Screw Constructs Research Articles

Treatment Failure in Femoral Neck Fractures in Adults Less Than 50 Years of Age: Analysis of 492 Patients Repaired at 26 North American Trauma Centers.

To assess the operative results of femoral neck fractures (FNFs) in young adults in a large multicenter series, specifically focusing on risk factors for treatment failure. Large multicenter retrospective cohort series. Twenty-six North American Level 1 trauma centers. Skeletally mature patients younger than 50 years with displaced and nondisplaced FNFs treated between 2005 and 2017. Operative repair of FNF. The main outcome measure is treatment failure: nonunion and/or failed fixation, osteonecrosis, malunion, and need for subsequent major reconstructive surgery (arthroplasty or proximal femoral osteotomy). Logistic regression models were conducted to examine factors associated with treatment failure. Of 492 patients with FNFs studied, a major complication and/or subsequent major reconstructive surgery occurred in 45% (52% of 377 displaced fractures and 21% of 115 nondisplaced fractures). Overall, 23% of patients had nonunion/failure of fixation, 12% osteonecrosis type 2b or worse, 15% malunion (>10 mm), and 32% required major reconstructive surgery. Odds of failure were increased with fair-to-poor reduction [odds ratio (OR) = 5.29, 95% confidence interval (CI) = 2.41-13.31], chronic alcohol misuse (OR = 3.08, 95% CI = 1.59-6.38), comminution (OR = 2.63, 95% CI = 1.69-4.13), multiple screw constructs (vs. fixed-angle devices, OR = 1.95, 95% CI = 1.30-2.95), metabolic bone disease (OR = 1.77, 95% CI = 1.17-2.67), and increasing age (OR = 1.03, 95% CI = 1.01-1.06). Women (OR = 0.57, 95% CI = 0.37-0.88), Pauwels angle ≤50 degrees (type 1 or 2; OR = 0.64, 95% CI = 0.41-0.98), or associated femoral shaft fracture (OR = 0.19, 95% CI = 0.10-0.33) had lower odds of failure. FNFs in adults <50 years old remain a difficult clinical and surgical problem, with 45% of patients experiencing major complications and 32% undergoing subsequent major reconstructive surgery. Risk factors for complications after treatment of displaced FNFs were numerous. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Lateral malleolar fractures Weber Type A and B: does percutaneous intramedullary screw confer a solid alternative to the traditional neutralization plate?

PurposeTo compare the clinical results, complication rates, and radiographic outcome between both methods of fixation of lateral malleolar fractures: lateral neutralization plates and intramedullary fully threaded screws.Patients and methodsThis prospective case series study involved 73 patients with fractured lateral malleolus of type A, B according to Weber classification, to whom internal fixation was performed by either lateral plate and screws construct (Group A) or intramedullary screw (Group B). All patients were followed up for 12 months at least, with an average follow-up time of 12.7 months.ResultsThere was no significant difference in the functional outcome score between both groups. The intramedullary screw group had a significantly shorter operative time and time to full union (P<0.001 and =0.006 respectively). There was a relatively higher accuracy of reduction with the plate fixation group, but it was statistically insignificant. There was a relatively fewer complication rate with the use of intramedullary screw fixation compared to plate fixation.ConclusionThe use of intramedullary fixation is a good alternative for plate fixation in low fibular fractures (Weber A and B). Although plate fixation provides an optimal anatomic reconstruction of the fractures, intramedullary fixation may have a lower risk of complications.

Supination Adduction Vertical Medial Malleolar Fracture Fixation with Buttress Plating vs a Novel Screw-Only Construct: A Cadaveric Biomechanical Study.

Supination adduction ankle fractures are unique among rotational ankle fractures as plate constructs are more commonly used than independent screws for medial malleolar fixation. The purpose of this study was to compare fracture displacement between plate fixation to a novel screw-only construct using a cadaveric biomechanical early-weightbearing model for the treatment of vertical medial malleolus fractures. Six nonosteoporotic fresh-frozen cadaver shanks and feet in matched pairs underwent a vertical osteotomy of the medial malleolus to simulate the supination adduction type injury. Osteoporosis was measured using DEXA scans. One specimen from each pair was fixed with a one-third tubular buttress plate and the other with screw-only fixation. The specimens were then axially loaded for 100 000 cycles to simulate protected weightbearing, and subsequently loaded to failure in supination. Stiffness, fracture displacement, and load to failure were recorded. Statistical significance was set at P <.05. There were no measurable differences in displacement between the 2 constructs during axial cyclic loading after 100 000 cycles (plate, 0.74 ± 0.09 mm; screws, 0.79 ± 0.18 mm; P = .225). During supination and axial load to failure, the plate outperformed the screw construct. For load to failure (2 mm displacement) at the fracture site, the plate group failed at 716 ± 240 N, whereas the screw group failed at 567 ± 237 N (P = .015). During load to catastrophic failure, the plate group outperformed the screw group (plate, 6011 ± 1646 N; screws, 4578 ± 1837 N; P = .002). For vertical medial malleolar fractures, the screw-only construct demonstrated no statistical difference when compared to buttress plating for cyclical axial loading, simulating early weightbearing in a boot. However, buttress plating is 21% to 24% stronger than the screw-only fixation construct in overall strength and prevention of catastrophic failure when loading in a supinated position. The screw-only construct is biomechanically similar to a buttress plate when simulating early protected weightbearing. This suggests that early weightbearing as tolerated in a controlled ankle motion boot beginning 2 weeks postoperatively is mechanically safe for this fracture pattern and does not result in unacceptable amounts of fracture displacement. This construct may be useful as a less invasive treatment modality for the treatment of vertical medial malleolus fractures in select patients.

Do the benefits of hook-hybrid construct justify their use over all-pedicle screws constructs in maintaining postoperative curve correction for adolescent idiopathic scoliosis patients from an Asian population?

Retrospective study. (1) Compare outcomes of all-pedicle screws (PS) and hook-hybrid (H) constructs in adolescent idiopathic scoliosis (AIS) patients; and (2) investigate whether BMI, height or pedicle size may modify the effect of the type of surgical construct on the extent of curve decompensation. AIS patients who underwent surgical fixation with H or PS constructs at a single tertiary institution were reviewed. Patients with implant density of at least 70% and 2-year follow-up were included. Demographic and perioperative data collected were age, sex, height, BMI, implant density and pedicle diameter. Cobb's angles and curve correction were compared preoperatively, postoperatively and at follow-up. In total, 59 patients were included. H group had a lower pedicle size at the highest level of construct and at T4 compared to PS group. Postoperatively, H group (30.2° ± 11.7°) and PS group (32.1° ± 10.4°) had similar correction (mean diff. 2.0°, p = 0.516). At 2-year follow-up, H group (1.6° ± 3.5°) and PS group (0.1° ± 2.8°) had similar curve deterioration (mean diff. 1.5°, p = 0.079). Uni- and multivariate analyses revealed that BMI and height were not associated with curve deterioration at 2-year follow-up among the H and PS groups. H constructs provided similar maintenance of curve correction at 2-year follow-up compared to PS constructs. BMI and Stature did not modify curve deterioration between both groups at follow-up. This study supports the use of H constructs when faced with difficult pedicle morphology associated with shorter stature as it provides comparable and satisfactory long-term maintenance of curve correction. Level III, retrospective cohort study.

Evaluating flexibility and predicting curve correction using fulcrum-bending radiographs in Lenke type 2 adolescent idiopathic scoliosis

BackgroundFulcrum-bending (FB) correction is considered to provide the best estimation of main thoracic (MT) curve flexibility and postoperative correction in surgical treatment for adolescent idiopathic scoliosis (AIS). However, few studies evaluated the usefulness of FB radiographs for proximal thoracic (PT) curve. We aimed to perform flexibility assessments using both active side-bending (SB) and FB radiographs and evaluate surgical outcomes after posterior spinal fusion (PSF) for Lenke type 2 AIS. MethodsThis study included 38 consecutive patients with Lenke type 2 AIS who underwent PSF using a pedicle screw construct with a minimum 2-year follow-up. Radiographic parameters, including correction rate, SB and FB flexibility, and FB correction index (FBCI: [correction rate/FB flexibility] × 100), were evaluated preoperatively, immediately after surgery, and at the 2-year follow-up. The clinical outcomes were preoperatively evaluated using the Scoliosis Research Outcomes Instrument-22 and at the follow-up. ResultsAll scoliosis curves significantly improved and shoulder balance shifted toward left shoulder elevation (all comparisons, p < 0.0001). There were significant differences between the SB and FB corrections in the PT and MT curves (p < 0.0001). The magnitudes of the discrepancies between the SB and FB corrections in the PT and MT curves were 11.2° ± 5.2° and 11.6° ± 7.2°, respectively. FB correction did not differ from postoperative Cobb angles correction immediately after surgery or at the 2-year follow-up; the mean FBCIs in the PT and MT curves were 98.8% and 105.5%, respectively. The self-image domain SRS-22 scores had significantly increased at the 2-year follow-up (p < 0.0001). ConclusionsThere were significant differences between the SB and FB corrections, and FB correction tended to approximate the postoperative curve correction (FBCI = 100%) for PT and MT curves in patients with Lenke type 2 AIS. FB flexibility is more reliable than SB flexibility in evaluating actual curve flexibility even for the PT curve.

The implant density does not change the correction rate of the main and the accompanying curves: A comparison between consecutive and intermittent pedicle screw constructs.

The aim of this study was to evaluate the clinical outcomes and the coronal correction rate of the main and accompanying curves of adolescent idiopathic scoliosis (AIS) corrected with pedicle screws inserted consecutively or intermittently. The prospectively collected data of 60 patients (8 men and 52 women; mean age: 14.6±2.5 years) who underwent corrective surgery for AIS between January 2010 and December 2015 were reviewed retrospectively. Two groups were constituted according to the pedicle screw construct type: consecutive pedicle screw construct (CPSC) and intermittent pedicle screw construct (IPSC) groups. The preoperative, early postoperative, and 24-month follow-up radiographs and the Scoliosis Research Society-22 (SRS-22) scores were reevaluated. The Cobb angle of the main and accompanying curves, the correction rate, and the flexibility of the curves were calculated. The mean preoperative Cobb angles were 57.03° and 57.46°, the mean postoperative Cobb angles were 14.93° and 14.4°, and the mean correction rates were 76.22% and 75.31% in IPSC and CPSC groups, respectively (p>0.05). The preoperative and postoperative accompanying curve magnitudes and correction rates were similar (p>0.05). These radiographic outcomes were also consistent with the SRS-22 scores. Both the pedicle screw constructs had satisfactory outcomes following the surgery, which were confirmed by both the SRS-22 scores and radiographs taken perioperatively and at follow-ups. The IPSC and CPSC groups did not demonstrate a significant change in the correction rate of the main and minor or major accompanying structural and nonstructural curves, and also in the SRS-22 scores. Level III, Retrospective comparative study.

Provisional fixation of unstable femoral neck basicervical fractures: A web-based survey and biomechanical assessment using a sliding hip screw construct

Objectives:Many hip fractures are considered rotationally unstable, especially during lag screw insertion. To counteract this instability, multiple provisional fixation constructs have been used to maintain the fracture reduction. This study aimed to compare the methods of provisional fixation biomechanically in ba sicervical femoral neck fractures.Methods:A web-based survey was sent by e-mail to members of three orthopedic assocations with questions concerning used techniques for provisional fixation of unstable basicervical femoral neck fractures and these results were used to guide our biomechanical assessment. Twenty, fourth-generation composite proximal femurs were osteotomized in the basicervical region to simulate a basicervical fracture. These fractures were anatomically reduced and one of the four provisional fixation constructs was applied. A sliding hip screw was then inserted with a torque limiter to the appropriate depth. The amount of fracture displacement during screw insertion was collected and analyzed.Results:Of the 142 respondents, 79.6% apply some form of provisional fixation. Derotational screw was the most commonly used provisional fixation (43.4%), followed by one superior Kirschner wire (K-wire) (39.8%). Biomechanically, the single derotation screw construct showed significantly less displacement (0.92 mm) than the one superior K-wire construct (3.09 mm). No other significant differences in fracture displacement were found between the groups.Conclusion:This study highlights that the majority of surgeons apply a form of provisional fixation during the surgical management of unstable basicervical femoral neck fractures. We have shown biomechanically that the single derotation screw had superior rotational stability when compared to the one superior K-wire.

Anterior Hemi-epiphysiodesis of the Distal Tibia for Residual Equinus Deformity in Children with Clubfeet

Background: Residual equinus deformity in toddlers with a history of clubfoot can be managed with soft tissue release, provided there is no articular incongruity. Distal tibia osteotomy is a reasonable choice in mature patients with a flattened talus provided the growth plate is closed. Anterior distal tibia hemi-epiphysiodesis is an option for children with articular incongruity who have substantial growth remaining. The aim of this study is to evaluate radiographic and clinical outcomes of this method. Methods: Fourteen clubfoot patients (20 ankles) with residual equinus deformity were treated between 2010-2015 with anterior distal tibial hemi-epiphysiodesis utilizing size appropriate modular plate and screw constructs. Patients were evaluated clinically and radiographically. Oxford Ankle Foot Questionnaire for Children (and caregivers) with supplemental questions were requested at most recent follow-up. Results: There were 12 males and 2 females, mean age 10 years at surgery (50-152 months), with the minimum 18 months of radiographic follow-up (Mean 34 months). Pre-surgical mean radiographic anterior distal tibial angle (ADTA) was 87.8 degrees (79-100) and mean maximum dorsiflexion was -5.7 degrees (-40-7). At follow-up, mean improvement of radiologic ADTA was 18 degrees and mean clinical dorsiflexion improvement was 8.4 degrees. On the Oxford Ankle Foot Questionnaire, children reported a mean functional score of 47% in the “Physical” domain, 71% in “School and Play”, 70% in “Emotional”, and 38% in footwear. Parents reported mean scores of 45% in Physical, 69% in School and Play, 56% in Emotional, and 28% in footwear. Sixty percent of parents reported increased foot flexibility, 80% noted improvement in their child’s walking, and 100% would choose this surgery again. Conclusions: Anterior distal tibial hemi-epiphysiodesis is a viable option for treatment of residual equinus in children with a clubfoot history and open growth plates. Radiographic improvement was at least 2x greater than the clinically measured improvements of dorsiflexion; yet each family would undergo the surgery again as they perceived an improvement in function.

Bilateral Isolated Third Metacarpophalageal Arthritis at Long-Term Follow Up After Bilateral Wrist Fusion

Total wrist fusion is an established surgical option for the management of severe wrist arthritis. Long-term sequelae of wrist fusion are numerous and incompletely understood. The following case documents a patient who developed third metacarpophalangeal (MCP) joint arthritis following radiocarpal wrist fusion with a plate and screw construct from the radius to the third metacarpal. An MCP arthroplasty was subsequently performed and outcomes reported. This case report outlines the need for further study of the force transmission through and motion of the MCP joint following a radiocarpal wrist arthrodesis.

Low-Density Pedicle Screw Constructs Are Associated with Lower Incidence of Proximal Junctional Failure in Adult Spinal Deformity Surgery.

Retrospective cohort study. Determine whether screws per level and rod material/diameter are associated with incidence of proximal junctional kyphosis (PJF). PJF is a common and particularly adverse complication of adult spinal deformity (ASD) surgery. There is evidence that the rigidity of posterior spinal constructs may impact risk of PJF. Patients with ASD and 2-year minimum follow-up were included. Only patients undergoing primary fusion of more than or equal to five levels with lower instrumented vertebrae (LIV) at the sacro-pelvis were included. Screws per level fused was analyzed with a cutoff of 1.8 (determined by receiver operating characteristic curve (ROC) analysis). Multivariable logistic regression was utilized, controlling for age, body mass index (BMI), 6-week postoperative change from baseline in lumbar lordosis, number of posterior levels fused, sex, Charlson comorbidity index, approach, osteotomy, upper instrumented vertebra (UIV), osteoporosis, preoperative TPA, and pedicle screw at the UIV (as opposed to hook, wire, etc.). In total, 504 patients were included. PJF occurred in 12.7%. The mean screws per level was 1.7, and 56.8% of patients had less than 1.8 screws per level. No differences were observed between low versus high screw density groups for T1-pelvic angle or magnitude of lordosis correction (both P > 0.15). PJF occurred in 17.0% versus 9.4% of patients with more than or equal to 1.8 versus less than 1.8 screws per level, respectively (P < 0.05). In multivariable analysis, patients with less than 1.8 screws per level exhibited lower odds of PJF (odds ratio (OR) 0.48, P < 0.05), and a continuous variable for screw density was significantly associated with PJF (OR 3.87 per 0.5 screws per level, P < 0.05). Rod material and diameter were not significantly associated with PJF (both P > 0.1). Among ASD patients undergoing long-segment primary fusion to the pelvis, the risk of PJF was lower among patients with less than 1.8 screws per level. This finding may be related to construct rigidity. Residual confounding by other patient and surgeon-specific characteristics may exist. Further biomechanical and clinical studies exploring this relationship are warranted.Level of Evidence: 3.

Divergent vs Parallel Screw Configurations for Subtalar Arthrodesis: Comparing Clinical Outcomes

Category:Ankle Arthritis; HindfootIntroduction/Purpose:Subtalar arthrodesis is a frequently performed surgery used to treat several hindfoot pathologies. Rigid fixation is essential for successful fusion and percutaneous screws are most commonly used. Controversy still exists regarding the most optimal screw configuration. While cadaveric biomechanical studies have shown diverging screw configuration to be superior to parallel screws, this has never been proven in the clinical setting. The aim of this study was to compare fusion rates and clinical outcomes between patients treated with divergent versus parallel screw constructs for subtalar arthrodesis.Methods:We conducted a retrospective review of 58 patients that underwent subtalar arthrodesis during a four-year period at our institutions. Patients were divided into two groups based on screw construct; diverging versus parallel. Outcomes measured were radiographic and clinical evidence of fusion at 3 months, American Orthopaedic Foot & Ankle (AOFAS) ankle-hindfoot and Visual Analog Scale (VAS) scores at final follow up and post-operative complications.Results:Thirty patients underwent subtalar fusion with a divergent screw construct and twenty-four with parallel screws. The mean age was 58.5+-13.9 years and mean follow up period was 44.5+-20.8 months. The overall fusion rate at 3 months was 94.8%. The fusion rate for the divergent screw group was 93.3% versus 96.4% for the parallel screw group, showing no statistical significance (p=0.60). Overall, the mean AOFAS and VAS scores improved post-operatively by 28.1+-5.49 and 4.27+-1.45 points respectively (p<.0001). In the divergent group, mean improvement in AOFAS and VAS scores was 28.5+- 4.99 and 4.39+-1.42 versus 27.7+-6.05 and 4.14+-1.48 in the parallel screw group, showing no statistical significance (p=0.59 and p=0.44). The overall complication rate was 5.2% with no statistically significant difference between the two groups (6.7% versus 3.6%, p=0.60).Conclusion:When used for fixation during subtalar arthrodesis, divergent and parallel screw constructs have similar radiological union rates and clinical outcomes when it comes to fusion rates at 3 months, post-operative improvement in AOFAS scores and complication rates. Screw configuration should be determined by surgeon experience and comfort level.

Early Results of A Nitinol Dynamic Compression Nail for Subtalar Joint Arthrodesis vs Two-Screw Fixation Construct

Category:HindfootIntroduction/Purpose:Subtalar joint arthrodesis (STJA) for deformity correction and management of arthritis is a common surgery. STJA is a reliable operation with high patient satisfaction scores. Securing the talus to the calcaneus, so as to optimize the physiologic environment for osseous healing, has been achieved with multiple fixation techniques including one, two, and three screw constructs, plates, and staples. The goal of our study is to introduce a nitinol nail system with dynamic compression as a novel fixation method for STJA and compare union rates with a standard 2 screw fixation construct. The secondary goal was to assess union rates for this subtalar fusion nail when performed below a previous ipsilateral ankle arthrodesis (AA), with comparison to results from previously published studies.Methods:From May 2019 through July 2020, 15 consecutive patients treated with a novel nitinol nail for STJA were compared to 27 patients undergoing STJA using a two-screw fixation method. The nail group was subcategorized into cases with (6 patients) or without (9 patients) ipsilateral AA. Concomitant talonavicular joint arthrodesis was also performed in patients from each group when indicated. Arthrodesis sites were augmented with autologous bone graft with or without bone graft substitute in all patients. Standard postoperative protocols were used. Primary outcomes included subtalar joint union rates determined by radiographic and clinical assessment. Perioperative complications were compared between groups. Patient specific risk factors were studied to assess any potential negative effects on STJA union rates.Results:Overall, the union rates between the nitinol nail group and screw group did not demonstrate any significant difference (87% vs 88.9%). The nail group with ipsilateral AA demonstrated a 67% union rate (4/6) whereas the nail group without previous AA achieved a 100% union rate (9/9). All patients in our study who underwent STJA with associated TNJA went on to union. Union rates were similar in both groups despite the average age of patients in the nail cohort (61.3 years) being greater than the screw cohort (55.4 years). The average age of patients in the nail group with previous AA was 71 years. No significant relationship was seen between smoking, diabetes or alcohol consumption and union rates.Conclusion:Our data supports the nitinol dynamic compression nail to have superior union rates to the two-screw fixation group when patients with previous AA were excluded (100% vs 88). Our data also indicate that the nitinol nail may provide at least equivalent or better union rates when performed under previous AA when compared to results from prior studies, despite the patients in our group having a much higher average age at the time of surgery. The early results of this nitinol nail for STJA are encouraging and appear to offer an alternative fixation construct with excellent union rates and minimal complications.

Hardware Choice and Risk Factors of Talonavicular Arthrodesis Non-Union

Category:Midfoot/Forefoot; AnkleIntroduction/Purpose:Talonavicular arthrodesis is a commonly performed procedure in orthopedic foot and ankle surgery, for conditions including osteoarthritis, instability, and others. The surgery is frequently performed as part of a double or triple arthrodesis. Multiple surgical constructs have been described, including screws, plate/screw constructs, and staple/screw constructs. Few studies exist that specifically focus on the talonavicular joint, and those that do are often limited by low patient volumes. Studies that do examine non-union of the talonavicular joint do not offer comparative data on non-union rates between the different methods of fixation. The purpose of this study was to determine the rate of arthrodesis in talonavicular fusion surgery among different fixation techniques and determine if hardware has a significant effect on union rate among patient factors.Methods:This is a retrospective single institution, multi-surgeon study evaluating arthrodesis rates in the talonavicular joint. Adult patients undergoing primary talonavicular fusion (isolated or as part of double/triple arthrodesis) from 2015-2018 with a minimum of 3-month radiographic follow-up were studied. Patients undergoing revision talonavicular fusion or fusion as part of Charcot reconstruction were excluded. Patient radiographic and chart notes were reviewed to assess fixation type (single screw, 2-hole compression plate, or screw + staple), the status of the arthrodesis at >=3 months and any hardware complications or reoperations following the index procedure. Descriptive statistics were generated for standard patient demographics and co- morbidities. Non-union rates were calculated for the cohort as a whole and for each fixation technique utilized along with the frequency of hardware complications/removal. Univariate analysis was performed to determine risk factors for increased non- union rate, including patient demographics, co-morbidities, and fixation technique.Results:A total of 198 patients were included. Hardware included 131 double straight screws, 42 two-hole compression plates, and 25 screw + staple constructs. Seventeen patients (8.59%) had a nonunion of the talonavicular joint at >3 months, while 18 patients (9.09%) had hardware complications of breakage or prominence and 11 (5.56%) required eventual removal. Hardware type was not a significant predictor of nonunion, as 11 patients had straight screw hardware (8.40%), while 3 had a two-hole plate (7.14%) and 3 had screw + staple (12%) (p=0.801). Hardware breakage or backing out occurred in 6/131 patients with straight screws (4.58%), 5/42 with 2-hole plates (11.90%), and 7/25 with staple + screw (28%) (p=0.001). Hardware removal was necessary in 5 (3.82%) straight screw patients, 3 (7.14%) two-hole plate patients, and 3 (12%) screw + staple patients (p=0.186). Patient age, sex, diabetic and smoking status were not significant for nonunion or hardware complication.Conclusion:The type of hardware used in talonavicular arthrodesis is not a significant factor in achieving union. Staple + screw constructs may be more susceptible to hardware breakage or migration, but was not significant for the necessity of hardware removal, as a number of patients remain painless and achieve the intended union. The authors recommend that physicians can make decisions of which to utilize based on familiarity and preference. Further study is indicated on even larger patient cohorts with increased population of nonunion cases so that further significant patient risk factors for nonunion of the joint can be identified.

Lesser Tarsal Metatarsal Joint Fusion Using Nitinol Staples, Bone Marrow Aspirate Concentrate and a Calcaneal Bone Dowel: A Retrospective Comparative Analysis

Category:Midfoot/Forefoot; Lesser ToesIntroduction/Purpose:Estimates suggest nonunion rates following lesser tarsometatarsal (TMT) fusion are up to 11.4%. Various techniques have been employed to improve fusion rates; however, none have shown significant improvement compared to other techniques. Autologous bone dowels, bone marrow aspirate concentrate (BMAC) and continuous compression devices (CCDs), such as nitinol staples, have each shown promising fusion rates in orthopedic literature. There is limited data that suggests using these techniques in conjunction with one another has been successfully employed in the fusion of lesser TMT joints. The aim of this study was to describe our technique using autologous calcaneal bone graft, CCDs and BMAC for lesser TMT fusion and to investigate whether this method improves fusion rates and decreases time to fusion in comparison to traditional constructs.Methods:All patients undergoing arthrodesis of the lesser (2nd/3rd) TMT joints from January 2015 to January 2020 were identified. Exclusion criteria included inadequate clinical or radiographic follow-up, those with only 1st TMT joint arthrodesis, and those less than 18 years old. Chart review allowed patient demographics, risk factors and surgical approach to be identified.Twenty patients (28 lesser TMT joints) treated with arthrodesis by the senior surgeon met inclusion criteria. These patients were then divided into two groups: 1) novel treatment (Nitinol staple, BMAC and calcaneal dowel) and 2) traditional treatment (compression plate and screw construct). We then assessed for radiographic union, time to union and complications.Results:All lesser TMT joints in the novel treatment arm went on to successful clinical and radiographic fusion. The radiographic union rate of the traditional treatment arm was 92% (P=.08). Overall time to fusion was 56 and 82 days for the novel and traditional constructs respectively (P <.05). All patients, regardless of construct, had returned to full weight bearing and maintained hardware at most recent follow-up (minimum 6 months).Conclusion:Continuous compression devices such as the nitinol staple and use of biologic adjuvants appear to decrease nonunion rates and significantly shorten overall time to fusion in lesser TMT joints. Further investigation towards identifying patient specific factors for nonunion is warranted.

A pragmatic single centre retrospective comparative review of complication profile between peek cages and zero- p cage screw constructs

A pragmatic single centre retrospective comparative review of complication profile between peek cages and zero- p cage screw constructs

PADRÕES FRONTAIS E SAGITAIS DAS DEFORMIDADES NEUROMUSCULARES DA COLUNA VERTEBRAL, SEGUNDO O PERFIL NOSOLÓGICO

ABSTRACT Objective: Reveal frontal and sagittal patterns of spinal deformity depending on neuromuscular nosology for surgery and outcome planning. The characteristics of spinal deformity vary according to the pathology. In cerebral palsy, muscular dystrophies, and spinal muscular atrophy, specific features of deformities are poorly written, especially in the sagittal profile. Methods: The evaluation criteria were age, gender of the patients, the volume of blood loss, duration of hospitalization, measurement of the deformity curve, thoracic and lumbar kyphosis (Cobb angle), pelvic obliquity concerning the horizontal line, the percentage of curve correction. Cobb angle was measured preoperatively before hospital discharge (up to 21 days postoperatively) and one year after surgery. Results: The cohort of 71 patients with spinal deformities due to neuromuscular diseases included four groups: muscular dystrophy (MD), spinal muscular atrophy (SMA), Duchenne muscular dystrophy (DMD), and cerebral palsy (CP). The most characteristic deformity in the frontal plane was C-shaped thoracolumbar scoliosis with rotation of the pelvis; rotation of the vertebrae increased according to the magnitude of scoliosis. Lumbar hyperlordosis was common in patients with PD, whereas decreased thoracic kyphosis or even thoracic lordosis occurs more frequently in patients with DMD. Moderate correction of scoliosis was observed in all groups. There was no significant improvement in functional status, according to the FIM. Conclusion: The findings showed that rigid hyperlordosis is the main problem of spinal deformities in neuromuscular patients. Scoliosis and pelvic obliquity can be well corrected in NMS by pedicle screw construction with standard maneuvers and pelvic screw fixation. Level of Evidence IV; Lesser quality prospective study.

Is it Possible to Achieve Satisfactory Results With Intramedullary Locking Nails In Adult Forearm Fractures ?

Objectives Plate osteosynthesis is the most commonly used surgical method in the treatment of diaphyseal forearm fractures in adults. Intramedullary nailing (IMN) is an easy surgical alternative for treating these fractures. In the present study we discussed the minimum 2 year follow up results of intramedullary nailing for the management of forearm fractures in a secondary trauma center. Methods A retrospective analysis of patients operated for adult forearm fractures, using intramedullary locking nails, between 2013 and 2015 in a secondary trauma center was performed. Patient demographics and clinical characteristics were retrieved from the hospital database. The union rates and complications were also recorded. Results Twenty nine patients (22 M 7 F) with mean age 29.4 years (range: 19 and 51) were included into the study. Mean follow up time was 26.8 months (range: 24 and 36). Twenty one patients had fracture of both bones, 4 had isolated ulna and 4 had isolated radius fractures. There were 2 open fractures. Average clinical healing time was approximately 20 days and radiologic healing time was 40 days. One patient with an open fracture underwent revision with plate screw fixation due to union delay. Patients improved in terms of health related quality of life questionnaire scores. Conclusion The intramedullary locking nail is a suitable treatment method for the surgical treatment of forearm fractures, and can be an alternative to open reduction and internal fixation with plate screw constructs when the patients can not undergo open surgery due to different factors.

Transforaminal Lumbar Interbody Fusion versus Posterolateral Fusion for Surgical Treatment of Segmental Lumbar Spinal Instability

Background Data: The rationale behind lumbar fusion surgery is to eliminate pathologic segmental motion and its accompanying symptoms, especially low back pain.Posterolateral fusion (PLF) using pedicle screw fixation (PSF) has been one of the most popular procedures among the posterior lumbar reconstruction techniques.Lumbar interbody fusion is a recognized surgical technique in treating chronic low back pain in segmental instability. Purpose: The purpose of this study was to compare the clinical and radiological outcomes of stabilizing the lumbar spine using TLIF versus PLF for lumbar segmental instability. Study Design: A prospective, nonrandomized clinical controlled trial. Patients and Methods: Forty patients with segmental lumbar instability were divided into two groups: TLIF and PLF groups, with twenty patients each. Top loaded pedicle screw construct was used with both groups. The mean age of the patients was 48.35 years in the TLIF group and 45.3 years in the PLF group. Sex distribution was 6 males and 14 females in the TLIF group and 7 males and 13 females in the PLF group. Mechanical low back pain was the chief complaint in all patients. Sciatica was a complaint in 12 patients (60%) of the TLIF group and 13 (65%) patients of the PLF group. Patients were evaluated pre- and postoperatively by visual analogue scale (VAS), Oswestry disability index (ODI), and radiographs. Results: The average operative time was 214.5 minutes in the TLIF group and 192.5 minutes in the PLF group. The mean estimated blood loss was 278 ml in the TLIF group and 259 ml in the PLF group. The average length of hospital stay was 3.85 days in the TLIF group and 3.8 days in the PLF group. Patients progressively improved regarding VAS and ODI in both groups with no statistically significant difference except for VAS for back pain, where the TLIF group gave better results. However, TLIF group gave better results in patients with postlaminectomy instability than the PLF group. Solid fusion occurred in 17 patients (85%) of the TLIF group and 16 patients (80%) of the PLF group with no statistical difference. Conclusion: Both transforaminal lumbar interbody fusion and posterolateral fusion are effective and safe options for treating segmental lumbar instability. However, interbody fusion yield superior results in patients with postlaminectomy instability. (2021ESJ253)

Addressing Transverse Plane Instability in the Modified Lapidus Arthrodesis: A Comparative Study of Screw Versus Suture and Button Fixation Device Technique

The Lapidus arthrodesis is a powerful procedure for the correction of hallux valgus with metatarsus primus varus. Yet, first ray instability may persist despite correction of the primary deformity with 2 crossed screw fixation. A third screw is often utilized as the additional point of fixation for noteworthy residual transverse plane motion, but it is not without potential complications. The suture and button fixation device may be an appropriate alternative to the third screw construct. This retrospective cohort study identified clinical / radiographic outcomes and complication rates following a third point of fixation with either a screw or suture and button fixation device in patients undergoing a modified Lapidus arthrodesis. One surgeon performed all of the Lapidus procedure with a third screw while the other surgeon performed all with a suture and button fixation device. Of 136 consecutive patients who underwent a modified Lapidus arthrodesis, 83 (61%) patients required a third point of fixation for satisfactory stabilization of the first ray. Surgical technique was similar between the 2 surgeons; however, one utilized the suture and button fixation device method (n = 36), while the other used a third screw for fixation (n = 47). Many of the clinical outcomes, radiographic results, and the union rate were similar between the 2 methods. Nineteen (40%) complications occurred in the third screw group compared to 6 (17%) in the suture and button fixation device group. However, the third screw group demonstrated 100% maintenance of deformity correction at 1 year versus 95% in the suture and button fixation device group. Although fixation with a suture and button fixation device was associated with fewer complications, a larger study is necessary to determine if these variations are statistically significant.

A pragmatic single centre retrospective comparative review of complication profile between PEEK cages and Zero-P cage screw constructs

Background Anterior Decompression and Fusion (ACDF) is a common surgery recommended for symptomatic cervical degenerative disc disease after failed conservative care. There is no consensus on the choice of implants, and it varies between surgeons. This study aims to analyse the early complications following ACDF performed using a standalone cage versus a Zero-P (Cage Screw – (CS)) construct for patients with cervical degenerative disc disease. Methods A total of 162 patients underwent an ACDF between August 2016 and July 2018. There were 83 patients (111 cervical disc levels) with standalone cage (SA) and 79 patients (111 cervical disc levels) with cage-screw (CS) fixation. There was no difference between the groups in terms of age, gender, and levels of surgery. The follow-up ranged from 2 months to 24 months. Complications, both clinical and radiological, were assessed between the groups. Results Both the SA and Zero-P (CS) groups were subdivided into single and multilevel surgery. Complications encountered in the SA group were temporary swallowing problems 10, hoarseness of voice 3, cage migration 1, delayed union 1, Horner’s syndrome 1, cage subsidence 2. In the CS group swallowing problems 4, hoarseness of voice 4, CSF leak 1, recurrent symptoms 1. The observed difference in the incidence of complications between the groups did not reach statistical significance. Univariate analysis between the groups did not show any difference in the improvement of cervical sagittal balance, fusion rate, subsidence, and complications encountered. Multivariate logistic regression analysis for complications showed no difference between the groups when assessed for smoking, gender, age, Charlson comorbidity index, levels of surgery, fusion status, Odom score, or the type of implant. Conclusion In this short-term study, the standalone (SA) cages showed no difference in their complication profile in comparison to a cage-screw construct for both single and multilevel ACDF. Standalone cages might be a cost-effective option without increased complication risks. Nevertheless, we propose a longer-term follow-up with a prospective randomized trial for further evaluation of this finding.