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Preoperative simulation of pedicle subtraction osteotomy for treating sagittal deformity of the spine-Comparison of prediction accuracy of 2 computerized protocols

Introduction: Pedicle subtraction osteotomy (PSO) is a powerful technique to correct sagittal malalignment of the spine. Inadequate correction during PSO may lead to poor functional outcome. Purpose: We used Surgimap to prove the efficacy of preoperative simulation. Methods: Two protocols of preoperative simulation were compared for their prediction accuracy of sagittal parameters including pelvic incidence minus lumbar lordosis (PI-LL), pelvic tilt (PT), and sagittal vertical axis (SVA) in twenty-four patients. PT method targeted 20° of PT postoperatively. Fixed wedge angle (FWA) method aimed to simulate a 30° wedge correction at the level of PSO. The location of PSO was decided by the results of simulation. The differences between these two methods were evaluated by Student’s t-test. Results: PT method could predict post-operative SVA, PI-LL and PT more accurately than FWA method although statistical significance was shown only in the SVA parameter. The achievement rate was around 80% in three parameters by PT method. Larger variation of achievement rates was noticed in FWA method (59.9–80.2%). The difference of osteotomy angle (proposed osteotomy angle according to simulation minus actual osteotomy angle) was significantly smaller in PT method (3.25 ± 1.42°) than in FWA method (7.17 ± 5.39°). Conclusion: PT method could provide more reliable simulation of PSO than FWA method, even though computerized simulation software did not take possible reciprocal changes in the unfused segments into considerations. PT method of simulation could provide suggestions of PSO location and angle for pre-operative planning of PSO. Since sagittal parameters are highly correlated to clinical functions, better outcomes could be expected if accurate correction is achieved.

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Use of a 3-D CT reconstruction image to locate the adductor tubercle and to measure the joint-line distance in knee arthroplasty

Background: There are difficulties in locating the adductor tubercle (AT) to measure the joint line distance on a radiograph because of landmark identification and the geographic magnification associated with the use of the radiograph. Purpose: The objective of this study was to determine if employing a three-dimensional computed tomography (3-D CT) image could overcome these disadvantages, making the AT an eligible image landmark. Methods: First, initial validation of the 3-D CT measurement was performed using a bone specimen study, where the AT to the joint line distance (ATJL) was measured on each of 10 femoral bone specimens physically and also on respective 3-D CT images. Second, 40 clinical 3-D CT images were employed to analyze the intraobserver and inter-observer reliability in the clinical setting. Lastly, these clinical 3-D CT data were compared to the intraoperative ATJL measurement in our previous publication, using statistical analysis to seek for further validation. Results: The intraclass correlation coefficient (ICC) for the bone specimen study was 0.95, which implied a high agreement between the measurement made by the caliper and on the 3-D CT image. In the clinical study, the statistical analysis showed an excellent intra-observer and inter-observer reliability for ATJL measurements (ICC: 0.964 and 0.939). When compared to the data of the intra-operative ATJL measurement in our previous publication, the Kolmogorov- Smirnov test showed the similarity of the two techniques. Conclusion: The accuracy and reliability of measurement of the ATJL on the 3-D CT image have been well demonstrated in this study. We suggest using this technique to plan the joint line position before surgery in revision knee arthroplasty involving significant bone loss.

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Simultaneous Bennett's fracture and trapezium fracture in an adolescent: A case report and literature review

An adolescent baseball player was hit by a pitch directly on the hand when batting. X-ray examination showed the presence of both Bennett's fracture and trapezium fracture. The fractures were successfully treated with closed reduction, percutaneous Kirschnerwire fixation and casting. Both fractures healed successfully. The patient who experienced no pain had fully functional recovery and returned to play.

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Traumatic rupture of the anterior tibial tendon following closed ankle and foot fracture: A case report and literature review

A 22-year-old man presented with traumatic rupture of the anterior tibial tendon associated with a closed ankle fracture. The tendon rupture was not diagnosed before surgery but was recognized at the time of open reduction. The tendon was repaired and the fracture was internally fixed. Six months after the operation, the patient had nearly full range of pain-free ankle movement and normal gait. To our knowledge, such a case has not been reported previously. Although anterior tibial tendon rupture is rare, it should be suspected in cases of closed ankle fracture, irrespective of the mechanism of injury.

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A rare case of supracondylar humerus fracture after the Outerbridge-Kashiwagi procedure: A case report

Outerbridge-Kashiwagi procedure (O-K procedure) or ulnohumeral arthroplasty is a procedure for treating degenerative osteoarthritis of the elbow. Although a previous biomechanical study has demonstrated a decrease in maximum strength of the distal humerus after fenestration, there is limited literature reporting distal humerus fractures as a complication of this procedure. We present an elderly woman with supracondylar humerus fracture that occurred after a low energy trauma six months after the O-K procedure. The thin medial column after ulnohumeral arthroplasty was a possible reason for the supracondylar humerus fracture six months after the surgery. Surgeons should be especially careful during the fenestration to avoid the related complications.

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A case report: Simultaneous bilateral posterior shoulder and unilateral central acetabular fracture dislocations secondary to epileptic seizure

Fracture dislocations of extremities are a possible complication following epileptic seizures. Management mainly depends on the severity of the injury and the current medical status of the patient. We describe a rare case of bilateral posterior shoulder and unilateral central acetabular fracture dislocations without direct trauma after a convulsive seizure related to lung cancer with brain metastases. Two weeks after the seizure, we performed an open reduction and internal fixation (ORIF) with locking plate to treat bilateral posterior shoulder fracture dislocations when the patient’s neurological condition became more stable. However, nonoperative treatment was selected for the acetabular fracture dislocation because of the patient’s advanced-stage cancer. Since the patient was responding well to the newest target therapy for his lung cancer, and his life span is beyond our estimate, we, therefore, performed a total hip replacement 6 months later because of traumatic osteoarthritis development. The clinical outcome was satisfactory at the 6-month follow-up. Due to medical progress in non-small cell lung cancer treatment, we consider aggressive treatment may be necessary even in such advanced stage patients.

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Bone mineral density in patients with symptomatic vertebral compression fractures after instrumented spinal fusion: A retrospective analysis

Background: Few studies have been published concerning about the osteoporotic symptomatic vertebral compression fractures (VCFs) following instrumented spinal fusion for degenerative spinal disease. Purpose: The purpose of this study was to evaluate the incidence of symptomatic VCFs and the differences in the timing of occurrence and bone mineral density (BMD) between patients with adjacent and remote VCFs after instrumented spinal fusion. Methods: We performed a retrospective analysis of 1,936 patients who received posterior instrumentation for degenerative spinal disease at our institution and were followed-up for at least 3 years. Dual-energy X-ray absorptiometry surveys were arranged, and symptomatic subsequent VCFs were identified during regular follow-up. Eligible patients were divided into two groups (adjacent or remote to instrumented spinal fusion, based on the location of their VCFs. The Wilcoxon signed-rank test or chi-square test was used to assess between-group differences. Linear regression analysis was used to examine the relationship between the timing of the occurrence of VCFs and BMD (T-score). Results: The incidence of symptomatic VCFs following instrumented lumbar spine fusion was 2.37% (46/1,936), which accounted for 20.53% (46/224) of patients with VCFs. Linear regression analysis revealed a positive trend between the timing of the occurrence of symptomatic VCFs and values of BMD (T-score). The mean time to develop adjacent VCFs was 6.8 months, while that to develop remote VCFs was 13.7 months (p ＜ 0.05). Conclusion: Symptomatic adjacent VCFs occurred much earlier than remote VCFs. Device-related osteoporosis may be one of risks in subsequent VCFs, which highlight the importance of osteoporosis medication.

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Results of posterior lumbar interbody fusion in post-laminectomy pain syndrome

Background: Patients who were diagnosed with failed back surgery syndrome (FBSS) underwent posterior lumbar interbody fusion (PLIF) with instrumentation at our hospital. Purpose: The aim of this study was to analyze the clinical and radiologic outcomes of PLIF for post-laminectomy pain syndrome and determine whether any single operation can be used to overcome most of these complications. Methods: The surgical technique consisted of wide decompression with further laminectomy over the ongoing fusion level, nearly total discectomy, end-plate preparation, bone graft packing, insertion of a dual intervertebral spacer, and rigid pedicle screw instrumentation. Results: The mean visual analog scale (VAS) pain score improved from 8.5 preoperatively to 1.9 at the final follow-up. The mean Japanese Orthopaedic Association (JOA) score improved from 9.3 preoperatively to 23.1 at the final follow-up (p ＜ 0.001). The mean recovery rate at the final follow-up was 70.1% (range, 21.0-94.1%). Complications were seen because of perioperative dural tears in six cases, but there were no cases of nerve root injury. A satisfactory result was achieved in 79.7% of our patients, while the overall fusion rate was 88.7%. Conclusion: According to the results of our series, we believe that PLIF can be a reasonable and effective procedure for post-laminectomy pain syndrome with different surgically correctable structural causes.

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Using magnetic resonance imaging (MRI) as an aid to better define the center of patella and tibial tubercle in determining quadriceps angles

Background: A full-length standing scanogram (FLSS) can be difficult to measure a quadriceps angle (Q-angle). The trochlear groove (TG) and tibial tubercle (TT) normally cannot be inspected. Purpose: The purpose of this retrospective study was to use magnetic resonance imaging (MRI) of knees to aid in accurately defining the TG and TT on FLSS radiographs. Methods: Sixty consecutive adult patients (29 men and 31 women; average, 46 years) took knee MRI for ligament or meniscus injury. A standardized patellar center was defined as the deepest point of the TG on a transverse MRI film along the femur trans-epicondylar line (TEL). The distance from this point to the lateral femoral cortex and the TEL were measured. The TT was chosen at the insertion of patellar tendon (the lowest margin) revealed on a transverse MRI film. Then, the distance from the TT to the lateral tibial cortex and the tibial diameter at this level were measured. Results: The standardized patellar center was at a point 42% from the lateral end of the femur TEL. The TT was 2 cm distal to the articular surface, and 37% from the lateral end of the tibial diameter. There was no statistical significance between men and women for the location of the TG and TT (p ＞ 0.05). However, men had more distal insertion of the TT (22.2 mm vs. 19.6 mm, p ＜ 0.001). Conclusion: A Q-angle may be more accurately defined on a FLSS by using MRI to aid localizing the TG and TT.

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Clinical outcomes of reverse shoulder arthroplasty: A retrospective study

Background: Reverse total shoulder arthroplasty (RSA) has also become popular in Taiwan, however, no related article regarding RSA has been reported in the orthopaedic literature in Taiwan. Purpose: To examine functional outcomes and complications after RSA. Methods: Patients undergoing RSA between March 2015 and March 2017 were reviewed for inclusion in this retrospective study. All patients had rotator cuff arthropathy, fracture malunion with cuff arthropathy, and locked shoulder. Clinical outcomes were evaluated using Constant scores and active range of motion (ROM) of the shoulder joint. Active ROM was evaluated in terms of anterior elevation, abduction, external rotation at 90 degree of abduction, and internal rotation. Constant scores and ROMs were analyzed postoperatively at 6 months and 1 year. Results: Fourteen patients (eight women, six men; average age, 75 years (range, 64 to 89 years) were evaluated with an average follow-up of 13.8 months. The average absolute Constant score at 6 months follow-up was 61.6 ± 10.6 points. Average degree of anterior elevation, abduction, external rotation, and internal rotation improved from 66.4, 27.8, 40, and sacrum, respectively, before surgery to 147.1, 33.9, 84.6, and L4, respectively, postoperatively. However, average external rotation did not improve significantly after surgery (p = 0.0055). Similar results were noted at 1 year follow-up. Two complications (14.3%) were recorded including RSA shoulder dislocation and postoperative acromion fracture. Conclusion: RSA provides reliable pain relief and return of shoulder function in patients with rotator cuff arthropathy.