New Sub-Classification of Vancouver B2 Periprosthetic Hip Fractures According to Fracture Pattern

IntroductionThere is currently a debate on whether all Vancouver type B2 (V-B2) periprosthetic hip fractures (PPHF) should be revised. Vancouver classification takes into account fracture location, implant stability and bone stock, but it does not distinguish between fracture patterns. The aim of our work was to study the different fracture patterns of V-B2 PPHF and to analyze if there is any pattern that presents lower osteosynthesis failure rates.Material and methodsAll patients with V-B2 PPHF treated by osteosynthesis between January 2009 and January 2019 were included in the study. Using the Gruen system the proximal femur was divided into 3 zones. The lateral zone (Gruen 1±2±3), medial zone (Gruen 5±6±7), and distal zone (Gruen 4±3±5) were analysed and it was determined whether each of the 3 zones was fractured.Results56 patients were included in the study. Their mean age was 79 years (R 45 - 92). The chosen treatment was: 39 Open reduction and internal fixation (ORIF), 10 Stem revision and 7 nonoperatively treatment. In ORIF group, no implant complications (0/24) were found in patients with a single fractured zone, while 5 implant complications (5/15) were discovered in patients with two or more fractured areas; this difference was significant (p=0.0147). All patients treated by stem revision had a fracture that involved two or more zones. In the nonoperatively group, the fracture pattern did not influence the treatment because of all of them had a very precarious functional and medical situation.ConclusionsV-B2 PPHF treated via ORIF affecting only one zone (medial, lateral, or distal) have a lower risk of complication than those affecting two or more zones. We propose a sub-classification of Vancouver B2 type fractures: B2.1 (1 fractured zone) and B2.2 (≥2 fractured zones).Level of evidenceHistorical cohorts. Level III     

Cervical and thoracic degenerative spinal instability

Although not as common as lumbar degenerative instability, instability in the cervical and thoracic spines, when present, typically manifests as a spondylolisthesis, or the forward translation of the cephalad vertebra on the caudal one. Cervical degenerative spondylolisthesis can occur at C1–2 or subaxially. It can result in a spectrum of symptoms ranging from axial neck pain, atlantoaxial or subaxial instability, radiculopathy and myelopathy. The pattern and severity of cord compression as well as the degree of instability determine the surgical approach. Bone quality available for fixation must also be considered. Thoracic degenerative spondylolisthesis is relatively rare due to the inherit stability in this region. Generally a posterior fusion with instrumentation is recommended when decompressing a thoracic level with associated spondylolisthesis, especially in cases where there is dynamic change in the spondylolisthesis on upright or flexion/extension radiographs.     

新型颈前路翼形钛网三维有限元分析

目的运用三维有限元法分析新型翼形钛网（aliform titanium mesh cage,ATMC）的生物力学性能;评价该内固定的外形设计及生物力学合理性并提出优化指导方案。方法在C4～C6三维有限元模型的基础上,利用Ansys9.0软件前处理器的建模功能建立颈前路椎体次全切减压翼形钛网植骨固定手术模型。对模型施加73.6N轴向压缩载荷及1.8Nm力矩,分析记录前屈、后伸、侧弯及旋转工况下新型翼形钛网内部应力分布及大小情况。结果在后伸、侧弯、旋转工况下,翼板基底部及钉孔周围均出现应力集中现象。应力集中以旋转工况最明显。各工况下笼内植骨块应力总体均匀,大小适宜。结论新型翼形钛网总体外形设计合理,模拟力学安全性能可靠;同时在翼板、翼板基底部存在应力集中现象,需待优化。     

可扩张通道下单侧椎弓根内固定融合治疗腰椎间盘突出症的临床疗效研究简

目的 对比分析Quadrant可扩张通道下单侧椎弓根内固定融合治疗术与常规双侧椎弓根内固定融合治疗术对腰椎间盘突出症的治疗效果,探讨腰椎间盘突出症的最优治疗方式.方法 回顾性分析2011年5月至2013年5月来院就诊的腰椎间盘突出症患者80例,按照手术方式的不同分为观察组40例（行Quadrant通道下单侧椎弓根内固定融合治疗）和对照组40例（行常规双侧椎弓根内固定融合治疗）,比较两组手术用时、出血量、术后住院时间,并使用改良Macnab疗效评定标准、视觉模拟评分系统（VAS）评价手术效果.结果 观察组手术用时（102.6±8.2）min、出血量（182.7±38.6）ml,与对照组相比差异明显（P〈0.05）;术后住院时间为（13.6±2.1）d、术后Macnab评定有效率为92.5%、术前与随访视觉模拟评分分别为（8.6±1.7）分、（1.6±2.2）分,与对照组比较无显著差异（P〉0.05）.观察组并发症发生率为7.5%,对照组并发症发生率为15.0%,对照组多于观察组,但组间差异无统计学意义（P〉0.05）.结论 观察组与对照组在治疗有效率方面没有显著差异,但是观察组的平均出血量较少、术后住院时间较短、并发症发生率也较低,优于对照组,故采用Quadrant通道下单侧椎弓根内固定融合术是治疗腰椎间盘突出症的一种良好方式,有较大的临床实用价值.     

同节段出口根减压对严重腰椎间盘脱出症治疗的影响

目的研究同节段出口根减压对严重腰椎间盘脱出手术效果的影响,探讨同节段出口根减压与腰椎术后邻近节段退变的关系。方法选择70例严重腰椎间盘脱出症患者,将其随机分为两组,所有患者均行腰椎后路全椎板减压植骨融合内固定术。实验组:术中对双侧同节段出口根进行充分减压;对照组:未对同节段出口根进行减压。对两组进行JOA评分,测量术后腰椎动力位像上手术邻近节段椎间隙高度和椎间活动度。结果实验组与对照组JOA改善指数比较有统计学意义(P<0.05),两组间术前与术后椎间高度差及邻近节段椎间活动度变化比较无明显统计学意义(P>0.05)。结论对于严重腰椎间盘脱出症患者行腰椎后路椎间融合术+同节段出口根减压术,可以有效缓解腰腿痛症状,并且术后6个月内不会增加邻近节段退变的危险。     

Two cases of glottic closure for refractory aspiration pneumonia after vertical partial laryngectomy

Vertical partial laryngectomy is a well-established surgical procedure for early glottic cancers with acceptable functional and oncological outcomes. However, on a long-term basis, aspiration might be a serious problem with aging. Here we presented two cases of refractory aspiration pneumonia after vertical laryngectomy. Case 1: A 76-year old gentleman with a past history of malignant lymphoma treated by chemotherapy and radiotherapy had glottic cancer, which was treated by repeated vertical partial laryngectomies. Although glottic caner had been well controlled, he started to suffer from refractory aspiration pneumonia. Since his cervical skin was very thin and hard and his general condition was poor, we employed modified Kano's method for glottic closure. Case 2: A 87-year old Japanese male had a past history of glottic cancer treated by radiotherapy and vertical partial laryngectomy. He was repeatedly hospitalized for severe aspiration pneumonia. At the age of 87, he had second primary oropharyngeal cancer. Kano's method was simultaneously performed at the time of resection of oropharyngeal cancer. Postoperative courses were uneventful without sign of leakage in both cases. The patients started oral intake 2 weeks after the surgery. They have been alive without aspiration pneumonia and takes normal diet.     

Effect of Minimally Invasive Technique on Return to Work and Narcotic Use Following Transforaminal Lumbar Inter-body Fusion: A Review

PURPOSE OF STUDY:: Low back pain is one of the most prevalent and disabling musculoskeletal conditions affecting the working population in the United States. Informed, shared decision making among patients, clinicians, and case managers about treatment options for chronic low back pain-including the role of spinal fusion where medically necessary-can have a meaningful impact on return to work, normal function, and economic outcomes. Minimally invasive techniques for lumbar spinal fusion, including transforaminal lumbar interbody fusion (MIS TLIF) have recently been introduced with the goal of smaller operative wounds, less tissue trauma, and faster postoperative recovery when compared with open fusion. Although similar long-term clinical outcomes have been reported for MIS TLIF and open TLIF, the relative merits with respect to workplace productivity have not been comprehensively investigated. Time to return to work and narcotic independence after MIS TLIF and open TLIF are important parameters that may affect overall workplace productivity, and as such are the focus of this study. PRIMARY PRACTICE SETTING(S):: This study was performed via a review of the literature. METHODOLOGY AND SAMPLE:: We performed a systematic literature review to identify all published articles that reported on the postoperative outcomes of patients, as assessed by return to work or narcotic independence status or both, following MIS TLIF or open TLIF. A cumulative comparison was made for all included MIS TLIF versus open TLIF surgeries. RESULTS:: Seventy-four published studies reported postoperative outcomes following MIS TLIF or open TLIF; only five (6.8%) studies directly described time to return to work or duration of narcotic use postoperatively or both, and were therefore included into the analysis of this review. Four studies in the published literature describe time to return to work following MIS TLIF or open TLIF, and two studies describe time to narcotic independence. Overall, the reviewed literature suggests that MIS TLIF may be associated with an accelerated time to narcotic independence and return to work versus open TLIF. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE:: There are limited data regarding time to return to work and duration of postoperative narcotic use following TLIF for low back pain. The available data appear to suggest that MIS TLIF may be associated with accelerated return to work and narcotic independence compared with open TLIF. Further analysis will be necessary to quantify the impact of MIS TLIF on workplace productivity and the indirect costs borne by patients and employers. Such information will be of value to case managers, disability managers, employers, patients, and clinicians aligned on reducing morbidity and hastening return to normal function.