Titanium Cables Research Articles

Evaluation of V-type titanium cable internal fixation for the treatment of young adult fifth lumbar spondylolysis: technical notes and a retrospective clinical study

BackgroundVarious strategies, each with its own set of limitations, are available for managing lumbar spondylolysis. In response, our department has developed an innovative solution: a V-shaped titanium cable integrated with a pedicle screw internal fixation system specifically designed for lumbar spondylolysis in young adults.AimThe objective of this study was to thoroughly investigate the long-term efficacy of V-type titanium cable internal fixation for the management of spondylolysis, especially in young adults.MethodsTwenty-one patients with fifth lumbar spondylolysis were treated using V-shaped titanium cables and pedicle screw internal fixation at the General Hospital Xinjiang Military Command. The duration of low back pain before surgery was 6 ~ 48 (15.85 ± 11.57) months. The Medtronic (S7) navigation system was used during surgery to guide the placement of pedicle screws, aiming to avoid damaging the L4-5 facet joint by positioning the screws lower and further to the side. Intraoperative indices (operative time and intraoperative blood loss) were recorded. The visual analog scale (VAS), Oswestry Disability Index (ODI), pelvic incidence (PI), and intraoperative imaging measurements of screw accuracy were meticulously recorded and assessed in a comprehensive manner. This thorough evaluation was conducted both intraoperatively and throughout the follow-up period, which lasted for at least one year.The Macnab efficacy criteria were used to assess postoperative outcomes during the final follow-up period.ResultsAll patients successfully completed the 1-year follow-up on time. Two patients experienced postoperative wound liquefaction and successfully recovered after undergoing dressing changes. The average duration of the surgical procedure was 113.09 ± 6.97 min, and an intraoperative blood loss of 50.47 ± 21.32 millilitres was observed. Significant differences were noted in visual analog scale (VAS) scores before and after surgery at various time intervals, indicating improvement with the progression of rehabilitation exercises. No significant changes were found in the pelvic incidence (PI), and there were no notable differences between the preoperative and postoperative periods. No loosening, breakage, or failure of the internal fixation was found during the long-term follow-up. Furthermore, there were no serious complications, such as infection or vascular or nerve injuries. occurred during the procedure. A patient who presented with a considerable cryptic fissure of sacrum 1 experienced dural injury during the surgical procedure. Intraoperatively, dural sutures were skillfully applied, and the adjacent muscles were fortified. Remarkably, the patient achieved successful healing in a single stage. On the first day postsurgery, a gradual improvement in mobility was noted.ConclusionsThe use of a V-shaped titanium cable in conjunction with a pedicle screw internal fixation system for the management of fifth lumbar spondylolysis in young individuals is characterized by its ease of execution and ability to yield favorable outcomes. This approach relies on the prerequisite that patients with minimal intervertebral disc injury or mild lumbar spondylolisthesis demonstrate high overall success rates but experience low failure rates associated with internal fixation. Most significantly, this technique involves segmental internal fixation, which safeguards the functional spinal unit (FSU).

A modified separate vertical fixation by wires and titanium cables for comminuted inferior patella fracture: A technique note and finite element analysis

PurposeComminuted inferior patellar pole fractures are challenging injuries and require adequate treatment due to the extension mechanism of the knee. MethodsA modified separate vertical fixation by wires and Titanium cables was established according to a finite element biomechanical study. Between September 2018 and May 2021, 18 patients with inferior pole fractures of the patella were retrospectively enrolled in this study. ResultsThe results of the finite element analysis showed the concentration of stress in the intermediate vertical wire and the cerclage wire. As a partial replacement for steel wires, Titanium cables provide less concentration of stress on the vertical wire (489.4 MPa vs 441.2 Mpa) and less cutting force on the bone (75.87 Mpa vs 53.27), which reduces the possibility of internal fixation failure and improves the stability of internal fixation. In the clinic study, No patients experienced non-union of the fracture, loss of fracture repositioning, malunion of wounds, or wire breakage. At the last follow-up, the average range of motion was 134.7°±11.2°, and the Lysholm Score was 90.7 ± 3.9. ConclusionsThe separate vertical fixation by wires and titanium cables is an effective fixation method for treating displaced, comminuted inferior pole fractures, which attributes to early exercise and better function.

Metallic versus Non-Metallic Cerclage Cables System in Periprosthetic Hip Fracture Treatment: Single-Institution Experience at a Minimum 1-Year Follow-Up.

Metallic cerclage cables are reliable and cost-effective internal fixation devices, which are largely used in surgical practice for the treatment of periprosthetic fractures. Nevertheless, complications connected with their use have been described in the literature, including the following: third-body generation, failure and consequent migration, fraying, allergies, and injury to the surgical team. The development of new materials offers alternatives to traditional metallic cables. This study compares the outcomes between two groups of patients affected by periprosthetic hip fractures, treated with titanium cables or with ultra-high-molecular-weight polyethylene (UHMWPe) iso-elastic cables. Our retrospective study aims to compare the clinical and radiological outcomes of titanium cables and UHMWPe iso-elastic cables, isolated or associated with dedicated plates, for the surgical treatment of periprosthetic fractures with stable implants. Two groups of 30 (group A—metallic cables) and 24 (group B—UHMWPe iso-elastic cables) patients have been surgically treated in our institution for hip periprosthetic fractures, between September 2017 and June 2020. The mean age of the patients was 81 years in group A and 80 years in group B. In our study, we included fractures classified as B1 or C, according to the Vancouver postoperative fractures classification; the patients were evaluated retrospectively at 1 year postoperatively, regarding the following: surgery time, blood loss, partial weight-bearing time, radiographical healing time, Harris hip score, and postoperative complications. Comparable outcomes were observed in patients from both groups. Group A showed a higher complication rate compared to group B, at 1 year postoperatively. Non-metallic nylon fiber and ultra-high-molecular-weight polyethylene (UHMWPe) cerclage cables could represent a reliable fixation device, ensuring comparable healing and complication rates with traditional titanium cerclage cables.

Indirect reduction technique via Nice knot for transverse fracture of patella

To assess the outcomes in indirect reduction technique via Nice knot for transverse patellar fractures. The clinical data of 25 patients with transverse patellar fractures meeting the inclusion criteria between January 2017 and December 2018 were retrospectively analyzed. The patients were divided into trial group ( n=13) and control group ( n=12) according to different intraoperative reduction methods. No significant difference was found in gender, age, affected side, cause of fracture, classification, or the time from injury to operation between the two groups ( P>0.05). In the trial group, No.2 suture was used to cross the quadriceps tendon and patellar tendon to construct the Nice knot, then the suture was tightened to make the distal and proximal fracture segments contact in an indirect reduction pattern. Depend on Nice knot's sliding compression and self-stabilizing function, the suture mesh created an anterior tension band as a temporary fixation. In the control group, Weber's clamp was used to hold the fracture segments directly and fixed temporarily. After reduction, terminal fixation was conducted using a titanium Kirschner wire with titanium cable in both groups. The operation time, intraoperative blood loss, follow-up time, fracture healing time, and complications were recorded and compared in the two groups. At last follow-up, the knee function was evaluated according to the Böstman scoring criteria for efficacy in patellar fractures. The operation time in the trial group was significantly shorter than that in the control group ( t=-2.165, P=0.041). There was no significant difference of intraoperative blood loss between the two groups ( t=0.514, P=0.612). The incisions of the two groups healed by first intention. All the patients were followed up 12-16 months, with an average of 14.4 months, no significant difference was found in the follow-up time between the two groups ( t=-0.309, P=0.760). One patient in the control group developed soft tissue irritation symptoms at 1 day after operation, and no special treatment was given, the symptoms disappeared at 2 months after operation. The fractures of the two groups healed at the 12-week follow-up. During the follow-up, there was no complication such as loosening and fracture of titanium cables and tendon tissue calcification. At last follow-up, the Böstman score presented no significant difference between the two groups ( t=-0.086, P=0.932). In the trial group, an 80-year-old female patient was evaluated as good (score, 27) due to atrophy of the quadriceps femoris, leg weakness, and affected stair climbing, and the rest 24 patients were all evaluated as excellent. The indirect reduction with Nice knot can shorten the operation time in the treatment of transverse patellar fractures, and obtain good effectiveness.

The contact pressure of ultra-high-molecular-weight polyethylene cables is twice as high as that of titanium cables

BackgroundMetal cables exhibit favorable clinical performance because of their high fixing force. Cables composed of ultra-high-molecular-weight polyethylene (UHMWPE) are relatively new and were first used for trauma around 2010; only a few cases involving the use of UHMWPE cables have been reported. Surgeons need to know whether the fixing force of UHMWPE cables is higher or lower than that of metal cables. This study aims to compare the fixing forces of UHMWPE cables and a titanium cable using the contact pressure as an index. MethodWe studied UHMWPE cables with widths of 3 mm and 5 mm and a titanium cable. A thin pressure sensor was set on the femoral diaphysis, and the cables were wrapped on simulated tissues and tightened with clamping forces based on the indication values displayed on the tensioner of each cable. During osteosynthesis, tissues can remain unremoved depending on the fracture site and procedure. Sus scrofa domesticus thigh tissues with thicknesses of 2 mm and 5 mm were prepared for simulating tissues, and the contact pressures in cases with and without tissues were compared. ResultsWhen no tissues were remained, the contact pressure of the titanium cable with a clamping force of 50 kgf was equal to that of the UHMWPE cables with a clamping force of 30 kgf. When tissues were remained, the contact pressure of the titanium cable with a clamping force of 50 kgf was twice as high as that of the UHMWPE cables with a clamping force of 30 kgf. ConclusionIt was revealed that the contact pressure of UHMWPE cables clamped with the maximum force was twice as high as that of metal cables. This result is expected to contribute toward the selection of cables according to a desired clamping force.

C1 Titanium Cables Combined with C2 Pedicle Screw-Rod Fixation for Atlantoaxial Instability Not Suitable for Placement of C1 Screws

We sought to develop a new posterior fusion technique composed of bilateral C1 titanium cables and C2 pedicle screw-rods for treatment of atlantoaxial instability not suitable for C1 screw placement. A study was conducted of 18 patients with atlantoaxial instability who had C1 broken screw trajectory or anatomic anomalies. All patients underwent posterior fixation with bilateral C1 titanium cables and C2 pedicle screws. The follow-up period was a minimum 1 year. Clinical outcomes measurements included visual analog scale score for neck pain assessment, the American Spinal Injury Association Impairment Scale and Japanese Orthopaedic Association score for neurologic status and function. According to preoperative computed tomography (CT) reconstruction and CT angiography, the patients selected in this study were not suitable for C1 screw placement. Postoperative plain radiographs and CT reconstruction were performed to evaluate the reduction, bony fusion, and implant position. All outcomes were evaluated at each follow-up. The average clinical follow-up period was 24 months (range 12-36 months). All patients had complete neck pain relief at postoperative 6 months. Their neurologic symptoms had improved significantly at 1-year follow-up. Radiologic outcomes indicated good bony fusion and construction stability in all patients without implant failure at the last follow-up. No neural or vascular complications related to this technique were observed. Posterior atlantoaxial fixation using C1 titanium cables and C2 pedicle screw-rod construct appears to be an effective and safe technique for treatment of atlantoaxial instability, which could be an alternative method for cases unsuitable for C1 screw placement when using C1-C2 screw fixation.

Treatment of periprosthetic femoral fractures following hip arthroplasty utilizing locking compression plates

Objective To evaluate the clinical outcomes of periprosthetic femoral fractures (PFF) following hip arthroplasty utilizing locking compression plates (LCP) in regard to tips and tricks on the construction of LCP augmented with locking attachment plate (LAP) and titanium cables (TC). Methods A total of 41 cases of PFF follow hip arthroplasty (THA 3, Hemi-arthroplasty 2) between May 2008 to April 2016 have been retrospectively analyzed. There were 13 males and 28 females with an average age of 70.5±8.6 years, including 11 case of Unified Classification System (UCS) type IV.3B1.1, 21 cases of B2.1 and 9 cases of type C. All were closed fractures caused by simple fall in terms of low-energy injury. Surgical options depended on individual configuration of the fractures with the combination of LCP and LAP or TC. In respect of reduction techniques, minimally invasive plate osteosynthesis (MIPO) was used in 5 cases for type B1.1 and 8 cases for type C, Mini-open in 6 cases for type B1.1 and 1 case for type C. Posterolateral approach with open reduction internal fixation were selected for type B2.1. The patients were followed up periodically. Harris score, Mukundan criteria and complications were recorded. Results Five cases died of the comorbidities (heart failure 3, pulmonary infection 1, multiple organs failure 1) within 1 year postoperatively. The follow-up rate was 78.0% (32 out of 41 cases) and the average follow-up time was 41 months (ranging 11 to 71 months). No malunion, no reduction lost, no hardware failure, no hip dislocation and revision surgery following PFF care found. All cases showed the signs of fracture healing from 8 to 12 (average 10 weeks) postoperatively except 2 cases of delay union. The postoperative complications shown in 11 cases, including 2 cases of superficial infection of the wound, 6 cases of deep vein thrombosis (popliteal vein 2, intramural gastrocnemius vein 4) and 3 cases of the prosthetic loosening. Harris score at the latest follow-up were 91.5±2.1 for group B1.1, 77.5±4.2 for group B2.1 and 83.5±3.8 for group C. The LCP lengths were 248.9±24.3 mm, 258.6±25.2 mm, 280.4±24.0 mm for group B1.1, B2.1 and C respectively. The LCP length of group B1.1 was short than that of group C (P 0.05). Conclusion Utilizing LCP for PFF following hip arthroplasty can achieve satisfactory short and mid-term clinical outcomes with the prerequisites of precise and individualized preoperative planning. LCP augmented by LAP and TC is a reliable option with low complication rate. However, type C PFF needs longer plate with more screws at distal fragment and more titanium cables. Key words: Femur; Periprosthetic fractures; Arthroplasty, replacement, hip; Fracture fixation, internal

Magnetic Mini-Mover Procedure for pectus excavatum IV: FDA sponsored multicenter trial

PurposeThe Magnetic Mini-Mover Procedure (3MP) is a minimally invasive treatment for prepubertal patients with pectus excavatum. This multicenter trial sought to supplement safety and efficacy data from an earlier pilot trial. MethodsFifteen patients with pectus excavatum had a titanium-enclosed magnet implanted on the sternum. Externally, patients wore a custom-fitted magnetic brace. Patients were monitored closely for safety. Efficacy was determined by the Haller Index (HI) and satisfaction surveys. After 2 years, the implant was removed. ResultsMean patient age was 12 years (range 8–14), and mean pretreatment HI was 4.7 (range 3.6–7.4). The device was successfully implanted in all patients. Mean treatment duration was 25 months (range 18–33). Posttreatment chest imaging in 13 patients indicated that HI decreased in 5, remained stable in 2, and increased in 6. Seven out of 15 patients had breakage of the implant's titanium cables because of fatigue fracture. Eight out of 13 patients were satisfied with their chest after treatment. ConclusionThe 3MP is a safe, minimally invasive, outpatient treatment for prepubertal patients with pectus excavatum. However, the magnetic implant design led to frequent device breakage, confounding analysis. The HI indicated mixed efficacy, although surveys indicated most patients perceived a benefit. Study type/level of evidenceCase series, treatment study. Level IV.

Pathologic Axis Fracture Secondary to Solitary Bone Plasmacytoma: A Case Report and Literature Review

Introduction Solitary bone plasmocytoma (SBP) is an uncommon entity. It represents 5 to 10% of all plasmatic cell neoplasms. Usually, it affects axial skeleton and rarely cervical spine. Patient and Methods: A case report of a 73-year-old woman with 1.5 month of progressive neck pain with limitation of cervical mobility is presented. A nonsystematic literature review about cervical spine SBP was conducted. Results Cervical X-ray study showed a lytic lesion in C2 vertebral body with anterolisthesis of the atlas over the axis. Computed tomography scan confirmed complete destruction of C2 vertebral body with partial occupation of the spinal canal seen in the magnetic resonance imaging. The systemic tumor spread was discarded. The patient went for surgery with the diagnosis of a vertebral tumor lesion of C2. Posterior occipitocervical fixation of C0 to C5 with iliac crest autogenous bone graft and complementary fixation of the posterior arc of C1 to the placed rods with titanium cables was performed. Bone tumor biopsy using a posterior approach through the pedicle was done. Histological and immunohistochemical study resulted concordant with an SBP. Immediate postoperative was satisfactory, with disappearance of neck pain and with no neurological deficit. Six weeks after surgery, radiotherapy was conducted completing a total of 25 sessions with complete remission of SBP. Three years' follow-up, the patient presented no neck pain and no recurrence of disease. Seven years postoperative CT scan showed no signs of cervical SBP. Conclusion Spine SBP is a rare entity. It has a good prognosis depending on the correct and early diagnostic approach, which will offer the highest probability of therapeutic success. The main pillars of treatment are as follows: (1) spine stabilization surgery, complemented in some cases if necessary with decompression on neural elements and (2) radiotherapy.

Retraction Note to: Evaluation of coracoclavicular stabilization of acute acromioclavicular joint dislocation with multistrand titanium cables.

Purpose The aim of this study was to evaluate the outcome of surgical treatment of acute acromioclavicular (AC) joint dislocation with multistrand titanium cables for coracoclavicular (CC) stabilization.

RETRACTED ARTICLE: Evaluation of coracoclavicular stabilization of acute acromioclavicular joint dislocation with multistrand titanium cables

The aim of this study was to evaluate the outcome of surgical treatment of acute acromioclavicular (AC) joint dislocation with multistrand titanium cables for coracoclavicular (CC) stabilization. Forty-two patients with acute AC joint dislocation, including Rockwood type III 14 cases, type IV 2 cases and type V 26 cases, were operated with CC stabilization using multistrand titanium cables. The cables were removed 3-12 months after surgery. The function outcome was evaluated by Constant scores and visual analog scale (VAS) scores. Radiological examination included bilateral antero-posterior and axillary radiography. Three patients were lost to follow-up. Thirty-nine patients had an average follow-up time of 42 months (range 34-60). The Constant scores were 95.3 ± 9.3 at final evaluation. Preoperative and final follow-up VAS scores were 5.6 ± 1.5 and 0.4 ± 1.2, respectively (P < 0.05). Radiographs showed anatomical reduction in 32 patients. Cables breakage occurred in two patients. CC stabilization with multistrand titanium cables was an effective and safe alternative to other procedures for the treatment of acute high-grade AC joint dislocations. It can provide immediate joint stabilization and allow early mobilization of limb with satisfied functional recovery.

C2 Pedicle Screw and Plate Combined With C1 Titanium Cable Fixation for the Treatment of Alantoaxial Instability not Suitable for Placement of C1 Screw

A method of atlantoaxial stabilization using individual fixation of the C1 posterior arch and the C2 pedicle with C2 pedicle screws and plates combined with C1 titanium cables is described. In addition, the clinical results of this method on 8 patients are described. To describe the method and the clinical and radiographic results for posterior C1-C2 fixation with a combined implant system. Stabilization of the atlantoaxial complex is a challenging procedure because of the unique anatomy of this region. Fixation by plate or rod and C1 and C2 screw and structural bone grafting leads to excellent fusion rates. The technique is technically demanding and has a potential risk of the injuries to the vertebral artery, the internal carotid artery, spinal cord, and hypoglossal nerves. In addition, how to stabilize the atlantoaxial complex in the cases not suitable for placement of C1 screw is not described in the literature. To address these limitations, a method of C1-C2 fixation has been developed: bilateral insertion of C2 pedicle screws and rolling of C1 titanium cable through the posterior arch of atlas and the cranial hole of the plate, followed by C1-C2 plate fixation. From February 2003 to March 2006, 8 patients with atlantoaxial instability and not suitable for placement of C1 screw were included in this study: 5 cases of broken C1 pedicle screw trajectory and 3 cases of C1 anatomic anomalies. Skull traction was performed in each patient preoperatively. The pedicle screws were inserted into C2 pedicles in the direction as its axis. C1 titanium cable was rolled superior to lower through posterior arch of atlas in the cases not suitable for placement of C1 screw. The C1-C2 plate was slightly bent to fit the upper cervical contour. Hyperflexion alignment of the atlantoaxial complex was corrected by application of extension force created by tightening of the nut on the pedicle screws and the C1 titanium cable, which was passed through the cranial hole of the plate. Morselized autogenous cancellous iliac grafts were placed on the surface of the posterior arches of both atlas and axis. All patients were assessed clinically for neurologic recovery by Odom's method. There were 5 males and 3 females with a mean age of 37.8 years (range, 17 to 59 y). There were 2 cases of old odontoid fracture, 2 cases fresh odontoid fracture (Aderson II C), 2 cases atlas transverse ligament laxation, 2 cases atlas transverse ligament rupture, and in these cases, 5 cases had failed placement of C1 screw because of broken C1 pedicle screw trajectory and 3 cases not suitable for placement of C1 screw because of anatomic anomalies. There were no spinal cord and vertebral artery and nerve injury after surgery. Follow-up duration was from 18 to 55 months with the average of 29 months. The plant bones all fused and there were no internal fixation rupture and mobility. All the patients showed improvement. C2 pedicle screw and plate combined with C1 titanium cable could be used to treat atlantoaxial instability in the cases not suitable for placement of C1 screw.

Square-lashing technique in segmental spinal instrumentation: a biomechanical study

Sublaminar wires have been used for many years for segmental spinal instrumentation in scoliosis surgery. More recently, stainless steel wires have been replaced by titanium cables. However, in rigid scoliotic curves, sublaminar wires or simple cables can either brake or pull out. The square-lashing technique was devised to avoid complications such as cable breakage or lamina cutout. The purpose of the study was therefore to test biomechanically the pull out and failure mode of simple sublaminar constructs versus the square-lashing technique. Individual vertebrae were subjected to pullout testing having one of two different constructs (single loop and square lashing) using either monofilament wire or multifilament cables. Four different methods of fixation were therefore tested: single wire construct, square-lashing wiring construct, single cable construct, and square-lashing cable construct. Ultimate failure load and failure mechanism were recorded. For the single wire the construct failed 12/16 times by wire breakage with an average ultimate failure load of 793 N. For the square-lashing wire the construct failed with pedicle fracture in 14/16, one bilateral lamina fracture, and one wire breakage. Ultimate failure load average was 1,239 N For the single cable the construct failed 12/16 times due to cable breakage (average force 1,162 N). 10/12 of these breakages were where the cable looped over the rod. For the square-lashing cable all of these constructs (16/16) failed by fracture of the pedicle with an average ultimate failure load of 1,388 N. The square-lashing construct had a higher pullout strength than the single loop and almost no cutting out from the lamina. The square-lashing technique with cables may therefore represent a new advance in segmental spinal instrumentation.

Dynamic anterior cervical plates for multilevel anterior corpectomy and fusion with simultaneous posterior wiring and fusion: efficacy and outcomes

To prospectively evaluate major complications associated with the application of dynamic ABC plates (Aesculap, Tuttlingen, Germany) to multilevel Anterior Corpectomy/Fusion (ACF) followed by posterior fusion (C2-C7 PF). To determine whether dynamic ABC (Aesculap, Tuttlingen, Germany) plates would minimize major complications (plate/graft extrusion, pseudarthrosis) while maximizing neurological outcomes in 40 consecutive patients undergoing simultaneous multilevel ACF/PF with halo application. USA. Patients averaged 53 years of age and preoperatively exhibited severe myeloradiculopathy (Nurick Grade 3.9). MR/CT studies documented marked ossification of the posterior longitudinal ligament/spondylostenosis. Surgery included two to four level ACF utilizing fibula strut allograft and ABC plates. Posterior spinous process wiring/fusions utilized braided titanium cables. The average operative time was 8.9 h. Fusion was confirmed on dynamic X-rays/CTs (3-12 months postoperatively). The average follow-up interval was 2.7 years. Outcomes (3 months-2 years postoperatively) were assessed utilizing Odom's Criteria, Nurick Grades, and SF-36 questionnaires. Major complications included one pseudarthrosis requiring secondary PWF. Minor complications in six patients included two pulmonary emboli (PE), two tracheostomies, and five superficial wound infections. At 1 year postoperatively, marked improvement was observed in all patients utilizing Odom's criteria (38 excellent/good), Nurick Grades (mild radiculopathy 0.4), and the SF-36 (3 Health Scales; Role Physical (12.5-38.6), Bodily Pain (39.9-65.5), and Role Emotional (53.8-75.8)]. The 2-year postoperative data showed minimal additional improvement. The average time to fusion was 6.3 months. Patients undergoing multilevel ACF/PF demonstrated marked neurological improvement (SF-36), and only one of 40 developed a delayed pseudarthrosis.

Aneurysmal Bone Cyst as a Rare Cause of Spinal Cord Compression in a Young Child

Case report. To report: 1) one of the youngest cases of aneurysmal bone cysts presenting with cord compression at the cervicothoracic junction with 7-year follow-up; and 2) the technique we used to stabilize such a small spine. Aneurysmal bone cyst is an uncommon but well-recognized tumor affecting the spine of children. The mean age of presentation is 16 years. It has hardly been reported below the age of 4 years. All data are in the form of case reports or series. Surgical or nonoperative management can be used. Spinal implant systems are not designed for use in very small children. Clinical data analysis. A girl presented at age 2 years and 3 months with cord compression at the cervicothoracic junction. After an inconclusive biopsy, a formal excision and reconstruction of the C7 and T1 were performed anteriorly and posteriorly. We used a fibular graft, internal fixation with crossed plates from the maxillofacial implant tray and a Cervifix rod contoured into a rectangle with sublaminar titanium cables. Postsurgery, she had a left Horner syndrome that has never recovered and motor weakness of the right arm that improved but did not fully recover. She developed a staphylococcal infection 6 months postsurgery that was managed by removal of the rectangle. She developed a posterior recurrence 10 months postsurgery, which was managed surgically. Follow-up has been for 7 years without further evidence of recurrence. Both surgical and nonsurgical management has been advocated for these tumors. The cord compression at presentation forced us toward surgical management. It is likely that observational data are the only evidence available for clinical decision-making. In this case, we were able to obtain good access to the front of the upper thoracic spine by a supraclavicular approach. Tiny plates are available to maxillofacial surgeons that can be adapted for use in the spines of small children.

Impact of interlaminar graft materials on the fusion status in atlantoaxial transarticular screw fixation

Structural interlaminar graft materials were used for atlantoaxial transarticular screw fixation (TSF), and its impact on the fusion status was investigated. Forty-two patients (10 men, 32 women, mean age 51 years, mean follow-up period 45 months; 30 with rheumatoid arthritis, and 12 with os odontoideum) underwent TSF and modified Brooks posterior wiring involving titanium cables. As interlaminar graft materials, autologous bone from posterior iliac crest alone was used in 20 patients (Group A), and a structural spacer (13 ceramic spacers, nine titanium mesh cages) in 22 (Group B). Lateral radiographs were evaluated to determine bone fusion, alignment of the cervical spine, and wire loosening. Solid osseous fusion was obtained in 95% of Group A and 96% of Group B patients. The mean atlantoaxial angle was 19.1+/-9.7 degrees and 16.7+/-10.4 degrees before surgery (p = 0.45), and 27.4+/-7.8 degrees and 22.1+/-5.5 degrees after surgery (p = 0.02) in Groups A and B, respectively. Atlantoaxial hyperlordosis (atlantoaxial angle > or = 30 degrees) was observed in 32% of Group A and 18% of Group B patients (p = 0.26). Postoperative kyphosis occurred in 40% of Group A and 23% of Group B patients (p = 0.28). Loosening of the cable was demonstrated in 50% of Group A and 36% of Group B patients(p = 0.37). In Group B patients maintenance of cervical lordosis was more likely than in those in Group A, although the differences did not reach statistical significance. These results indicate that structural interlaminar spacers can maintain proper cervical alignment without a decease in the fusion rate; the authors recommend their use in conjunction with TSF.

Posterior cervical fusion failure in three morbidly obese patients following circumferential surgery

Background The stability of multilevel anterior corpectomy with fusion (ACF) is often enhanced by simultaneous posterior fusion (PF) which provides a “posterior tension band.” Three morbidly obese patients undergoing circumferential surgery had posterior fusions performed without autogenous iliac crest graft to avoid donor site morbidity. Methods Three morbidly obese patients (300–350 lbs.), averaging 48 years of age, presented with rapidly progressive moderate/severe myelopathies. Magnetic resonance imaging (MRI) and computed tomography (CT) studies demonstrated severe ventral ossification of the posterior longitudinal ligament. Two to four level plated ACFs were performed utilizing fibula strut allograft and plates. Posterior spinous process wiring/fusion from C2-T1 were completed with braided titanium cables, fibula strut allografts, Inductive Conductive Matrix (a form of demineralized bone matrix), and allograft bone to avoid iliac crest donor site morbidity in such morbidly obese patients. Halo devices were utilized until fusion was documented on postoperative X-ray and 2D-CT studies subsequently obtained 3, 6, and up to 12 months postoperatively. Patients were followed an average of 3 years. Results Postoperatively, all 3 patients demonstrated mild residual myelopathy (Nurick Grade 0-I). Nevertheless, all 3 exhibited posterior pseudarthroses accompanied by anterior strut/plate extrusion (1 patient), partial anterior graft pseudarthrosis (1 patient), and a delayed strut fracture (1 patient). The first 2 patients required secondary posterior fusions performed with autogenous iliac crest graft, while the third fused with 6 months of additional bracing. Conclusions Following circumferential cervical procedures, posterior fusions failed in 3 morbidly obese patients where iliac crest autograft was omitted in an attempt to avoid donor site morbidity.

Failure of posterior titanium atlantoaxial cable fixation

Background context: The operative treatment of rotatory atlantoaxial instability remains controversial. The use of cable fixation has largely replaced the use of wire for interlaminar fixation. Although cable fixation offers biomechanical advantages over wire fixation, it is still at risk of fatigue failure. The authors were unable to locate any published reports of fatigue failure of titanium cables in the fixation of atlantoaxial instability. Purpose: The purpose of this case study is to describe an unusual case of fatigue failure of a titanium cable used to aid in atlantoaxial fusion for the treatment of rotatory atlantoaxial instability. Study design: Case study. Methods: We reviewed the medical records and X-rays of a patient with rotatory atlantoaxial instability treated with posterior C1–C2 fusion and atlantoaxial fixation with a titanium multistranded cable, who developed fracture of the cable and migration of the cable into the spinal canal. Results: The patient was revised with removal of the broken cable, repair of the pseudarthrosis and fixation with atlantoaxial screws. Conclusion: Interlaminar fixation with cables or wires is at risk for failure with potential migration of the wire or cable into the spinal canal. The authors found that failure of the cables or wire can be salvaged with application of transarticular screws.

A new technique for the surgical management of deformities in the growing spine.

The Luque procedure was developed to correct the deformity without the need of bracing and maintaining that correction with growth. However many authors are disappointed by their results and the complications which appear in the management of infantile scoliosis with Luque trolley alone. Besides failed implants, pseudarthrosis, modest spinal growth and protuberant rods and wires, the major problem of the Luque systems is the high incidence of loss of correction by postoperative rotation. Therefore a new application technique is recommended. A standard posterior extraperiostal approach is chosen. Sublaminar titanium cables are passed at each level except the caudal lamina. Then the rods are precontoured in shape of the planed curve correction. We use a low profile titanium instrumentation with 5.0 mm diameter rods and 4.2 mm pedicle screws. In contrast to the conventional use of two antiparallel "L"-rods we recommend the use of one reversed "U"-rod securing the laminae with sublaminar titanium cables of the upper end vertebrae. For fixation of the lower spine a dual-opening pedicle screw system is used. Using a holding forceps the distal rods are introduced and fixed into the side opening of the screws then secured by sublaminar wires. In addition both single rods are stabilized by a low profile cross link bar. This technique allows to correct pelvic obliquity and a stable anchorage of two screws reduces risk of postoperatively rotation or caudal rod slippage due to gravity forces.

Isola spinal instrumentation system for idiopathic scoliosis.

Since the definition of three-dimensional components of the scoliotic deformity, there have been important improvements in the surgical treatment of the problem. A derotation maneuver was proposed as a treatment option with CD instrumentation, but the reports of imbalance and decompensation with this system repopularized sublaminar wiring and translation as a corrective maneuver. Isola spinal instrumentation is one of the modern systems that utilizes vertebral translation instead of rod rotation. This study analyzes the results of 24 patients with idiopathic scoliosis who had been followed up for at least 2 years, and were surgically treated with titanium Isola Spinal Instrumentation in the Department of Orthopaedics and Traumatology, Ankara Social Security Hospital. Patients were grouped according to the King-Moe classification. Patients with type III, IV or V curves received only posterior instrumentation while this procedure followed anterior release and discectomy in the same session in patients with type I or II curves. A translation maneuver was utilized in the correction of scoliotic curves using the cantilever technique, either alone or supplemented by sublaminar wiring with Songer multifilament titanium cables. This study aimed to elucidate the effects of this technique in the frontal and sagittal plane curves and the trunk balance. The balance was analyzed clinically and radiologically by measurement of the lateral trunk shift (LT), shift of stable vertebra (SS), and shift of head (SH) in vertebral units (VU). The postoperative correction was significant in the frontal plane for all types of curves (p < 0.05). The postoperative correction was 80.9% +/- 9.5% in type III curves. Overall, the mean Cobb angle of the major curve value in the frontal plane was 66.9 degrees +/- 18.8 degrees, and it was corrected by 62.8% +/- 20.1%. The correction loss of Cobb angles in the frontal plane was 5.4 degrees +/- 5.5 degrees at the last follow-up visit. A normal physiologic thoracic contour (30 degrees - 50 degrees) was achieved in 83.3% of the patients and normal lumbar contour (40 degrees - 60 degrees) in 66.7% of the patients in the sagittal plane. The correction was found to be significant in all balance values (p < 0.05). The postoperative correction in LT values correlated with the correction of the Cobb angle values in the frontal plane. All patients had complete balance (SH: 0 VU and SS: 0 VU) or balanced curves (0 VU < SH, SS < 0.5 VU).Finally, the study concluded that the translation maneuver, especially when used with the cantilever technique, resulted in high correction rates in the frontal plane. Additionally, the technique was also successful in obtaining normal sagittal contours and correcting balance values.