Restoration Of Alignment Research Articles

Navigated versus conventionally instrumented total knee arthroplasty techniques: No difference in functional alignment or balance.

Much debate exists about the superiority of navigated versus conventional instrumentation for achieving optimal balance and alignment during total knee arthroplasty (TKA). Recent registry data indicate no long-term survivorship benefit for TKAs performed using technology assistance, despite the added resource and financial costs. However, outcome comparisons are confounded by varying surgeon techniques and targets for ideal balance and alignment. This study aimed to investigate alignment or balance outcome differences between navigated and conventionally instrumented TKAs performed using an identical operative sequence and alignment strategy. Fifty navigated and 50 conventionally instrumented primary TKAs, using an identical inverse kinematic alignment strategy, were included. Navigation equipment was used intraoperatively to 'post-cut' record the conventionally instrumented TKAs. Intraoperative balance, range, and alignment; and post-operative radiographic accuracy for restoration of constitutional alignment were compared. Forty-nine navigated and 49 conventionally instrumented TKAs were compared (n = 2 excluded due to inadequate radiographs). No preoperative demographic or deformity severity differences existed. No intraoperative balance, range or alignment difference existed. Neither technique was more accurate for restoration of constitutional alignment. Whilst large registry data may be confounded by uncaptured variables such as surgeon balancing techniques or surgeon alignment strategy preferences, this study found no alignment or balance differences between navigated versus conventionally instrumented TKA techniques for a surgeon and technique-controlled study. Although the increased resources necessary for technology assistance are not justified by this study, further studies may identify significance using larger samples or comparison of alternative outcomes. Level II.

Unicompartmental Knee Arthroplasty: What is the optimal alignment correction to achieve success? The role of kinematic alignment

Unicompartmental knee arthroplasty (UKA) is in many ways the ultimate kinematic operation, as the express aim is to resurface the diseased side of the joint and restore pre-arthritic alignment and balance while maintaining integrity of both cruciate ligaments. An increasing body of knowledge relates the outcomes of UKA to pre-arthritic anatomy rather than an arbitrarily defined neutral. The Coronal Plane Alignment of the Knee (CPAK) classification provides a validated technique for calculating pre-arthritic limb alignment (the arithmetic hip-knee-ankle angle (aHKA)) and joint line obliquity (JLO) and will enable a greater understanding of the interactions between pre-arthritic anatomy, choice of prosthetic position and outcomes. When pre-arthritic alignment is not taken into consideration a post-operative limb alignment of mild to moderate varus for medial UKA and moderate valgus for lateral UKA appears to produce the best outcomes. When pre-arthritic anatomy is taken into account, superior results have been reported with restoration of pre-arthritic limb alignment and joint line obliquity. Restriction boundaries have yet to be clearly defined for tibial component coronal and hip-knee-ankle (HKA) angles when applying this new paradigm, but existing evidence would suggest a 6° varus limit for the tibial coronal angle may be a reasonable starting point. Lateral UKA has inherent differences in terms of tibial component positioning and ligament balance targets. Mobile bearing UKA demands a three-dimensional understanding of the effect of implant position on bearing stability. Modification of technique is necessary to produce anatomic tibia component angles with equipment designed for mechanical alignment. Robotic technology allows accurate understanding of pre-arthritic anatomy, precise reproduction of patient specific virtual planning, equally precise manipulation of soft tissue balance, and future research using these platforms is likely to further clarify in terms of ideal patient-specific component and limb alignment targets.

High accuracy of component positioning and restoration of lower limb alignment using robotic medial unicompartmental knee arthroplasty.

Unicondylar arthroplasty was performed using robotic medial unicompartmental knee arthroplasty (R-mUKA) and gap-balancing instrumentation. Our hypothesis was that robotic unicondylar knee arthroplasty accurately restores component positioning and lower limb alignment when compared to preoperative planning with actual implantation throughout the range of knee motion due to proper knee balancing. Data were collected prospectively and were analysed for patients undergoing RM-UKA. A cemented UKA was implanted using the MAKO® robotic system. Lower limb alignment at 0°, 30°, 45°, 60° and 90° of flexion was recorded of the native knee, with the trial components in place and finally after component implantation. A spacer according to the femorotibial gap was introduced and the alignment was measured. The position of the final component was planned based on three-dimensional computed tomography images before making the bone cuts. The positioning of the femoral and tibial components was analysed in all three planes. A total of 52 patients were included (mean age 66.3 ± 6.7 years; 34 males, 18 females). The difference in femoral component position after planning and final implantation was 0.04° ± 0.58° more valgus in the coronal plane (p = 0.326) and 0.6° ± 1.4° more flexion relative to the sagittal plane (p = 0.034). The tibial component was placed in the coronal plane in 0.3° ± 0.8° of more varus (p = 0.113) and in the sagittal plane in 0.6° ± 1.2° of more posterior tibial slope (p = 0.001). Lower limb alignment of the native knee in extension was 5.8° ± 2.6° of varus and changed to 3° ± 2.1° varus after UKA (p ≤ 0.01). R-mUKA helps to achieve the target of alignment and component position without any significant differences to the planning. Ligament balancing causes non-significant changes in component position. It allows optimal component position even for off-the-shelf implants respecting the patient's specific anatomy. II.

CT of Periarticular Adult Knee Fractures: Classification and Management Implications.

Periarticular knee fractures, which include fractures of the distal femur, tibial plateau, and patella, account for 5%-10% of musculoskeletal injuries encountered in trauma centers and emergency rooms. These injuries are frequently complex, with articular surface involvement. Surgical principles center on reconstruction of the articular surface as well as restoration of limb length, alignment, and rotation to reestablish functional knee biomechanics. Fixation principles are guided by fracture morphology, and thus, CT with multiplanar reformats and volume rendering is routinely used to help plan surgical intervention. Fractures involving the distal femur, tibial plateau, and patella have distinct management considerations. This comprehensive CT primer of periarticular knee fractures promotes succinct and clinically relevant reporting as well as optimized communication with orthopedic trauma surgeon colleagues by tying fracture type and key CT findings with surgical decision making. Fracture patterns are presented within commonly employed fracture classification systems, rooted in specific biomechanical principles. Fracture typing of distal femur fractures and patellar fractures is performed using Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association (AO/OTA) classification schemes. Tibial plateau fractures are graded using the Schatzker system, informed by a newer explicitly CT-based three-column concept. For each anatomic region, the fracture pattern helps determine the surgical access required, whether bone grafting is warranted, and the choice of hardware that achieves suitable functional outcomes while minimizing the risk of articular collapse and accelerated osteoarthritis. Emphasis is also placed on recognizing bony avulsive patterns that suggest ligament injury to help guide stress testing in the early acute period. ©RSNA, 2024 Supplemental material is available for this article.

Changes in Alignment at Untreated Vertebral Levels Following Short-Segment Fusion Using Personalized Interbody Cages: Leveraging Personalized Medicine to Reduce the Risk of Reoperation.

An abnormal postoperative lordosis distribution index (LDI), which quantifies the ratio between the lordosis at L4 to S1 and the lordosis at L1 to S1, contributes to the development of adjacent segment disease and increased revision rates in patients undergoing short-segment lumbar intervertebral fusions. Incorporating preoperative spinopelvic parameters and LDI into the surgical plan for short-segment fusion is important for guiding alignment restoration and preserving normal preoperative alignment in unfused segments. This study examined changes in LDI, segmental lordosis, and lordosis of the unfused levels in patients treated with personalized interbody cage (PIC) implants. This retrospective study evaluated radiographic measurements from 111 consecutively treated patients diagnosed with degenerative spinal conditions and treated with a short-segment fusion of L4 to L5, L5 to S1, or L4 to S1 using PIC implant(s) within 6 months of the fusion procedure. Comparisons of intervertebral lordosis for treated and untreated levels as well as LDI pre- and postoperatively were performed. In patients with a preoperative hypolordotic distribution (LDI < 50%), statistically significant increases were found in LDI postoperatively, approaching the normal LDI range (LDI 50%-80%). Likewise, patients with hyperlordotic distribution preoperatively (LDI > 80%) experienced a decrease in LDI postoperatively, trending toward the normal range, although the changes were not statistically significant. Intervertebral lordosis for the L5 to S1 level increased significantly following the placement of a PIC in the normal and hypolordotic LDI groups. Changes in intervertebral lordosis for L5 to S1 were not significant for patients with preoperative hyperlordotic LDI. Reciprocal changes in intervertebral lordosis at L1 to L4 were not observed in any groups. PIC implants may provide a benefit for patients, particularly those with hypolordotic distributions preoperatively. They have the potential to further improve patient outcomes by helping surgeons to achieve patient-specific lordosis goals, which may help to reduce the risk of adjacent segment disease and revisions in patients undergoing short-segment lumbar intervertebral fusions. Personalized implants can help surgeons achieve patient-specific alignment goals, potentially prevent adjacent segment disease, and reduce long-term reinterventions.

Patient reported outcomes after revision ankle fixation

BackgroundFunctional outcome following ankle fracture fixation is linked to the restoration of joint congruity, anatomic alignment and stability. If surgical fixation fails to achieve these goals, revision surgery may be indicated. This retrospective study aims to report a consecutive series of fourteen patients with a minimum of one year follow up after revision ankle fixation and describe CT scan based modified Pettrone score used to assess quality of primary fixation. MethodsBetween April 2019 and August 2021, fourteen patients underwent revision ankle fracture fixation. Patients were identified by the multidisciplinary team through a review of intra-operative radiographs. Subsequently, a CT scan-based criteria which is modification of original Pettrone criteria based on plain radiographs was applied to further assess sub-optimal fixation. Demographic, clinical, radiological and patient-reported outcome measures data were collected and examined. ResultsTwelve patients exhibited protonation type injuries according to the Lauge-Hansen classification system. Syndesmotic joint was readdressed in eleven patients. The mean duration between the index surgery and the subsequent revision surgery was 46 days (inter-quartile range – 42 days). The mean Olerud-Molander Ankle Score was calculated as 58, with an IQR of 45. Similarly, the mean EQ-5D-3L VAS score was determined to be 69, with an IQR of 35. In our series, 60 % patients reported good to excellent results using OMAS. The quality-of-life scores of in these patients were also satisfactory. ConclusionWe recommend early revision fixation should be considered when primary fixation is considered inadequate in early post-operative period. The modified Pettrone criterion can be used to assess sub-optimal fixation.

Fibular Lengthening Surgeries in Treatment of Malunited Pott's Fracture Ankle: A Systematic Review

Abstract Background The primary goal of ankle fracture treatment is restoration of ankle stability and alignment. Following an ankle fracture, the fibular fracture deformity is usually shortening and external rotation. This shortening permit lateral shift of the talus with persistent instability and valgus tilt. Many fibular malunions can be successfully salvaged using grafting and plating techniques. In malunited ankle fractures with a shortened fibula and lateral talar shift, reconstruction of the ankle has been advocated to restore function. Lengthening of the fibula is an important step in such cases. Aim to study the functional outcomes and results of fibular lengthening surgeries of malunited pott's fracture ankle and to know the complications of surgery. Patients and Methods The search strategy identified 77 unique citations. Screening of titles and Abstracts identified 27 potentially relevant articles. Full text review of these articles identified 10 studies meeting the inclusion criteria. Results The common interventions procedures used was Ankle joint re-balancing with fibular lengthening, Fibular Lengthening Osteotomy with Revision Syndesmotic Repair. Satisfactory (excellent\good) in 73 cases and unsatisfactory (fair\poor) in 12 cases. VAS score mentioned in 1 study and improved from 6.76 ± 1.03 pre to 2.03 ± 1.21 post. Six studies showed that the infection rate was 31.996 %. Conclusion Correction must be performed once diagnosed, and there is no maximum elapsed time subsequent to which treatment efficacy is reduced. Even if anatomical reduction cannot be achieved, the improved alignment can produce a satisfactory result.

Anterior cervical hybrid constructs reduce superior adjacent segment burden compared to multilevel anterior cervical discectomy and fusion.

Traditional surgical treatment for symptomatic cervical degenerative disc disease is anterior cervical discectomy and fusion (ACDF), yet the increased risk of adjacent segment degeneration (ASD) requiring additional surgery exists and may result in limiting long-term surgical success when it occurs. Disc arthroplasty can preserve or restore physiologic range of motion (ROM), decreasing adjacent level stress and subsequent surgery. For patients with multilevel pathology requiring at least a 1-level fusion, interest is growing in anterior cervical hybrid (ACH) surgery as a partial motion-preserving procedure to decrease the adjacent level burden. This radiographic study compares postoperative superior adjacent segment motion between ACH and ACDF. Secondarily, total global motion, construct motion, inferior adjacent segment motion, and sagittal alignment parameters were compared. This is a single-center, multi-surgeon, retrospective cohort study of 2- and 3-level ACH and ACDF cases between 2013 and 2021. Degrees of motion were analyzed on flexion/extension views using Cobb angles to measure global (C2-C7) construct and adjacent segment lordosis. Neutral lateral X-rays were analyzed for alignment parameters, including global lordosis, cervical sagittal vertical axis (cSVA), and T1 slope (T1S). Differences were determined by independent t-test and Fisher's exact test. Of 100 patients, 38% were 2-level cases (47% ACH, 53% ACDF) and 62% were 3-level cases: (52% ACH, 48% ACDF). Postoperatively, superior adjacent segment motion increased with ACDF and decreased with ACH (-1.3°±5.3° ACH, 1.6°±4.6° ACDF, P=0.005). Postoperatively, the ACH group had greater ROM across the construct (16.3°±8.7° ACH, 4.7°±3.3° ACDF, P<0.001) and total global ROM (38.0°±12.8° ACH, 28.0°±11.1° ACDF, P<0.001). ACH resulted in a significant reduction of motion loss across the construct (-10.0°±11.7° ACH, -18.1°±10.8° ACDF, P<0.001). Postoperative alignment restoration was similar between both cohorts (-2.61°±8.36° ACH, 0.04°±12.24° ACDF, P=0.21). Compared to ACDF, hybrid constructs partially preserved motion across operative levels and had greater postoperative global ROM without increasing superior adjacent segment mobility or sacrificing alignment restoration. This supports the consideration of ACH in patients with multilevel degenerative cervical pathology requiring at least a 1-level fusion and suggests a propensity for long-term success by reducing the superior adjacent segment burden.

Study Protocol for a Randomized Controlled Clinical Trial on the Outcome of Surgical Versus Primary Nonsurgical Treatment of Traumatic Thoracolumbar Spine Burst Fractures in Patients Without Neurological Symptoms—A34RCT

BACKGROUND AND OBJECTIVES: There are still major global differences in the treatment of acute traumatic thoracolumbar burst fractures in patients without neurological deficits and without posterior column injury. Treatment strategies range from conservative treatment with orthosis or early functional mobilization to various surgical stabilization techniques. The study's objectives are to evaluate the clinical (Oswestry Disability Index [ODI]) and radiographical outcomes (restoration and maintenance of spinal alignment; injury of the affected intervertebral disk) and determine the prevalence of complications until 24 months of follow-up. METHODS: The study is designed as a randomized, controlled, noninferiority clinical trial. All patients with a thoracolumbar burst fracture (Arbeitsgemeinschaft für Osteosynthesefragen spine type A3 or A4) age 18 to 70 years without neurological deficit and without posterior ligament injury can be enrolled. We will randomly assign 52 patients for either surgical or nonsurgical treatment. The surgical group will receive combined anterior–posterior (360°) spinal stabilization therapy. Participants in the nonsurgical group will be treated with a 3-point hyperextension orthosis for 6 weeks. The primary outcome is the difference in ODI at 2 years after injury. EXPECTED OUTCOMES: We expect to find that conservative treatment of burst fractures in the thoracolumbar spine will be noninferior to the surgical treatment. DISCUSSION: This study will provide high-quality data comparing a modern surgical treatment regime with a standardized conservative treatment in patients with thoracolumbar burst fractures.

Anatomical Reduction of Spondylolisthesis Through Lateral Lumbar Interbody Fusion With Percutaneous Pedicle Screw Fixation: An Intraoperative Technical Note

Surgical management of lumbar spondylolisthesis requires neural decompression, stabilization, and alignment restoration. Minimally invasive spine approaches offer a wide variety of advantages for spondylolisthesis management. This intraoperative note describes the treatment of L4-L5 lumbar spondylolisthesis with lateral lumbar interbody fusion (LLIF) and percutaneous pedicle screw fixation (PSF). The surgical technique for treating L4-L5 lumbar spondylolisthesis using a minimally invasive approach with LLIF and percutaneous PSF is described. This operative technique is illustrated with figures, and an intraoperative case example of its application is described. LLIF with percutaneous PSF can be a safe, effective, and reliable option for treating lumbar spondylolisthesis when applied with appropriate surgical technique in a selected patient population. This technique is a valuable addition to the range of available spine surgical options. LLIF with percutaneous PSF can be an effective technique for treating lumbar L4-L5 spondylolisthesis.

A Simple Surgical Technique for Correction of Varus Deformity in Advanced Osteoarthritis of Knees by Medial Femoral Condylar Sliding Osteotomy-Description of Procedure and short term Outcome-A Prospective Study.

Advanced osteoarthritis of knees with varus deformity consists of attenuation of lateral structures with contracture of the posteromedial structures and formation of medial osteophytes. The conventional step-wise medial and posteromedial release with measured resection may sometimes hinder achievement of perfectly balanced flexion and extension gaps with maintenance of flexion stability, without the use of a constrained prosthesis. Medial femoral epicondylar sliding osteotomy tailors the balancing to the need of the kinematics of the native knee and precludes the use of a constrained implant. 15 patients with Ahlbäck Grades III through V osteoarthritic changes at Howrah Orthopaedic Hospital were included in a prospective cohort case series with a minimum period of follow-up being 12months. Physical examination, clinical questionnaire and radiographic evaluation were done post-operatively for objectification by functional Knee Society and Oxford Knee Scores respectively. The mean post-operative femorotibial angulation ameliorated to a value of 3.73 ± 1.58° from 18.67 ± 4.2° in the pre-operative stage. The mean overall Range of Motion of operated knee was 109.87 ± 6.86° with no residual frontal laxity and/or laxity in the coronal plane. The mean amount of resection of tibial plateau in patients with severe varus deformity was kept to a minimum, 6.56mm from the least deficient portion of the lateral condyle. There were no complications as regards component loosening and/or surgical-site infection. The main objective of balancing a severely varus-afflicted knee is to preserve as much of the Medial Collateral Ligament as possible, to retain its check rein function and not jeopardise the stability. This is ensured by distalisation and posteriorizing the medial epicondyle by an incomplete osteotomy in addition to modest tibial resection fetching a non-isometric point of knee flexion. All osteotomies united by bony union and restoration of kinematic alignment. The limitation of this study however includes the lack of long-term results, such as late instability and polyethylene wear.

The Incremental Clinical Benefit of Adding Layers of Complexity to the Planning and Execution of Adult Spinal Deformity Corrective Surgery.

For patients with surgical adult spinal deformity (ASD), our understanding of alignment has evolved, especially in the last 20 years. Determination of optimal restoration of alignment and spinal shape has been increasingly studied, yet the assessment of how these alignment schematics have incrementally added benefit to outcomes remains to be evaluated. Patients with ASD with baseline and 2-year were included, classified by 4 alignment measures: Scoliosis Research Society (SRS)-Schwab, Age-Adjusted, Roussouly, and Global Alignment and Proportion (GAP). The incremental benefits of alignment schemas were assessed in chronological order as our understanding of optimal alignment progressed. Alignment was considered improved from baseline based on SRS-Schwab 0 or decrease in severity, Age-Adjusted ideal match, Roussouly current (based on sacral slope) matching theoretical (pelvic incidence-based), and decrease in proportion. Patients separated into 4 first improving in SRS-Schwab at 2-year, second Schwab improvement and matching Age-Adjusted, third two prior with Roussouly, and fourth improvement in all four. Comparison was accomplished with means comparison tests and χ 2 analyses. Sevenhundredthirty-two. patients met inclusion. SRS-Schwab BL: pelvic incidence-lumbar lordosis mismatch (++:32.9%), sagittal vertical axis (++: 23%), pelvic tilt (++:24.6%). 640 (87.4%) met criteria for first, 517 (70.6%) second, 176 (24%) third, and 55 (7.5%) fourth. The addition of Roussouly (third) resulted in lower rates of mechanical complications and proximal junctional kyphosis (48.3%) and higher rates of meeting minimal clinically important difference (MCID) for physical component summary and SRS-Mental ( P < .05) compared with the second. Fourth compared with the third had higher rates of MCID for ODI (44.2% vs third: 28.3%, P = .011) and SRS-Appearance (70.6% vs 44.8%, P < .001). Mechanical complications and proximal junctional kyphosis were lower with the addition of Roussouly ( P = .024), while the addition of GAP had higher rates of meeting MCID for SRS-22 Appearance ( P = .002) and Oswestry Disability Index ( P = .085). Our evaluation of the incremental benefit that alignment schemas have provided in ASD corrective surgery suggests that the addition of Roussouly provided the greatest reduction in mechanical complications, while the incorporation of GAP provided the most significant improvement in patient-reported outcomes.

Support from advanced practitioners in critical care for ankle fracture dislocation

Background: Analgesic imitations, under-recognition of injury severity and delayed restoration of neutral alignment are common problems around ankle fracture dislocation (AFD). Optimal prehospital management improves long-term outcomes. Aims: This study aimed to explore ambulance clinicians' experiences of AFD incidents when supported by advanced practitioners in critical care (APCCs). Methods: Semi-structured online interviews were conducted. Data sets were coded and grouped to identify themes via thematic content analysis. Findings: Six clinicians agreed to take part (response rate 42%). AFDs were encountered infrequently (once per year). Four themes were identified: clinicians' confidence in managing AFD; value-added role of APCCs; prehospital challenges; and reflections on the incident. Conclusions: Benefits of the APCC role include enhanced technical skills, including in ankle reduction and analgesia, and in non-technical skills, such as leadership and decision-making. Improvements in clinician recognition and management of AFD and better awareness of the APCC role are recommended, as is research on optimal prehospital AFD management.

Restoration of Spinopelvic Alignment After Reduction of High-grade Spondylolisthesis: Myth or Reality? A Systematic Review of the Literature and Meta-analysis.

Systematic review and meta-analysis of literature. The aim of the presented study is to assess whether the reduction of high-grade spondylolisthesis (HGS) through the correction of lumbosacral kyphosis leads to a decrease in the sagittal spinopelvic compensatory mechanisms. HGS is as an anterior translation of a vertebra, >50%. It is also characterized by a kyphotic deformity of the affected level. This combination of translation and kyphosis leads to compensatory mechanisms on the sagittal plane [pelvic retroversion, increased lumbar lordosis (LL), reduction in thoracic kyphosis (TK)]. A systematic search of electronic databases was conducted. Inclusion criteria were diagnosis of HGS (Meyerding >II, Slip% >50%), partial or complete reduction surgery (with a significant decrease in Slip%), and report of spinopelvic parameters (pelvic incidence, pelvic tilt, or sacral slope). Clinical and radiographic outcomes were extracted and summarized. Meta-analyses were performed to estimate the differences between preoperative and postoperative spinopelvic alignment measures. P <0.05 was considered significant. Eighteen studies were included. PT showed a statistically significant decrease of -2.1217 (95% CI: -3.4803 to -0.7630), while SS showed a significant increase of 4.8349 (95% CI: 2.7462-6.9236). Conversely, both LL and TK showed nonsignificant changes, -4.7043 (95% CI: -10.4535 to 1.0449) and 6.3881 (95% CI: -0.8344 to 13.6106), respectively. VAS significantly decreased by -3.1950 (95% CI: -4.9462 to -1.4439). The meta-analysis showed mild, yet statistically significant, decrease of PT and an increase in SS after HGS reduction. Conversely, nonstatically significant decrease in LL and an increase in TK occurred. The clinical significance of these results remains questionable. Level IV.

Nonvascularized Bone Grafting for Scaphoid Nonunion

Abstract Background Surgical management of scaphoid nonunions requires not only stable fixation but restoration of carpal alignment and reconstruction of bone defects. The latter can be done with either vascularized or non-vascularized bone grafts, depending largely on surgeon preference. Materials and Methods This article describes the use of non-vascularized bone grafts for scaphoid nonunions and examines reported outcomes. We also describe the senior author's preferred surgical treatment, the hybrid Russe procedure. Description of Technique The hybrid Russe procedure utilizes a corticocancellous strut from the volar aspect of the distal radius to restore anatomy in scaphoid nonunions with flexion deformities. Once the alignment of the scaphoid and associated lunate postural deformities are corrected, fixation then proceeds with a headless compression screw. This combination resulted in healing of 17 scaphoid fracture nonunions at an average time of 15 weeks. Conclusions The literature does not demonstrate a difference in union rates when comparing the use of vascularized and non-vascularized grafts for scaphoid nonunions. When the proximal pole of the scaphoid can be salvaged, the choice of fixation is left to the surgeon's discretion.

Application of Piezosurgery in Revision Surgery through Posterior Approach for Infection after Percutaneous Vertebral Augmentation: Technique Note with Case Series.

Pyogenic spondylitis after vertebral augmentation (PSVA) is a severe complication and even threatens the life of patients. How to deal with infectious bone cement is a big problem for surgeons. The application of piezosurgery has advantages in removal the infectious bone cement in limb bone and spinal laminectomy, but it is rarely used in PSVA. So, the present study aimed to introduce the application of piezosurgery in revision surgery for PSVA and report the preliminary radiological and clinical results. The data of nine patients with PSVA who had undergone revision surgery were retrospectively reviewed between May 2017 and January 2023 in our hospital. The technique of removal of infectious bone cement and lesion by piezosurgery and the reconstruction of the spinal stability were described, and the operation time and intraoperative blood loss were recorded. Postoperatively, radiographs and computed tomography scans were reviewed to evaluate the condition of bone cement removal, control of infection, and bone fusion. Oswestry disability index (ODI) and visual analog scale (VAS) were assessed pre- and postoperatively, and clinical outcomes were assessed using Odom's criteria. All patients achieved satisfactory tainted bone cement cleaning and restoration of spinal alignment. The surgical time was 258.8 ± 63.2 (160-360) min, and the intraoperative blood loss was 613.3 ± 223.8 (300-900) mL. The VAS score decreased from 7.0 (6-8) points preoperatively to 2.4 (1-4) points postoperatively. The ODI index decreased from 71% (65%-80%) preoperatively to 20% (10%-30%) postoperatively. The patient's VAS and NDI scores after operation were significantly improved compared with those before surgery (p ≤ 0.05). Odom's outcomes were good for all patients in the last follow-up, and all patients reported satisfactory results. Piezosurgery can effectively remove large blocks of infectious bone cement through a posterior approach while avoiding nerve and spinal cord damage. We cautiously suggest that a one-stage posterior approach using piezosurgery is an alternative option for surgical treatment of PSVA.

Expandable cages that expand both height and lordosis provide improved immediate effect on sagittal alignment and short-term clinical outcomes following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF).

Failure to restore lordotic alignment is not an uncommon problem following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF), even with expandable cages that increase disc height. This study aims to investigate the effect of the expandable cage that is specifically designed to expand both height and lordosis. We evaluated the outcomes of MIS TLIF in restoring immediate postoperative sagittal alignment by comparing two different types of expandable cages. One cage is designed to solely increase disc height (Group H), while the other can expand both height and lordosis (Group HL). Patients undergoing MIS TLIF using expandable cages were retrospectively reviewed, including 40 cases in Group H and 109 cases in Group HL. Visual analog scores of back and leg pain, and Oswestry disability index were collected. Disc height, disc angle, and sagittal alignment were measured. Complications were recorded, including early subsidence which was evaluated with computed tomography. Clinical and radiographic outcomes significantly improved in both groups postoperatively. Group HL showed superior improvement in segmental lordosis (4.4°±3.5° vs. 2.1°±4.8°, P=0.01) and disc angle (6.3°±3.8 vs. 2.2°±4.3°, P<0.001) compared to Group H. Overall incidence of early subsidence was 23.3%, predominantly observed during initial cases as part of the learning curve, but decreased to 18% after completion of the first 20 cases. Expandable cages with a design specifically aimed at increasing lordotic angle can provide favorable outcomes and effectively improve immediate sagittal alignment following MIS TLIF, compared to conventional cages that only increase in height. However, regardless of the type of expandable cage used, it is crucial to avoid applying excessive force to achieve greater disc height or lordosis, as this may contribute to subsidence and a possible reduction in lordotic alignment restoration. Long-term results are needed to evaluate the clinical outcome, fusion rate, and maintenance of the sagittal alignment.

SIRT6 activates PPARα to improve doxorubicin-induced myocardial cell aging and damage

The Sirtuins family, formally known as the Silent Information Regulator Factors, constitutes a highly conserved group of histone deacetylases. Recent studies have illuminated SIRT6's role in doxorubicin (DOX)-induced oxidative stress and apoptosis within myocardial cells. Nevertheless, the extent of SIRT6's impact on DOX-triggered myocardial cell aging and damage remains uncertain, with the associated mechanisms yet to be fully understood. In our research, we examined the influence of SIRT6 on DOX-induced cardiomyocyte senescence using β-galactosidase and γ-H2AX staining. Additionally, we gauged the mRNA expression of senescence-associated genes, namely p16, p21, and p53, through Real-time PCR. Employing ELISA assay kits, MDA, and total SOD activity assay kits, we measured inflammatory factors TNF-α, IL-6, and IL-1β, alongside oxidative stress-related indicators. The results unequivocally indicated that SIRT6 overexpression robustly inhibited DOX-induced cardiomyocyte senescence. Furthermore, we established that SIRT6 overexpression suppressed the inflammatory response and oxidative stress induced by DOX in cardiomyocytes. Conversely, silencing SIRT6 exacerbated DOX-induced cardiomyocyte injury. Our investigations further unveiled that SIRT6 upregulated the expression of genes CD36, CPT1, LCAD, MCAD associated with fatty acid oxidation through its interaction with PPARα, thereby exerting anti-aging effects. In vivo, the overexpression of SIRT6 was observed to restore DOX-induced declines in EF and FS to normal levels in mice. Echocardiography and HE staining revealed the restoration of cardiomyocyte alignment, affording protection against DOX-induced myocardial senescence and injury. The findings from this study suggest that SIRT6 holds significant promise as a therapeutic target for mitigating DOX-induced cardiomyopathy.

Sagittal imbalance syndrome, a new concept, helps determining a long fusion for patients with degenerative lumbar spinal stenosis and severe global sagittal imbalance

ObjectiveTo retrospectively investigate the postoperative clinical and radiographic outcomes in elderly patients with degenerative lumbar spinal stenosis (DLSS) and severe global sagittal imbalance who underwent different fusion levels.MethodsA total of 214 patients with DLSS and severe global sagittal imbalance were included. Sagittal imbalance syndrome was defined as the severe decompensated radiographic global sagittal imbalance accompanied with the following symptoms: severe back pain in naturel posture that disappears or significantly relieves in support position, living disability with ODI score > 40% and dynamic sagittal imbalance. Thereinto, 54 patients were found with sagittal imbalance syndrome and were performed the lumbar decompression with a long thoracolumbar fusion (Group A) or a short lumbar fusion (Group B). Thirty patients without sagittal imbalance syndrome who underwent short lumbar decompression and fusion were selected as the control (Group C).ResultsPatients with sagittal imbalance syndrome were detected to have more paraspinal muscle degeneration and less compensatory potentials for sagittal imbalance (smaller thoracic kyphosis and larger pelvic tilt) than those without this diagnosis. Postoperative comparisons revealed significant restoration of global sagittal alignment and balance and improvement of living quality in Groups A and C at the final follow-up. Six patients in Group B and one in Group A were found to have proximal junctional complication during follow-up.ConclusionOur results indicated that DLSS patients with sagittal imbalance syndrome had inferior surgical outcomes in terms of living quality and proximal junctional complication after lumbar decompression with a short fusion.

Patient-Specific Surgical Correction of Adolescent Idiopathic Scoliosis: A Systematic Review.

The restoration of sagittal alignment is fundamental to the surgical correction of adolescent idiopathic scoliosis (AIS). Despite established techniques, some patients present with inadequate postoperative thoracic kyphosis (TK), which may increase the risk of proximal junctional kyphosis (PJK) and imbalance. There is a lack of knowledge concerning the effectiveness of patient-specific rods (PSR) with measured sagittal curves in achieving a TK similar to that planned in AIS surgery, the factors influencing this congruence, and the incidence of PJK after PSR use. This is a systematic review of all types of studies reporting on the PSR surgical correction of AIS, including research articles, proceedings, and gray literature between 2013 and December 2023. From the 28,459 titles identified in the literature search, 81 were assessed for full-text reading, and 7 studies were selected. These included six cohort studies and a comparative study versus standard rods, six monocentric and one multicentric, three prospective and four retrospective studies, all with a scientific evidence level of 4 or 3. They reported a combined total of 355 AIS patients treated with PSR. The minimum follow-up was between 4 and 24 months. These studies all reported a good match between predicted and achieved TK, with the main difference ranging from 0 to 5 degrees, p > 0.05, despite the variability in surgical techniques and the rods' properties. There was no proximal junctional kyphosis, whereas the current rate from the literature is between 15 and 46% with standard rods. There are no specific complications related to PSR. The exact role of the type of implants is still unknown. The preliminary results are, therefore, encouraging and support the use of PSR in AIS surgery.