSM) to minimize confounding factors. Endpoints included operative time, pleural effusion, complications (frequency and Clavien-Dindo scores), chest drainage removal, length of stay, pleural space, collapse rate, and bronchial kinking. Results: Following PSM, 276 patients were included in each group, with no significant differences in baseline characteristics. Ligament resection correlated with longer operative times, increased lymphadenectomy sampling at station #9 (p < 0.001), and a bigger change in the bronchial angle (p < 0.001). No statistically significant differences were observed for the other endpoints. Conclusions: Ligament resection during upper lobectomy may impact the bronchial angle without immediate postoperative outcome changes. Further research is necessary to comprehensively assess the risks and benefits of ligament resection in upper lobectomies for neoplastic disease.

Hypertrophy of the Annular Ligament as a Cause of Painful Elbow Snapping: Case Report and Literature Review.

Snapping annular ligament is an uncommon cause of lateral elbow pain. Due to the limited literature, snapping annular ligament is often misdiagnosed as lateral epicondylitis. Recognition of this uncommon condition is important as early surgical intervention is recommended to prevent erosion of articular cartilage caused by the hypertrophic synovial fold and early-onset arthritis. We present a 37-year-old male with left lateral elbow pain and clicking for 5years. MRI of the elbow revealed hypertrophy of the annular ligament with associated lateral epicondylitis. After failing conservative management, the patient underwent open resection of the hypertrophied annular ligament in addition to lateral epicondylitis surgery. The patient demonstrated complete relief of symptoms. Our aim is to increase the nurse's and hand surgeon's awareness of hypertrophy of the annular ligament as an uncommon cause of lateral elbow snapping and pain. We also review the literature, pathophysiology, nursing and surgical management and outcomes of treatment for this rare condition.

Modeling of the native knee with kinematic data derived from experiments using the VIVO™ joint simulator: a feasibility study

BackgroundDespite advances in total knee arthroplasty, many patients are still unsatisfied with the functional outcome. Multibody simulations enable a more efficient exploration of independent variables compared to experimental studies. However, to what extent numerical models can fully reproduce knee joint kinematics is still unclear. Hence, models must be validated with different test scenarios before being applied to biomechanical questions.MethodsIn our feasibility study, we analyzed a human knee specimen on a six degree of freedom joint simulator, applying a passive flexion and different laxity tests with sequential states of ligament resection while recording the joint kinematics. Simultaneously, we generated a subject-specific multibody model of the native tibiofemoral joint considering ligaments and contact between articulating cartilage surfaces.ResultsOur experimental data on the sequential states of ligament resection aligned well with the literature. The model-based knee joint kinematics during passive flexion showed good agreement with the experiment, with root-mean-square errors of less than 1.61 mm for translations and 2.1° for knee joint rotations. During laxity tests, the experiment measured up to 8 mm of anteroposterior laxity, while the numerical model allowed less than 3 mm.ConclusionAlthough the multibody model showed good agreement to the experimental kinematics during passive flexion, the validation showed that ligament parameters used in this feasibility study are too stiff to replicate experimental laxity tests correctly. Hence, more precise subject-specific ligament parameters have to be identified in the future through model optimization.

Treatment of hyoid bone syndrome with surgical excision: our monocentric experience in the past five years

PurposeIn 1968, Steinmann described the hyoid bone syndrome as a degenerative and inflammatory insertion tendinosis. It causes unilateral pain in the neck, increased by swallowing and palpation. The treatment is conservative, but when this fails, surgery is an option. Our aim is to assess the post-operative outcome of patients for whom a surgical hyoid bone resection procedure was performed in the University Hospital of Antwerp (UZA). MethodsA retrospective study was performed. Patients were seen at the laryngology clinic in the UZA from 2018 until 2023. They were diagnosed with the hyoid bone syndrome based on anamnesis and clinical examination. Pre-operative imaging was performed to evaluate for anatomical changes and fiberoptic laryngoscopy performed to exclude other causes. Pre- and postoperative VAS pain scores were questioned. ResultsSeventeen patients were operated, two of them bilaterally. All patients had pain located to the affected side, and almost half of patients (n = 7) had dysphagia. On imaging, 10 patients had an elongated styloid process and 7 had calcification of the stylohyoid ligament. All patients underwent resection of the greater horn of the hyoid bone, 13 patients underwent resection of the stylohyoid ligament and in 9 patients the superior horn of the thyroid cartilage was removed. Mean pre-operative VAS pain score was 9 (/10) and mean postoperative score was 1.3 (/10). ConclusionOur preliminary results show a good clinical effect of the surgical excision procedure and offer insight in the hyoid bone syndrome. Follow-up is necessary to assess the long-term results and potential recurrence of symptoms.

Eagle syndrome presentation and outcomes in a large surgical case series.

The purpose of this study is to describe both the common and uncommon symptoms associated with Eagle syndrome and share our experience treating a large group of patients with surgical intervention, primarily intraoral excision of the calcified stylohyoid ligament. This retrospective case series included 56 patients at least 18 years of age or older with a diagnosis of Eagle syndrome. All operations were conducted by a single surgeon at a tertiary medical center from 2015 to 2022. Charts were reviewed for demographics, prior medical/surgical history, symptoms, imaging results, operative details, and follow-up history. A phone survey inquired about presenting symptoms and symptom resolution following surgery. The most common areas of pain were the ear (64.3%), underneath the angle of the mandible (50%), throat (46.4%), and neck (30.4%). Over 70% of patients reported tinnitus, dysphagia, and pain that were exacerbated by head rotation. Fifty-one of the 56 patients underwent surgical treatment, 92.2% via intraoral and 7.8% via cervical approaches. All patients (100%) reached in a phone survey stated that their symptoms resolved or improved after surgery. Eagle syndrome typically presents with common symptoms. However, healthcare providers must also be vigilant for less common manifestations, such as seizures or episodes of dizziness/fainting. These may be caused by calcification of the stylohyoid ligament. Intraoral surgical resection of the calcified ligament is a safe and effective treatment for most patients. Level 4.

A New Methodology for the Accurate Measurement of Tibiofemoral Kinematics in Human Cadaveric Knees: An Evaluation of the Anterior-Posterior Laxity Pre- and Post-Cruciate Ligament Resection.

Anterior-posterior (AP) stability is an important measure of knee performance after total knee arthroplasty (TKA). To improve the stabilizing effect of implants designed to compensate for the loss of the cruciate ligaments, it is important to understand the tibiofemoral contact situation within the native ligamentous situation of the knee and how it changes after cruciate ligament resection. This in vitro study introduces a new approach to accurately measure the tibiofemoral kinematics in a six-degrees-of-freedom joint motion simulator by tracking landmark-based coordinate systems and their corresponding bone geometries. The tibiofemoral contact situation was investigated by projecting the medial and lateral flexion facet centers onto the tibial plateau under AP shear forces across various flexion angles in thirteen knees. Tests were conducted pre- and post-cruciate ligament resection. Post-cruciate ligament resection, the femoral condyles shifted closer to or even exceeded the posterior border of the tibial plateau, but only slightly closer to the anterior border. This study presents a new methodology for measuring the tibiofemoral kinematics that can be applied to multiple loading profiles. It provides a basis for further investigations, including passive or active muscle forces, to enhance the design of total knee protheses and improve surgical outcomes.

A Reinterpretation of Paracolpium in Radical Hysterectomy: New Insights into Its Surgical Implication

ObjectiveTo reinterpret the surgical anatomy of paracolpium in radical hysterectomy and to explore its implications for the surgery. SettingThe term “paracolpium” first defined by Fothergill in 1907, is essential in radical hysterectomy. However, several challenges remain unresolved. These include: (1) inconsistent terminology in relation to its defined attributes; (2) the lack of consensus on anatomical landmarks; (3) unclear associations with the cardinal and sacral ligaments; and (4) the critical implications and requirements of paracolpium resection in radical hysterectomy practices. ParticipantsA patient in her 60s diagnosed with stage IB2 cervical cancer was enrolled in a clinical trial and assigned to the laparoscopic surgery group. A step-by-step, narrated video demonstration. InterventionsDuring the procedure, post-excision of the uterosacral, cardinal, and vesicovaginal ligaments, we identified a ligament-like structure situated between the middle third of the vagina and the pelvic wall. We have termed this structure the “paracolpium ligament.” A detailed anatomical description was performed, outlining its crucial attachments:• Medial attachment: middle third of the vagina• Lateral attachment: tendinous arch of the pelvic fascia (TAPF)• Cranial attachment: cardinal-uterosacral ligaments confluence• Caudal attachment: pubococcygeus muscle fascia• Dorsal: paravaginal space• Ventral: pararectal spaceTo ensure a safe dissection, the paracolpium ligament was exposed by removing anterior and posterior fat tissue. The extent of surgical resection was adapted based on the tumor's location. Extensive resection of the paracolpium ligament was essential when the tumor was localized to one side of the vagina to ensure complete removal of the disease; otherwise, preservation of the ligament was considered feasible. ConclusionIn this video, we meticulously name and define the “paracolpium ligament,” providing groundbreaking insights into its anatomical and surgical implications in radical hysterectomy. Our findings contribute to a better understanding of surgical anatomy for cervical cancer.

Effect of Posterior Cruciate Ligament Resection on Gap Balancing in Robot-assisted Total Knee Arthroplasty.

Retention or sacrifice of the posterior cruciate ligament (PCL) is one of the most controversial issues while performing total knee arthroplasty (TKA). This study aimed to evaluate the impact of PCL resection on flexion-extension gaps, femoral component rotation, and bone resection amounts during robot-assisted TKA. This prospective study included 40 patients with knee osteoarthritis who underwent robot-assisted posterior-stabilized (PS) TKA between September 2021 and February 2022. Of the patients, 75% were women (30/40) with a mean age and BMI of 72.6 years and 27.4 kg/m2, respectively. The guidance module and camera stand assembly were used to capture gaps before and after PCL resection. Measurements of femoral component rotation and bone resection amounts were made in cruciate-retaining (CR) TKA mode and PS-TKA mode. After PCL resection, the mean change in the medial and lateral compartments of flexion gaps increased by 2.0 and 0.6 mm, respectively (p < 0.001). Compared with the CR-TKA mode group, the bone resection amounts of the medial posterior condyle and the lateral posterior condyle in the PS-TKA mode group decreased by 2.0 ± 1.1 and 1.1 ± 1.1 mm, respectively, and the external rotation of the femoral prosthesis relative to the posterior condylar axis and trans-epicondylar line was reduced by 1.0° ± 1.3° and 1.2° ± 1.6°, respectively (p < 0.001). The release of the PCL did not affect the extension gap, but significantly increased the flexion gap. Moreover, the increases in the medial flexion gap were greater than those of the lateral flexion gap. After PCL resection, less external rotation of the femoral prosthesis and fewer bone cuts of the posterior femur were needed in PS-TKA.

Physiolysis with Resection of Vickers' Ligament in Adolescent Patients with Madelung's Deformity

Madelung's deformity is a congenital or acquired growth disorder of the forearm that can lead to significant impairments in the quality of life of affected patients. Various surgical treatment options for the condition have been described in the literature. This study aimed to investigate whether physiolysis with resection of the Vickers ligament can successfully halt the progression of the disease in a cohort of young patients, as would be expected based on existing literature on this topic. An analysis was performed on the records of all patients with Madelung's deformity who were primarily treated with physiolysis with resection of the Vickers ligament between January 2001 and June 2017. Patients were invited for follow-up examinations, and surgical outcome was assessed. Parameters evaluated included pain at rest and under load, range of motion of the wrists, and activity level. Additionally, standard X-rays and radiological measurements were performed for each operated wrist. The collected data was compared with the preoperative data from patient records. Nine wrists were included in the study. The average age at the time of surgery was 13.2 years, and the average follow-up period was five years. Extension and ulnar abduction showed a slight decrease from preoperative to follow-up, while flexion improved minimally, and radial abduction and forearm rotation showed noticeable improvement. The visual analogue scale score for pain at rest increased from preoperative 0.25 points to 1.88 points at follow-up. Under load, the average pain score increased from 2.00 to 4.25 points. The mean DASH score increased from 6.04 points before the surgical procedure to 12.20 points at follow-up. The average values of two out of the five measured McCarroll parameters increased, the increase being statistically significant for lunate subsidence. A follow-up procedure was required in one wrist. In our cohort, the progression of Madelung's deformity was only partially halted by physiolysis with resection of the Vickers ligament, and a significant increase in pain symptoms during the study period could not be avoided. Therefore, this procedure should be used cautiously in skeletally immature patients.

Valgus malalignment causes increased forces on a medial collateral ligament reconstruction under dynamic valgus loading: Abiomechanical study.

To investigate the forces on a medial collateral ligament (MCL) reconstruction (MCLR) relative to the valgus alignment of the knee. Eight fresh-frozen human cadaveric knees were subjected to dynamic valgus loading at 400 N using a custom-made kinematics rig. After resection of the superficial medial collateral ligament, a single-bundle MCLR with a hamstring tendon autograft was performed. A medial opening wedge distal femoral osteotomy was performed and fixed with an external fixator to gradually adjust the alignment in 5°increments from 0° to 10° valgus. For each degree of valgus deformity, the resulting forces acting on the MCLR were measured through a force sensor and captured in 15° increments from 0° to 60° of knee flexion. Irrespective of the degree of knee flexion, increasing valgus malalignment resulted in significantly increased forces acting on the MCLR compared to neutral alignment (p < 0.05). Dynamic loading at 5° valgus resulted in increased forces on the MCLR at all flexion angles ranging between 16.2 Nand 18.5 N (p < 0.05 from 0° to 30°; p < 0.01 from 45° to 60°). A 10° valgus malalignment further increased the forces on the MCLR at all flexion angles ranging between 29.4 Nand 40.0 N (p < 0.01 from 0° to 45°, p < 0.05 at 60°). Valgus malalignment of the knee caused increased forces acting on the reconstructed MCL. In cases of chronic medial instabilities accompanied by a valgus deformity ≥ 5°, a realigning osteotomy should be considered concomitantly to the MCLR to protect the graft and potentially reduce graft failures. Level III.

Real-Time Intraoperative Ultrasound Using a Minimally Invasive Transducer During Anterior Cervical Spine Surgery.

Intraoperative ultrasound (IOUS) during anterior cervical surgery is hindered by large transducer size and small operative corridor. We hypothesized that a linear (minimally invasive) transducer designed for transsphenoidal surgery can visualize the spinal cord, nerve roots, and surrounding structures during anterior cervical approaches, facilitating intraoperative assessment of central and foraminal decompression. IOUS was used to evaluate 26 levels in 17 patients (15 anterior cervical discectomy and fusion, 1 corpectomy, 1 arthroplasty) with a linear probe (7 × 6-mm end-fire transducer, 150-mm length, 12-15 MHz). After pin-based distraction, discectomy, and posterior longitudinal ligament resection, IOUS assessed adequacy of cord decompression and, following proximal foraminotomy or uncinectomy, nerve root decompression. If indicated, additional decompression was completed. Criteria for adequate central and foraminal decompression were visualization of subarachnoid space around the cord and cerebrospinal fluid pulsatility along the root sleeve/absence of nerve root compression distal to the root sleeve, respectively. IOUS successfully visualized the cord, nerve roots, and surrounding structures in all 26 levels and influenced management in 11 levels (42.3%). IOUS indicated persistent cord and nerve root compression in 2 and 7 levels, respectively. Planned uncinectomy was aborted in 2 levels after IOUS demonstrated adequate nerve root decompression with intervertebral distraction/proximal foraminotomy alone. IOUS identified persistent nerve root compression after initial proximal foraminotomy in 4 levels and uncinectomy in 2 levels. An unplanned uncinectomy was performed in 1 level after IOUS showed persistent nerve root compression after multiple iterations of proximal foraminotomy. At follow-up (mean 3.1 months), the mean improvement in Numeric Rating Scale neck and arm pain, Neck Disability Index, and modified Japanese Orthopedic Association was 4.0%, 3.2%, 3.7%, and 0.7%, respectively. The neural elements and their relationships to surrounding bone/soft tissue can be visualized using a minimally invasive IOUS transducer during anterior cervical surgery without having to remove pin-based distraction. This allows surgeons to intraoperatively verify the extent of central and foraminal decompression.

One-piece resection for the treatment of ventral intradural extramedullary spinal meningioma: a retrospective study.

This study aimed to evaluate the feasibility and efficacy of one-piece resection for the treatment of ventral intradural extramedullary spinal meningiomas (VIESMs). Between January 2017 and December 2023, all patients who underwent one-piece resection for VIESMs were retrospectively reviewed with their demographic, intraoperative and postoperative data being recorded. In addition, postoperative neurological status based on the modified McCormick functional schema (mMFS), along with radiological manifestations on the magnetic resonance imaging (MRI) were assessed and compared with that before the operation. A total of 27 cases (7 men and 20 women) with an average age of 63.37 ± 10.48 years old were included in the present study with the operation time, blood loss, length of hospital stay, and follow-up periods being 292.41 ± 42.64 min, 286.85 ± 47.03 ml, 10.37 ± 1.69 days, and 16.81 ± 10.79 months, respectively. Postoperatively, one case experienced cerebrospinal fluid leakage without neurological deterioration. At the final follow-up, the mMFS scores were unchanged in seven (25.93%) cases while they improved in the remaining 20 (74.07%) cases. Finally, the MRI examinations showed that one-piece resection was successfully performed for each VIESM without a recurrence. One-piece resection was a feasible, safe and effective procedure for treating VIESMs. Partial removal of the ipsilateral pedicle, facet joint, and even posterior vertebral wall to establish a wide surgical corridor and vision, resection of the dentate ligaments to minimize spinal cord traction, and meticulous coagulation of the dural attachment to reduce recurrence were the key technical points.

Streamlining robotic-assisted abdominoperineal resection

BackgroundRobot-assisted surgery has proven to be a safe and feasible approach for the management of rectal cancer, including abdominoperineal resection (APR). However, it often incurs longer operative times and higher costs. This study aimed to overcome these limitations by adopting a synchronous approach utilizing an optimized team composition.MethodsData on patients who underwent robot-assisted APR at our facility between June 2022 and June 2023 were analyzed. The key points of the optimized approach included the following: At the start of the surgery, the surgeon performed an anococcygeal ligament resection from the perineal side while the bedside assistants set up the ports. Then, through console manipulation, the presacral fascia, elevated by previously placed gauze, was easily and safely incised, providing access to the perineal region.ResultsA total of nine patients were included in this study. The median operation time was 231 min, and the intraoperative blood loss was 170 ml. The operation time was reduced to 167.5 min, and the blood loss was 80.5 ml in cases without a trainee. Surgical site infections, classified as Clavien–Dindo grade II complications, were observed in two cases, but no obvious urinary or erectile dysfunction was observed.ConclusionThe study results indicate that the challenges associated with APR can be efficiently addressed without requiring additional personnel by streamlining team composition and the synchronous approach. This optimization strategy minimizes the need for a larger surgical team, while maximizing the utilization of surgical time and resources.

Biomechanical Assessment of Bicortical Suspension Device Fixation for Proximal Tibiofibular Joint Instability: Single Versus Double Device

Background: Bicortical suspension device (BCSD) fixation treats proximal tibiofibular joint (PTFJ) instability in both the anterolateral and posteromedial directions. However, biomechanical data are lacking as to whether this technique restores the native stability and strength of the joint. Purpose: To test (1) if BCSD fixation restores the native stability and strength and (2) if using 2 devices is needed. Study Design: Controlled laboratory study. Methods: Sixteen pairs of fresh-frozen cadaveric specimens were obtained. Six pairs were assigned to the control group and 10 matched pairs assigned for transection to model PTFJ and subsequent BCSD fixation (one specimen with 1-device repair and the other with 2-device repair). Joint stability and strength were assessed by translating the fibular head relative to the fixed tibia either anterolaterally or posteromedially. Control specimens received 20 cycles of 0- to 2.5-mm joint displacement tests (subfailure) and then proceeded to load to failure (5 mm). For the experimental group, cyclic tests were repeated after ligament resection and after fixation. Forces and stiffness at 2.5- and 5-mm displacement were recorded for comparisons of joint strength and stability at subfailure and failure loads, respectively. Results: After repair of anterolateral instability, both the single- and double-device fixations successfully restored near-native states, with no significant differences as compared with the intact group for forces at subfailure load (P = .410) or failure load (P = .397). Regarding posteromedial instability, single-device repair did not restore forces to the near-native state at subfailure load (intact: 92.9 N vs single: 37.4 N; P = .001) or failure load (intact: 170.7 N vs single: 70.4 N; P = .024). However, the double-device repair successfully restored near-native posteromedial forces at both subfailure load (P = .066) and failure load (P = .723). Conclusion: For treatment of the most common form of PTFJ instability (anterolateral), this cadaveric study suggests that 1 BCSD is sufficient to restore stability and strength. The current biomechanical results also suggest that 2 devices are needed for restoring PTFJ posteromedial stability and strength. Using 2 devices addresses both types of instability and provides more PTFJ posteromedial stability. Clinical Relevance: The results suggest that 1 device should be used for treating anterolateral instability and 2 devices used for posteromedial instability based on the biomechanical study.

Total Glucosides of Peony Alleviate Joint Destruction in Rabbits With Osteoarthritis

Objective Although many painkillers can be used to relieve the symptoms of osteoarthritis (OA), these drugs do not address joint bone degeneration and muscle wasting, highlighting the need for alternative treatments. This study evaluated the ability of various plant extracts to inhibit joint destruction, focusing on the total glucosides of peony (TGP) obtained from the normal Chinese medication white peony. Methods A rabbit OA model was established by anterior cruciate ligament resection (ACLT) and TGP treatment was initiated for 3 months. The morphologies of the skeletal muscle fibers, articular cartilage, and subchondral bone of the knee joint were histologically observed via X-ray and micro-computed tomography scan. Results TGP significantly reduced the histopathological changes associated with skeletal muscle atrophy and inflammation, and alleviated cartilage degeneration. In addition, TGP treatment significantly improved the bone density and microstructure of subchondral bone in rabbit knee joints compared with the model group. Conclusion The results suggested that TGP treatment may alleviate the progression of osteoarthritis and reduce the destruction of joint cartilage and bone in ACLT.

Conversion surgery after successful response to chemotherapy (S-1 + oxaliplatin + nivolumab) in a patient with stage IV gastric cancer with peritoneal metastasis (P1, CY1): a case report.

We here present a case report of a patient with Stage IV gastric cancer with peritoneal metastasis (P1, CY1) who underwent conversion surgery after a successful response to chemotherapy (S-1 + oxaliplatin + nivolumab). The patient was a woman in her 60s. Her chief complaint was epigastric pain. Upper gastrointestinal endoscopy showed Type 4 advanced carcinoma on the lesser curvature of the gastric body. Biopsy showed Group 5 (poorly differentiated adenocarcinoma) and HER2 was negative. Staging laparoscopy revealed seeding in the round ligament of the liver (P1) and adenocarcinoma cells in ascites (CY1). Ten courses of chemotherapy (S-1 + oxaliplatin + nivolumab) were administered, after which contrast-enhanced computed tomography showed that the primary tumor had shrunk and seeding was no longer detectable. Upper gastrointestinal endoscopy revealed scar-like changes. A second staging laparoscopy revealed that ascites cytology was negative and a biopsy of the round ligament of the liver showed no malignant cells (P0, CY0). Conversion surgery comprising laparoscopic total gastrectomy with D2 lymph node dissection and resection of the round ligament of the liver was performed. The postoperative course was uneventful. Histopathological examination of the resected specimen revealed no tumor cells in the gastric mesentery or the round ligament of the liver. The pathological diagnosis was gastric cancer [M, U, L, Less, Ant, Post, type4, T3(SS), N0, M0 (H0, P0, CY0), ypStage IIA]. Adjuvant chemotherapy (S-1) was commenced. The patient is still alive 7months later with no evidence of recurrence.

A Novel Technique for Pars Defect Direct Repair with a Modified Smiley Face Rod for Spondylolysis and Isthmic Spondylolisthesis.

Lumbar spondylolysis is a common fatigue fracture of the pars interarticularis of the lamina of the lumbar spine in adolescent athletes presenting with pars clefts. Some pseudarthrotic lumbar spondylolysis causes low back pain or radiculopathy. This study presents a case of pseudarthrotic lumbar spondylolysis that was successfully treated using a modified smiley face rod technique. We developed a modified smiley face rod technique, which places pedicle screws in the lateral edge of the pedicle to preserve the erector spinae muscles and inserts a U-shaped rod between the spinous processes to preserve the supraspinous ligament. When a U-shaped rod penetrates the interspinous ligament subcutaneously, the resection of the supraspinous ligaments can be avoided. When the screw head is positioned more anterolaterally, a compression force is applied perpendicular to the surface of the pars cleft by rod clamping. This intrasegmental fusion technique preserves the mobile segment and simultaneously repairs the pars cleft. It is less invasive and more appropriate than interbody fusion for young athletes to avoid the possibility of future adjacent segment disorders. This is a minimally invasive procedure that can easily achieve bone fusion and should be introduced for patients who are suffering from the symptoms of pseudarthrotic lumbar spondylolysis.

Ossification of yellow ligament-lesser known common cause of thoracic myelopathy in Indian subcontinent treated surgically

Background: To undertake a study which outlines the clinical and radiological features of ossification of yellow ligament (OYL) causing thoracic myelopathy (TM) in Indian subcontinent, to assess the outcomes of surgical resection of yellow ligament and compare different preoperative factors that contribute to be a risk factor in the overall post-surgical recovery rates (RR). Methods: A retrospective analysis of prospectively collected data from a cohort of 45 patients who visited our spine OPD from January 2012 to December 2019 who underwent surgical decompression for TM due to OYL was studied. The surgical outcomes and RR were calculated, compared and pre operative risk factors which could possibly be involved in giving poorer RR were analysed. Results: Our study included 45 patients who underwent surgical resection of OYL for TM. On comparison of post operative improvement in myelopathic symptoms, pre-operative mJOA score of 4.56 had increased significantly to 7.83 at 2 years follow up. While the majority (80%) of patients had an excellent and good recovery rate while 16% of patients had a fair recovery rate and 4% had no change at all in comparison to pre-operative mJOA scores. Preoperative risk factors for poor outcomes were also analysed. Conclusions: Early and timely before the onset or progression of any neurologic involvement. The pre operative risk factors which could give guarded prognosis and lower RR are, the presence of intramedullary signal changes (myelomalacia), &gt;6-10 months of progressive pre operative symptoms and an mJOA&lt;5.

Optimizing Asymmetric Native Knee Flexion Gap Balance Promotes Superior Outcomes in Primary Total Knee Arthroplasty.

Replicating native knee kinematics remains the ultimate goal of total knee arthroplasty (TKA). Technology, such as robotics, provides robust intraoperative data; however, no evidence-based targets currently exist for improved clinical outcomes. Furthermore, some surgeons target a rectangular flexion space in TKA unlike the native knee. This study evaluated the effect of in vivo flexion gap asymmetry on patient-reported outcome measures (PROMs) in contemporary TKA. In vivo tibiofemoral joint space dimensions were measured during 129 TKAs using a calibrated tension device before and after complete posterior cruciate ligament resection. PROMs were compared based on the final dimensions and the change in flexion gap dimensions at 90° of flexion: (1) equal laxity, (2) lateral laxity, and (3) medial laxity. Groups did not differ by demographics ( P ≥ 0.347), clinical follow-up ( P = 0.134), tibiofemoral alignment ( P = 0.498), or preoperative PROMs ( P ≥ 0.093). Mean follow-up for the cohort was 1.5 years (range, 1-3). Pain with climbing stairs, pain while standing upright, and knees "always feeling normal" scores were superior for patients with equal or lateral laxity compared with medial laxity ( P ≤ 0.064). Pain with level walking, University of California Los Angeles activity level, KOOS JR, and satisfaction scores also tended to be superior for patients with equal or lateral laxity, although it lacked statistical significance ( P ≥ 0.111). Results of this study suggest that patients with either an equally tensioned rectangular flexion space or with later-flexion lateral laxity after posterior cruciate ligament resection may achieve superior PROMs. Findings support the clinical benefit of facilitating posterolateral femoral roll back in flexion, which mimics native knee kinematics and further helps define targets for advanced technology.