Transarticular Technique Research Articles

Defining role of atlantoaxial and subaxial spinal instability in the pathogenesis of cervical spinal degeneration: Experience with "only-fixation" without any decompression as treatment in 374 cases over 10 years.

The authors analyze their published work and update their experience with 374 cases of cervical radiculopathy and/or myelopathy related to spinal degeneration that includes ossification of the posterior longitudinal ligament (OPLL). The role of atlantoaxial and subaxial spinal instability as the nodal point of pathogenesis and focused target of surgical treatment is analyzed. During the period from June 2012 to November 2022, 374 patients presented with acute or chronic symptoms related to radiculopathy and/or myelopathy that were attributed to degenerative cervical spondylotic changes or due to OPLL. There were 339 males and 35 females, and their ages ranged from 39 to 77 years (average 62 years). All patients were treated for subaxial spinal stabilization by Camille's transarticular technique with the aim of arthrodesis of the treated segments. Atlantoaxial stabilization was done in 128 cases by adopting direct atlantoaxial fixation in 55 cases or a modified technique of indirect atlantoaxial fixation in 73 patients. Decompression by laminectomy, laminoplasty, corpectomy, discoidectomy, osteophyte resection, or manipulation of OPLL was not done in any case. Standard monitoring parameters, video recordings, and patient self-assessment scores formed the basis of clinical evaluation. During the follow-up period that ranged from 3 to 125 months (average: 59 months), all patients had clinical improvement. Of 130 patients who had clinical evidences of severe myelopathy and were either wheelchair or bed bound, 116 patients walked aided (23 patients), or unaided (93 patients) at the last follow-up. One patient in the series was operated on 24 months after the first surgery by anterior cervical route for "adjacent segment" disc herniation. No other patient in the entire series needed any kind of repeat or additional surgery for persistent, recurrent, increased, or additional related symptoms. None of the screws at any level backed out or broke. There were no implant-related infections. Spontaneous regression of the size of osteophytes was observed in 259 patients where a postoperative imaging was possible after at least 12 months of surgery. Our successful experience with only spinal fixation without any kind of "decompression" identifies the defining role of "instability" in the pathogenesis of spinal degeneration and its related symptoms. OPLL appears to be a secondary manifestation of chronic or longstanding spinal instability.

Posterior intra-articular fixation stabilizes both primary and secondary sacroiliac joints: a cadaveric study and comparison to lateral trans-articular fixation literature

BackgroundPosterior and lateral techniques have been described as approaches to sacroiliac joint arthrodesis. The purpose of this study was to compare the stabilizing effects of a novel posterior stabilization implant and technique to a previously published lateral approach in a cadaveric multidirectional bending model. We hypothesized that both approaches would have an equivalent stabilizing effect in flexion–extension and that the posterior approach would exhibit better performance in lateral bending and axial rotation. We further hypothesized that unilateral and bilateral posterior fixation would stabilize both the primary and secondary joints.MethodsRanges of motion (RoMs) of six cadaveric sacroiliac joints were evaluated by an optical tracking system, in a multidirectional flexibility pure moment model, between ± 7.5 N-m applied moment in flexion–extension, lateral bending, and axial rotation under intact, unilateral fixation, and bilateral fixation conditions.ResultsIntact RoMs were equivalent between both samples. For the posterior intra-articular technique, unilateral fixation reduced the RoMs of both primary and secondary joints in all loading planes (flexion–extension RoM by 45%, lateral bending RoM by 47%, and axial RoM by 33%), and bilateral fixation maintained this stabilizing effect in both joints (flexion–extension at 48%, lateral bending at 53%, and axial rotation at 42%). For the lateral trans-articular technique, only bilateral fixation reduced mean RoM of both primary and secondary sacroiliac joints, and only under flexion–extension loads (60%).ConclusionDuring flexion–extension, the posterior approach is equivalent to the lateral approach, while producing superior stabilization during lateral bend and axial rotation.

Sesamoid excision during first metatarsophalangeal joint arthrodesis via a transarticular approach: A cadaveric study

Sesamoids of the first metatarsophalangeal joint can be a source of residual pain after surgical intervention for hallux rigidus. Theoretically, after fusion of the first metatarsophalangeal joint there should be little to no motion at the metatarsosesamoid articulations; however in many cases significant arthritis disease of the sesamoids may create hypertrophy and pain. Residual motion about the sesamoid articulations could result in recalcitrant pain after joint arthrodesis. Previous studies have discussed surgical sesamoidectomy for treatment of painful sesamoid bones, while frequently advocating for ancillary incisions in an attempt to obtain direct visualization. The goals of this cadaveric study were to identify any observable motion of the sesamoid bones after simulated first MTP joint fusion and assess if adequate visualization of the sesamoid bones can be obtained for proper excision through a standard dorsomedial approach. Using live fluoroscopy, no residual sesamoid range of motion was noted after fusion fixation. We were able to perform successful total sesamoidectomy in all specimens (n = 10) via the transarticular approach, with only 1 incident of minor tendon injury. Total sesamoidectomy took an average of 2:10 minutes, and average incision length was 4.9 cm. Despite the cadaveric nature of the present study, our results confirm a lack of motion to the sesamoid articulations after arthrodesis of the first MTP joint. Furthermore, using the transarticular technique discussed in this study, we exhibited that the standard dorsomedial approach can be used for safe and efficient sesamoidectomy, when indicated in conjunction with first MTP joint arthrodesis.

Report of an eight-year experience with Camille’s transarticular technique of cervical spinal stabilization

We present our experience with Camille’s cervical transarticular screw fixation technique. During the period June 2012 to April 2020, 2422 screws were implanted in 321 patients by Camille’s transarticular cervical spinal screw fixation technique. The indications of screw implantation were radiculopathy/myelopathy related to cervical spondylosis in 258 cases, cervical OPLL in 54 cases and Hirayama disease in 9 cases. The follow-up ranged from 6 to 92 months. In the entire series, there were no nerve or vessel injury or any other intraoperative ‘complications’ related to screw implantation. There was no instance of screw pull out or screw failure. There was no metal implant related infection. Satisfactory arthrodesis of all the treated spinal segments was observed on investigations done at a minimum follow-up of 6 months.Camille’s transarticular screw fixation technique is a relatively simple surgical procedure and provides a safe, strong and reliable arthrodesis at the fulcrum of spinal movements.

Ossification of the Posterior Longitudinal Ligament: Analysis of the Role of Craniovertebral and Spinal Instability.

This paper reviews an experience of surgically treating ossification of the posterior longitudinal ligament (OPLL) with fixation of the involved spinal segments alone, without resorting to any bony or soft tissue decompression or attempts at direct resection of the OPLL. While in the early part of the experience, stabilization of only the involved subaxial cervical spinal segments was done, in the later part of the experience, atlantoaxial fixation was included in the multisegmental spinal fixation construct. This treatment is based on the understanding that spinal instability that includes atlantoaxial instability forms the nodal point of the pathogenesis and development of OPLL, and maturation of the presenting clinical symptoms. Twenty-nine patients were treated in this series. There were 28 males and one female, and their ages ranged from 28 to 75years (average 57years). All patients presented with symptoms of neck pain, and progressive and disabling myelopathy-related quadriparesis. In the early part of the series (from 2012 to 2014), 14 patients underwent multilevel subaxial cervical spinal fixation by a transarticular technique of facetal fixation. After November 2014, atlantoaxial lateral mass fixation was included in the fixation construct in the subsequent 15 patients. Clinical assessments were done using a visual analogue scale (VAS), the Japanese Orthopaedic Association (JOA) scale and Goel's clinical grading scale. All patients' clinical symptoms improved in the immediate postoperative period, and the improvement was sustained and progressive in 28 patients. Atlantoaxial and subaxial spinal instability seems to be the nodal pathogenetic factor in OPLL. Only stabilization of spinal segments that includes the atlantoaxial joint can provide a safe, simple and rational form of treatment.

Technical nuances of percutaneous sacroiliac joint fixation: A cadaveric study

Sacroiliac (SI) joint can produce debilitating lower back pain with radiation to groin, buttocks, and lower extremities. SI joint dysfunction poses a clinical challenge to the spine surgeons. Studies entailing surgical arthrodesis utilizing Titanium implants have been reported with reputedly high level of patient satisfaction. Authors have described technical aspects of surgical technique with use of titanium screw implants. The transarticular technique is used to places SI joint screw implants across the articular portion of SI joint. Cadaveric SI joint instrumentation is performed under fluoroscopic guidance. Moreover, Medline literature search is conducted to study surgical outcome, and patient satisfaction. 4 cadavers are prepped prone for the percutaneous approach. Bilaterally 6 screws are placed using transarticular placement technique under fluoroscopic guidance. The posterior technique utilizes alignment guide to place the screws inline on the inlet view, parallel in the outlet view, and parallel to the dorsal aspect of the sacral body in the lateral view. One C-arm is used in the entire technique. The technical aspects of surgical technique have been described in a stepwise fashion for easy reproducibility in the operating room. Each screw track is checked with tactile feel of a blunt K-wire before final deployment. All bilateral screws were checked on a set of fluoroscopic views. A detail clinical examination, diagnostic joint injection, with the radiological imaging must be considered before surgical consideration. SI Joint fusion utilizing 3 transarticular sacral screws is equally effective and safe procedure to treat chronic lower back pain ensuing from SI joint dysfunction.

Treatment of proximal phalangeal fractures with an antegrade intramedullary screw: a cadaver study.

The aim of this study was to quantify the articular cartilage defect created with two different antegrade techniques of intramedullary osteosynthesis with a headless compression screw inserted through the metacarpophalangeal joint. In 12 out of 24 fingers from six cadaveric hands, a trans-articular technique with cannulated headless compression screws (2.2 and 3.0 mm diameter) was used; whereas in the other 12 fingers, an intra-articular fixation technique was used. The areas of the articular surface and the defects created were measured with a digital image software program. All measurements were made twice by two observers. In the intra-articular technique, the average defect in the base of the articular surface of the proximal phalanx was 4.6% with the 2.2 mm headless compression screw and 8.5% with the 3.0 mm screw. In the trans-articular technique, the defect size was slightly smaller; 4.2% with the 2.2 mm screw and 8% with the 3.0 mm screw, but the differences were not statistically significant. The main advantage of the intra-articular technique was that it avoided damage to the articular surface of the metacarpal head.

The effect of implant placement on sacroiliac joint range of motion: posterior versus transarticular.

A human cadaveric biomechanical study of 2 sacroiliac (SI) joint fusion implant placement techniques. To evaluate and compare the biomechanical properties of 2 implant placement techniques for SI joint fusion. Minimally invasive placement of SI joint fusion implants is a potential treatment of SI joint disruptions and degenerative sacroiliitis. Biomechanical studies of screw fixation within the sacrum have shown that placement and trajectory are important in the overall stability of the implant. Although clinical results have been promising, there is the possibility that a more optimal arrangement of implants may exist. Bilateral SI joints in 7 cadaveric lumbopelvic (L4-pelvis) specimens were tested using a single leg stance model. All joints were tested intact, pubic symphysis sectioned, and treated (3 SI joint fusion implants). The implants were laterally placed using either a posterior or transarticular placement technique. The posterior technique places the implants inline in the inlet view, parallel in the outlet view, and parallel to the posterior sacral body in the lateral view. The transarticular technique places all implants across the articular portion of the SI joint. For all conditions, the range of motion was tested in flexion-extension, lateral bending, and axial rotation. The posterior technique significantly reduced the range of motion in flexion-extension, lateral bending, and axial rotation by 27% ± 24% (P = 0.024), 28% ± 26% (P = 0.028), and 32% ± 21% (P = 0.008), respectively. The transarticular technique significantly reduced the range of motion in flexion-extension, lateral bending, and axial rotation by 41% ± 31% (P = 0.013), 36% ± 38% (P = 0.049), and 36% ± 28% (P = 0.015), respectively. No significant differences were detected between the posterior and transarticular placement techniques (P > 0.25). Posterior and transarticular placement of SI joint fusion implants stabilized the SI joint in flexion-extension, lateral bending, and axial rotation. N/A.

Lateral soft-tissue release through a medial incision: Anatomic comparison of two techniques.

The distal soft tissue procedure is an integral part of hallux valgus surgery, providing soft tissue balance and alignment restoration of the first metatarsophalangeal joint. Various approaches have been established to this end. For techniques that do not include a separate dorsal incision, lateral release may be achieved via a transarticular approach or via a medial incision and a dorsal flap over the first metatarsal. Compared to the double-incision technique, these techniques are not only cosmetically superior and thus meet the demands of most surgeons and patients. Using six pairs of frozen cadaveric feet, lateral release was performed using one of the above techniques in a randomized manner with pair comparison. The specimens were then dissected and the completeness of the release as well as any damage to anatomic structures was documented. The transarticular technique enabled complete release of the metatarsal-sesamoid suspensory ligament (MSL) and the transverse and oblique head of the adductor hallucis muscle in five of six specimens. The comparative technique enabled the same in only two of six cases for the adductor hallucis muscle and in four cases for the MSL. The transarticular approach achieved complete release of the lateral joint capsule in three of six specimens, whereas the dorsal approach achieved no release in any specimen. Neither of the methods caused any macroscopic injury to the surfaces of the first metatarsophalangeal joint. The examined arteries, veins, and nerves remained intact in all specimens treated with the transarticular approach, but dorsal release resulted in one documented injury to the first dorsal metatarsal artery and its concomitant veins. Compared to release by dissection superficially to the extensor tendons, transarticular release provides a more complete lateral release and less injuries to neurovascular bundles. Further anatomic and clinical studies are needed, however, before conclusive recommendations can be made.

Clinically relevant complications related to posterior atlanto-axial fixation in atlanto-axial instability and their management

BackgroundThe Magerl transarticular technique and the Harms–Goel C1 lateral mass-C2 isthmic screw technique are the two most commonly used surgical procedures to achieve fusion at C1–C2 level for atlanto-axial instability. Despite recent technological advances with an increased safety, several complications may still occur, including vascular lesions, neurological injuries, pain at the harvested bone graft site, infections, and metallic device failure. MethodsWe retrospectively analyzed all patients (n=42 cases) undergoing a Harms–Goel C1–C2 fixation surgery with polyaxial C1 lateral mass screws and C2 isthmic screws at two different institutions between 2003 and 2012 and report clinical and radiological complications. One patient was lost to follow-up. The mean follow-up of the remaining 41 patients was 18.7 months (range 12–90). A clinically relevant complication was defined as a complication determining the onset of a new neurological deficit or requiring the need for a revision surgery. ResultsA total of 14 complications occurred in 10 patients (24.4% of 41 patients). Greater occipital nerve neuralgia was evident in 4 patients (9.8%). All but one completely resolved at the end of the follow-up. Persistent neck pain was reported by 3 patients (7.3%), hypoesthesia by 1 patient (2.4%), and anesthesia in the C2 area on both sides in 1 patient (2.4%). Furthermore, a superficial, a deep, and a combined superficial and deep wound infection occurred in 1 patient each (2.4%). One patient (2.4%) had pain at the iliac bone graft donor site for several weeks with spontaneous resolution. A posterior progressive intestinal herniation through the iliac scar was seen in 1 case (2.4%), which required surgical repair. No vascular damages occurred. Altogether, 5/41 patients (12.2%) had a clinically relevant complication including 4 patients necessitating a revision surgery at the C1–C2 level (9.8%). ConclusionsAtlanto-axial fixation surgery remains a challenging procedure because of the proximity of important neurovascular structures. Nevertheless, on the basis of our current experience, the C1 lateral mass-C2 isthmic screw technique appears to be safe with a low incidence of clinically relevant complications. Postoperative C2 neuralgia, as the most frequent problem, is due to surgical manipulation during preparation of the C1 screw entry point.

Anatomic Determination of Optimal Entry Point and Direction For C1 Lateral Mass Screw Placement

Anatomic study of C1 osteology using computerized tomography. To define the anatomy of the C1 lateral mass and make recommendations for optimal entry point and screw placement at C1. C1 lateral mass screw fixation is a reliable biomechanical technique that gives equivalent stability to that of Magerl transarticular screw fixation combined with posterior wiring for C1-C2 fusion. Use of a lateral mass screw allows alternative stabilization constructs to the transarticular technique when C2 vertebral artery anatomy is unfavorable. Because the vertebral artery travels lateral to the lateral mass, then crosses medially over the C1 neural arch, it is at risk during instrumentation. Medially, the cord and canal contents are at risk. While the anatomy of the C1 vertebra and lateral mass is well known, specific definition of ideal entry points, screw pathway direction, and dimensions of screws requires further clarification to enable a clinically safe surgical technique. Fifty consecutive patients underwent computerized tomography scans of their cervical spine. Using calibrated scans, measurements were taken to give the average dimensions of the C1 vertebra with a view for insertion of lateral mass screws beneath the posterior arch. The range of anatomic dimensions was examined to assess risk of vertebral artery damage in this population. The average length of screw within the lateral mass is 17.9 mm with 21.5 mm of screw posterior to the lateral mass, necessary to allow rod placement posteriorly. The safest entry point was directly beneath the medial edge of the posterior arch/lamina where it joins the lateral mass. The ideal direction of screw angulation in the sagittal plane was parallel to the posterior arch of C1. In the medial lateral plane, direct anterior placement could be used, but the lateral mass will tolerate 20 degrees of medial angulation from this starting point. The average distance between the vertebral artery foramen laterally and the screw pathway was 8.8 mm using these landmarks, and 5.8 mm from the medial aspect of the lateral mass. The range of anatomic variation was such that 9 lateral masses had a vertebral artery foramen to screw distance of only 3 mm. The vertebral artery was not at risk when these anatomic landmarks were used. C1 lateral mass screws are best placed beneath the posterior arch, parallel with the arch in the sagittal plan. The entry point is the medial border of the neural arch at its junction with the lateral mass. Straight ahead screw direction is safe in the axial plane, but up to 20 degrees of medial angulation will increase the safety margin from the vertebral artery foramen, and this technique avoids vertebral artery damage and optimizes lateral mass screw purchase. We suggest that this is the preferred method of entry into the lateral mass of C1.

Traumatic acromioclavicular joint separation – Current concepts

BACKGROUND: The concept of treatment strategies in dislocations of the acromioclavicular joint has changed in recent years. The recommended indication for operative treatment of complete dislocations has been questioned due to the lack of evidence-based results indicating the superiority of such treatment. Although the traumatic acromioclavicular joint separation is a well-known topic, there are different classifications, diagnostic procedures, concepts of intervention and a great variety of implants. Therefore, a comparison of the numerous papers dealing with this topic is difficult. METHODS: An overview of the recent literature is given in this paper. The different therapeutical methods, ranging from nonoperative techniques to different operative procedures such as percutaneous K-wires or other transarticular techniques, extra-articular techniques or secondary procedures like tendon transfers are compared. RESULTS: The current therapeutical algorithms that help to decide on whether operative or nonoperative treatment is the best solution are oriented on the morphological classification, the clinical appearance of the injury and the individual patient's expectations. The wide range of implants available demand a decision based on anatomical and biomechanical considerations. CONCLUSIONS: In this paper an overview of current concepts is given and possible treatment options for acute and chronic cases are discussed. The indication for operative intervention is restricted to the young and physically active patient with a high-grade dislocation of the AC-joint.

Femoral fixation of hamstring tendon autografts using the TransFix device with additional bone grafting in an anteromedial portal technique.

The femoral fixation of hamstring tendon grafts by a cross-pin is an established method with excellent biomechanical properties. Until now, this surgical procedure was associated with a transtibial placement of the femoral tunnel and a graft-tunnel diameter mismatch due to the different volumes of the tendon loop and the tendon strands. By use of an electrical knee positioning device, the transfixation technique can be performed safely through the anteromedial arthroscopic portal (transarticular technique), reaching the optimal lateral '10:30' position in the intercondylar notch. By use of a specific harvesting and implantation device, a cancellous bone plug is harvested and inserted into the femoral tunnel, thus stabilizing the tendon bundle and eliminating dead space in the tunnel. The femoral cross-pin guarantees a secure anchorage of the graft, drilling through the anteromedial portal eases optimum tunnel placement, and the insertion of a solid cancellous bone plug eliminates the femoral graft-tunnel diameter discrepancy and improves the press-fit contact between graft and tunnel wall. The long-term benefit of this technical modification remains to be proven.

Biofix fixation techniques and results in foot surgery

Biofix absorbable rods have been used for internal fixation for 10 years, and one of its most utilized applications has been osteotomies of the first metatarsal. This study evaluates 59 procedures on 49 patients completed over a 3-year period, using the 2.0-mm. Biofix rods. The transarticular technique for the fixation of osteotomies in the 1st and 5th metatarsals and the intramedullary technique used for digital fusions are described. All of the patients were followed for a minimum of 3 months, but most for > 1 year, and all of the procedures were evaluated for failure of fixation, osteolytic bone changes, sterile sinus development, and infection. There were no failures of fixation and no infections in this series. Patients (22.4%) developed radiographic osteolytic changes, and 4.1% of the patients developed sterile sinus discharge. However, these had no effect on the procedures' success or outcomes. An introduction to future application of the technology using Biofix screws and plates is made with a pantalar fusion case as an example.