Single Posterior Incision Research Articles

Transvaginal single posterior incision Extraperitoneal bilateral sacrospinous ligament suspension combined with reconstruction of pericervical ring through cervical cerclage.

Transvaginal single posterior incision Extraperitoneal bilateral sacrospinous ligament suspension combined with reconstruction of pericervical ring through cervical cerclage.

Single-Stage Lateral Anterior-to-Psoas Interbody Fusion and Facet Screws as a Treatment for L5–S1 Adjacent Segment Disease in a Patient With a Long-Segment Construct

Objective: Adjacent segment disease (ASD) occurs in 9% of patients with long-segment lumbar spine fusion and results from the transmission of a greater degree of stress to the segments cranial and caudal to a fused segment. The treatment of symptomatic ASD typically involves extending fusion to the involved segment. Revision and extension of posterior instrumentation bears the disadvantage of involving the exposure and modification of old hardware. Lateral interbody fusion cannot be performed at L5/S1 due to the iliac crest. Anterior lumbar interbody fusion typically still requires flipping the patient to augment the construct posteriorly. Here, we present a method to treat L5/S1 ASD using single-position anterior-to-psoas (ATP) interbody fusion combined with facet screw instrumentation.Methods: An 80-year-old man, who had undergone L2-5 fusion 27 years ago, presented with persistent lower back pain and gait dysfunction with imaging findings of L5/S1 spondylosis and ASD. Under intraoperative computed tomography navigation, left L5/S1 ATP interbody fusion was performed with simultaneous L5/S1 percutaneous facet screw fixation. Results: The abdominal incision was 4.0 cm and the single posterior incision was 1.5 cm long. Blood loss was lower than 10 mL, and the procedure lasted for less than 1.5 hours. The patient was discharged to rehabilitation after 3 days.Conclusion: ATP interbody fusion enabled the placement of an interbody device with a large footprint to promote fusion and reduce the risk of subsidence and pseudoarthrosis. The combined use of interbody fusion and facet screws obviates the need to link to the previous construct.

Latissimus Dorsi Tendon Reconstruction at the Myotendinous Junction With Acellular Dermal Allograft

Background: Limited available data have shown latissimus dorsi tendon reconstruction to be an effective treatment for tendon tears in specific subpopulations of elite overhead throwing athletes. Indications: Primary indication for latissimus dorsi tendon reconstruction is a symptomatic, full-thickness humeral avulsion with or without a concomitant teres major tendon tear. Surgical candidates are typically young, high-demand, elite or professional overhead throwing athletes. In this case, the patient is a 29-year-old male former minor league pitcher and current pitching coach with a full-thickness avulsion of the latissimus dorsi tendon. Technique Description: The patient was positioned left lateral decubitus with a dynamic limb positioner maintaining the arm in 90° abduction and maximal internal rotation. This technique used a single posterior axillary incision, which was performed and dissected down to the ruptured latissimus dorsi tendon. We circumferentially applied an acellular dermal allograft to augment the reconstruction at the myotendinous junction. Subsequently, the construct was prepared for transfer with a Krackow suture technique. Suture buttons were used to secure the reconstructed latissimus dorsi tendon to the anatomic footprint on the proximal humerus with a tension slide technique. Results: One case series showed return to the previous level of competition for all baseball pitchers who underwent a latissimus dorsi reconstruction with excellent improvement in visual analog scale pain, American Shoulder and Elbow Surgeons, and Kerlan-Jobe Orthopaedic Clinic scores. Another larger study demonstrated equal return to play rates for professional baseball pitchers with a latissimus dorsi tear treated either nonoperatively or operatively. However, those treated operatively had no decline in performance, whereas the nonoperative cohort saw decline in some statistics. Conclusion: Latissimus dorsi tendon reconstruction using an acellular dermal allograft at the myotendinous junction is a viable treatment option for elite overhead throwing athletes with full-thickness tendon avulsions. It allows for full return to play, particularly if the patient has failed nonoperative management.

Early Outcome of Mid-Shaft Radius & Ulna Fracture Osteosynthesis through Single Posterior Incision Approach

Objective: To determine the early outcome of mid-shaft radius and ulna fracture osteosynthesis through single posterior incision approach.
 Study Design and Setting: This is a retrospective study carried out at Orthopaedic Surgery department, Liaquat University of Medical and Health Sciences Jamshoro, from September 2019 to December 2020.
 Material and Methods: In total 14 patients were operated out of which 9(64.29%) were male and 5 were females through posterior single incision approach (Thompson approach). Demographic data regarding the pattern of fracture and the complications after the surgery at 2,6 and 12 weeks was collected respectively.
 Results: The total number of cases operated from September 2019 to December 2020 were 14, out of 14 patients 9(64.29%) were males and 5(35.71%) were females. The average age of patients was 26.5 years ranging from 16-40 years .The average time of surgery was 61 minutes ranging from 50-70 minutes. The patients were discharged on 3rd post-operative perficial wound infection which was treated with antibiotics after culture and sensitivity There was no neurovascular deficit in all patients. All the fractures were united within 3 months time, and there was no radio ulnar synostosis observed within mean time.
 Conclusion: To conclude we can say that the single posterior incision approach for treatment of mid-shaft radius ulna fractures osteyosynthisis is effective and safe provided the surgical expertise and good anatomical knowledge for identification of the vital structures are there.

Transolecranon Exposure of Monteggia Variant Fracture-dislocations of the Elbow.

Posterior Monteggia fracture-dislocations are uncommon injuries that can result from a fall onto an outstretched hand. Often, these injuries are associated with coronoid and/or radial head fractures. When this is the case, direct fixation can require 3 separate fascial incisions: posterior to address the proximal ulnar fracture, lateral to address the radial head fracture, and medial to address the coronoid fracture. We illustrate a transolecranon surgical approach for fixation of a type IIA posterior Monteggia fracture-dislocation with associated radial head and coronoid fractures. In this approach, the 3 associated fractures can be addressed through a single posterior incision, thereby minimizing soft tissue disruption around the elbow.

Latissimus Dorsi Tendon Repair

Latissimus dorsi tendon ruptures are less-common injuries that can occur in elite throwing athletes. Physical examination of the thrower with a latissimus injury may show ecchymosis of the upper arm and asymmetry of the posterior axillary fold along with possible weakness in shoulder adduction, extension, and internal rotation. Magnetic resonance imaging is used to confirm the diagnosis. Latissimus tendon ruptures are largely treated nonoperatively; surgical repair is only advocated for in professional throwing athletes with complete avulsion injuries or midsubstance latissimus tendon tears. Surgical repair options include the use of suture anchors, cortical suture buttons, or transosseous sutures via a single posterior axillary incision or a 2-incision technique. Given the limited literature on this topic, there have been no studies evaluating the different fixation options or surgical approaches for tendon repair. This article and accompanying video show the technique and discusses the technical pearls of a latissimus tendon repair using suture button fixation via a single-incision approach.

Surgeries for Patients with Tandem Spinal Stenosis in Cervical and Thoracic Spine: Combined or Staged Surgeries?

Cervical and thoracic tandem spinal stenosis (ct-TSS) is a rare yet challenging degenerative disease. When the diagnosis is made, surgical decompression is indicated for both lesions. However, literature about the surgical approaches and prognosis of this disease is lacking. From March 2005 to April 2013, 30 patients with ct-TSS and a mean age of 49.8 years were recruited. We outlined 2 types of ct-TSS lesions-adjacent and skip lesions. The surgical approach for ct-TSS with adjacent lesions was combined cervical and thoracic decompression via a single posterior incision; the approach for skip lesions was 2-stage sequential cervical and thoracic decompressions. Neurologic status was evaluated with the Japanese Orthopaedic Association scale for cervical myelopathy. Seventeen patients underwent 1-stage surgery, and 13 patients underwent the 2-stage procedure. After surgery, 27 patients (90%) experienced improvement. Main complications included transient neurologic deterioration in 7 patients, dural tears in 14 patients, and new radiculopathy in 4 patients. Combined and staged groups were comparable in terms of total length of decompression, occurrence of perioperative complications, and recovery rate (P > 0.05). The average Japanese Orthopaedic Association score increased significantly from 9.8 ± 1.9 to 13.7 ± 3.0 (P < 0.05), and the average recovery rate was 54.4%. The types of stenotic lesions should be considered when planning surgery for patients with ct-TSS. One-stage decompression is suitable for patients with adjacent stenotic lesions; staged procedures should be considered for other patients.

Biomechanical Analysis of Suture Anchor vs Tenodesis Screw for FHL Transfer.

Chronic Achilles injury is often treated with flexor hallucis longus (FHL) tendon transfer to the calcaneus using 1 or 2 incisions. A single incision avoids the risks of extended dissections yet yields smaller grafts, which may limit fixation options. We investigated the required length of FHL autograft and biomechanical profiles for suture anchor and biotenodesis screw fixation. Single-incision FHL transfer with suture anchor or biotenodesis screw fixation to the calcaneus was performed on 20 fresh cadaveric specimens. Specimens were cyclically loaded until maximal load to failure. Length of FHL tendon harvest, ultimate load, stiffness, and mode of failure were recorded. Tendon harvest length needed for suture anchor fixation was 16.8 ± 2.1 mm vs 29.6 ± 2.4 mm for biotenodesis screw ( P = .002). Ultimate load to failure was not significantly different between groups. A significant inverse correlation existed between failure load and donor age when all specimens were pooled (ρ = -0.49, P < .05). Screws in younger specimens (fewer than 70) resulted in significantly greater failure loads ( P < .03). No difference in stiffness was found between groups. Modes of failure for screw fixation were either tunnel pullout (n = 6) or tendon rupture (n = 4). Anchor failure occurred mostly by suture breakage (n = 8). Adequate FHL tendon length could be harvested through a single posterior incision for fixation to the calcaneus with either fixation option, but suture anchor required significantly less graft length. Stiffness, fixation strength, and load to failure were comparable between groups. An inverse correlation existed between failure load and donor age. Younger specimens with screw fixation demonstrated significantly greater failure loads. Adequate harvest length for FHL transfer could be achieved with a single posterior incision. There was no difference in strength of fixation between suture anchor and biotenodesis screw.

The Circumferential Graft Technique for Treatment of Chronic Multidirectional Ligamentous Elbow Instability.

The circumferential graft technique1,2 represents a potential option for the treatment of multidirectional ligamentous elbow instability using a single tendon graft (Video 1). Approach the elbow joint through either a single posterior skin incision or separate lateral and medial incisions. Create humeral and ulnar bone tunnels for circumferential graft placement. Use a plantaris allograft, which we recommend; however, a semitendinosus autograft may also be used. Ensure that meticulous wound closure is achieved as it is key to preventing postoperative complications such as superficial or deep infection and persistent seroma. As multidirectional instability represents a rather rare complication following ligamentous elbow dislocation, clinical data regarding the circumferential graft technique are scarce1,2.

One-staged combined decompression for the patients with cervico-thoracic tandem spinal stenosis

PurposeTo report the techniques and safety of one-staged combined decompression for the patients with tandem spinal stenosis (TSS) at cervical and thoracic spine.MethodsSixteen TSS subjects, who received combined decompression from Aug 2005 to Feb 2012, were reviewed. The essentials of our surgical strategy included: choosing patients with TSS from cervical to upper or middle thoracic spine, using one single posterior incision, simplifying surgical maneuvers and performing circumferential decompression for thoracic compression if it was indicated. The Japanese Orthopedic Association (JOA) scale for cervical myelopathy was employed to evaluate the neurological status, and Hirabayashi’s system to assess neurological recovery rate.ResultsThe average operation duration, blood loss and postoperative hospitalization were 242.8 ± 89.9 min, 1581.3 ± 1237.2 ml and 11.9 ± 7.5 days, respectively. Six subjects (37.5 %) suffered instant neurological deterioration. Other complications included cerebrospinal fluid leakage (10 subjects, 62.5 %), new radiculopathy (two subjects), urinary infection, lung infection and pulmonary thromboembolism. Four subjects received extra-thoracic decompression due to the remaining anterior compression in one subject and new emerging compression in other three subjects. Eventually, mean JOA score was elevated from 9.8 ± 2.1 to 13.7 ± 2.7 after this procedure, and the neurological recovery of seven subjects was rated as excellent, four as good, two as fair, three as unchanged or deteriorated. The overall recovery rate was 53.7 %.ConclusionCombined cervico-thoracic decompression could provide fair neurological outcomes for patients with cervico-thoracic TSS, but it was complicated with high rate of undesirable postoperative events. So, more efforts should be done against its eventful postoperative course before its wide application.

Modified soft tissue release procedure in idiopathic congenital talipes equinovarus

Introduction: Initial treatment of clubfoot is non operative usually, but cases which prove to be resistant require surgical treatment. The most commonly used posteromedial incisions have been reported to have complications like skin sloughing, dehiscence, infection, limitation of full correction, hypertrophic scar and recurrence. Thus the treatment is shifting towards less aggressive surgeries. The aim of the study is to evaluate the result of a “modified soft tissue release procedure” through a single posterior incision for the correction of the idiopathic clubfoot. Materials and Methods: We conducted a prospective therapeutic study reviewing patients with idiopathic congenital clubfoot resistant to conservative management in our institution between August 2013 and July 2014. Surgical management was given by modified soft tissue release procedure. Pre and post treatment clinical, podogrammical, and radiological assessments were done. Results: A total of 82 clubfeet were reviewed. Surgical correction observed in the feet was clinically significant as per Pirani scoring, foot bimalleolar angle and talocalcaneal angle lateral view and talocalcaneal index. Improvement was clinically not significant as per talocalcaneal angle in anteroposterior view. Complications included postoperative pyrexia, pain and stiffness and superficial wound infection, 1 foot of treatment failure and 2 feet of residual deformity in the follow up period. Final clinical outcome revealed excellent and good result in 85.36% cases by this technique. Conclusion: The present study concludes that the procedure is effective in treating the deformity. The results are equivalent while complications are lesser compared to more aggressive surgeries. FBM angle is a simple method for assessment of correction.

Mast Quadrant-assisted minimally invasive modified transforaminal lumbar interbody fusion: single incision versus double incision.

Background:The concept of minimally invasive techniques is to make every effort to reduce tissue damage. Certainly, reducing skin incision is an important part of these techniques. This study aimed to investigate the clinical feasibility of Mast Quadrant-assisted modified transforaminal lumbar interbody fusion (TLIF) with a small single posterior median incision.Methods:During the period of March 2011 to March 2012, 34 patients with single-segment degenerative lumbar disease underwent the minimally invasive modified TLIF assisted by Mast Quadrant with a small single posterior median incision (single incision group). The cases in this group were compared to 37 patients with single-segment degenerative lumbar disease in the double incision group. The perioperative conditions of patients in these two groups were statistically analyzed and compared. The Oswestry Disability Index (ODI) scores, Visual Analog Scale (VAS) scores, and sacrospinalis muscle damage evaluation indicators before operation and 3, 12 months postoperation were compared.Results:A total of 31 and 35 cases in the single incision and double incision groups, respectively, completed at least 12 months of systemic follow-up. The differences in perioperative conditions between the two groups were not statistically significant. The incision length of the single incision group was significantly shorter than that of the double incision group (P < 0.01). The ODI and VAS scores of patients in both groups improved significantly at 3 and 12 months postoperation. However, these two indicators at 3 and 12 months postoperation and the sacrospinalis muscle damage evaluation indicators at 3 months postoperation did not differ significantly between the two groups (P ≥ 0.05).Conclusions:Mast Quadrant-assisted modified TLIF with a small single posterior median incision has excellent clinical feasibility compared to minimally invasive TLIF with a double paramedian incision.

Terrible Triad Elbow Fracture-Dislocation With Triceps and Flexor-Pronator Mass Avulsion

Terrible triad elbow injuries, consisting of fractures of the radial head and coronoid with ulnohumeral dislocation, are challenging to treat. They require a comprehensive understanding of the complex anatomy of the elbow to effectively treat all of the pathology and create a stable, congruent joint. The authors present a case of a terrible triad injury with avulsion of the triceps and flexor-pronator mass after a low-energy fall in a young patient. Although most terrible triad fracture-dislocations can be successfully treated with coronoid fixation, radial head fixation or replacement, and repair of the lateral collateral ligament complex, this case involved a completely circumferential injury to the elbow. The coronoid and anterior capsule were disrupted anteriorly, the radial head and lateral collateral ligament complex were disrupted laterally, the triceps was disrupted posteriorly, and the flexor-pronator mass was disrupted medially. Although the authors prefer to address most terrible triad injuries through a lateral approach, they suspected a circumferential injury preoperatively and elected to use a single posterior incision to address all of the pathology conveniently. This injury required treatment of all disrupted structures, because the elbow remained unstable until the triceps and flexor-pronator mass avulsions were ultimately repaired. With any elbow fracture-dislocation, surgeons should look for evidence of additional injuries that do not fit the commonly described patterns, because they may necessitate modifications to the treatment plan. Given the relatively common complications of stiffness and instability despite modern surgical techniques, additional injuries may further compromise functional outcomes unless they are addressed properly.

Exposure of both the radius and ulna through a single posterior incision: a technical note

Fractures of both the radius and ulna are usually treated with two separate incisions and rarely with one single incision. However, both methods have disadvantages. For this we describe a relatively safe single straight posterior incision for exposure of the whole shafts of both the radius and ulna with the forearm rested on a board across the chest. This procedure was used in 116 forearms in 115 patients. The incision was in a straight line from the lateral humeral epicondyle to the ulnar head. The ulna was exposed between the extensor carpi ulnaris muscle and flexor digitorum profundus muscle covered by the aponeurosis of the flexor carpi ulnaris muscle and the radius between the extensor digitorum muscle and the extensor carpi radialis brevis muscle. During operation there was no difficulty in reducing or fixing any of the fractures in the whole shafts of the radius and ulna and at follow-up (average 5.2 years) there was no radioulnar synostosis or neurovascular injury in any of the forearms.

Mini-open transpedicular lumbar vertebrectomy reconstructed with double cages and short segment fixation

Background:The purpose of this study was to assess the feasibility of using dual expandable cages plus short segment posterior fixation for reconstruction of vertebral bodies following a mini-open transpedicular approach.Methods:A single posterior incision was used to perform a laminectomy of L2, a partial laminectomy of L1 and bilateral transpedicular approaches for a piecemeal vertebrectomy in a patient with spinal compression secondary to metastatic cancer. Subsequently, bilateral cages were placed through the transpedicular corridors and percutaneous pedicle screws were inserted a single level above and below the level of the vertebral column resection.Results:The bilateral transpedicular approach facilitated the use of a mini-open incision (6.0 cm) compared with the extensive dissection normally employed for a lateral extracavitary type approach in the lumbar region. The bilateral transpedicular approach at L2 allowed for a vertebrectomy and complete decompression of neurological elements. The use of expandable cages allowed the nerve roots to be preserved. Placement of the cages in the lateral position was straightforward despite minimal exposure. The reconstruction with double expandable cages appeared robust.Conclusions:In select patients requiring circumferential decompression of the lumbar spine, dual cage reconstruction decreases the technical difficulty of the operation and facilitates a mini-open approach. The durability of this construct will need biomechanical assessment and long-term clinical follow-up.

Dual Plating for Fractures of the Distal Third of the Humeral Shaft

In this study, we present a novel method for performing dual plating of extra-articular fractures of the distal third of the humerus. Since 2006, we have treated 15 such fractures with dual plates from a single posterior midline incision. In the first part of the study, we provide the surgical protocol we have used in addressing these fractures. In the second part, the charts of these patients were reviewed retrospectively to examine their clinical and radiographic outcomes. Using this technique, we have achieved an excellent union rate without significant complications while allowing early and aggressive range of motion.

Subacute repair of latissimus dorsi tendon avulsion in the recreational athlete: Two-year outcomes of 2 cases

An avulsion injury to the latissimus dorsi tendon is considered to be the result of forceful resisted adduction and/or extension of the arm and is an uncommon occurrence. There are a limited number of cases reported in the literature utilizing both conservative and operative treatments for latissimus dorsi tendon avulsions. Only 1 repair of a chronic latissimus injury has been reported. No reports exist for repairs accomplished in the sub-acute setting using a single incision technique. We defined subacute here as greater than 6 weeks post injury, in the manner described by Wolfe et al for pectoralis major injuries. Repair of an acute latissimus dorsi tendon avulsion has been achieved using a single posterior axillary incision in the acute setting. We present 2 cases of sub-acute latissimus dorsi tendon avulsion in recreational athletes, who were treated surgically through a single incision using suture anchors with minimum 2-year follow up.

Thoracolumbar Burst Fractures Treated with Posterior Decompression and Pedicle Screw Instrumentation Supplemented with Balloon-Assisted Vertebroplasty and Calcium Phosphate Reconstruction

The treatment of unstable thoracolumbar burst fractures with short-segment posterior spinal instrumentation without anterior column reconstruction is associated with a high rate of screw breakage and progressive loss of reduction. The purpose of the present study was to evaluate the functional, neurologic, and radiographic results following transpedicular, balloon-assisted fracture reduction with anterior column reconstruction with use of calcium phosphate bone cement combined with short-segment posterior instrumentation and a laminectomy. A consecutive series of thirty-eight patients with an unstable thoracolumbar burst fracture with or without neurologic deficit were managed with transpedicular, balloon-assisted fracture reduction, calcium phosphate bone cement reconstruction, and short-segment spinal instrumentation from 2002 to 2005. Twenty-eight of the thirty-eight patients were followed for a minimum of two years. Demographic data, neurologic function, segmental kyphosis, the fracture severity score, canal compromise, the Short Form-36 score, the Oswestry Disability Index score, and treatment-related complications were evaluated prospectively. All thirteen patients with incomplete neurologic deficits had improvement by at least one Frankel grade. The mean kyphotic angulation improved from 17 degrees preoperatively to 7 degrees at the time of the latest follow-up, and the loss of vertebral body height improved from a mean of 42% preoperatively to 14% at the time of the latest follow-up. Screw breakage occurred in two patients, and pseudarthrosis occurred in one patient. The present study demonstrates that excellent reduction of unstable thoracolumbar burst fractures with and without associated neurologic deficits can be maintained with use of short-segment instrumentation and a transpedicular balloon-assisted reduction combined with anterior column reconstruction with calcium phosphate bone cement performed through a single posterior incision. The resultant circumferential stabilization combined with a decompressive laminectomy led to maintained or improved neurologic function in all patients with neurologic deficits, with a low rate of instrumentation failure and loss of correction.

Thoracolumbar Burst Fractures Treated with Posterior Decompression and Pedicle Screw Instrumentation Supplemented with Balloon-Assisted Vertebroplasty and Calcium Phosphate Reconstruction

The treatment of unstable thoracolumbar burst fractures with short-segment posterior spinal instrumentation without anterior column reconstruction is associated with a high rate of screw breakage and progressive loss of reduction. The purpose of the present study was to evaluate the functional, neurologic, and radiographic results following transpedicular, balloon-assisted fracture reduction with anterior column reconstruction with use of calcium phosphate bone cement combined with short-segment posterior instrumentation and a laminectomy.A consecutive series of thirty-eight patients with an unstable thoracolumbar burst fracture with or without neurologic deficit were managed with transpedicular, balloon-assisted fracture reduction, calcium phosphate bone cement reconstruction, and short-segment spinal instrumentation from 2002 to 2005. Twenty-eight of the thirty-eight patients were followed for a minimum of two years. Demographic data, neurologic function, segmental kyphosis, the fracture severity score, canal compromise, the Short Form-36 score, the Oswestry Disability Index score, and treatment-related complications were evaluated prospectively.All thirteen patients with incomplete neurologic deficits had improvement by at least one Frankel grade. The mean kyphotic angulation improved from 17 degrees preoperatively to 7 degrees at the time of the latest follow-up, and the loss of vertebral body height improved from a mean of 42% preoperatively to 14% at the time of the latest follow-up. Screw breakage occurred in two patients, and pseudarthrosis occurred in one patient.The present study demonstrates that excellent reduction of unstable thoracolumbar burst fractures with and without associated neurologic deficits can be maintained with use of short-segment instrumentation and a transpedicular balloon-assisted reduction combined with anterior column reconstruction with calcium phosphate bone cement performed through a single posterior incision. The resultant circumferential stabilization combined with a decompressive laminectomy led to maintained or improved neurologic function in all patients with neurologic deficits, with a low rate of instrumentation failure and loss of correction.

Interference Screw Fixation for Flexor Hallucis Longus Tendon Transfer for Chronic Achilles Tendonopathy

Chronic Achilles tendinosis can be a challenging problem to the foot and ankle surgeon. Multiple surgical treatment options have been described for this condition including transfer of the Flexor Hallucis Longus (FHL) tendon for an incompetent Achilles tendon. Our technique describes FHL tendon transfer into the calcaneus to replace or supplement the Achilles tendon using a single posterior incision, a "short harvest" and interference screw fixation.