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2.
Study Design
A report of two cases with complex cervical spondylotic myelopathy (CSM) and review of the literature.Objective
To describe two unique patients with complex CSM due to simultaneous anomalies as anteroposterior compressions of the spinal cord in both upper and lower cervical spine, caused by hypertrophic transverse ligament of atlas (TLA), dysplasia of the posterior arch of atlas, disc herniation, hypertrophic ligamentum flavum and osteophytes.Methods
We present such two cases with clinical, imageological presentations, and describe the surgical procedure, to which both patients responded favorably.Results
The neurological functions of both patients gradually improved according to the JOA scores and VAS scores in preoperative clumsiness and gait disturbance during the mean follow-up period lasted for 18 months. The latest plain radiographs and computed tomography (CT) revealed good fusion without instrumental failure and magnetic resonance imaging (MRI) showed good decompression of C1–7 spinal cord of both patients. Both patients are progressively followed-up.Conclusion
Posterior surgical approach as C1–7 laminectomy with fixations or occipital-cervical fusions may obtain better reconstructions of the cervical spine and good neurological recovery for the patients with complex CSM we present. However, the incidence and ethnic predisposition for the patients with complex CSM are still unclear.3.
Background
Anterior cervical discectomy and fusion (ACDF) as well as posterior instrumentation of the cervical spine are frequently performed surgeries for cervical disc prolapse or spinal stenosis. Surgery itself harbors a very low risk of adverse events. Postoperative palsy of the C5 nerve root, however, is a severe complication and its origin is still not fully understood. The risk of such a C5 palsy is reported to be between 0 and 30%; 5% on average according to the literature.Objectives
To describe underlying pathomechanisms and to recommend strategies for risk reduction.Materials and methods
An extensive literature research via Medline was performed.Results
Potential risk factors are male gender, sagittal diameter below 5.6?mm, anterior approach, and higher age.Conclusions
Currently available data only originates from retrospective or anatomical studies. A prospective register study with the goal to put light on the pathogenesis is currently being performed.4.
H. J. Nickenig 《Der MKG-Chirurg》2016,9(2):88-100
Background
The clinical relevance of implant malpositioning and avoidance of the complications are presented.Objective
The aim of this study was the development of strategies for avoidance of potential complications caused by incorrect positioning of implants.Methods and methods
A literature search was carried out in the Cochrane library and Medline database using the terms vertical positioning of dental implants, horizontal positioning of dental implants, inter-implant distances, tooth-to-implant distance, distances of dental implants and neighboring structures, implant failure, implants and biomechanical failure and distribution of implants. The studies identified were screened by reading the abstracts and irrelevant studies were excluded. All articles that were found to be potentially relevant were obtained in full text form.Results
Only a few randomized controlled trials were available on the subject. The results are discussed under the aspects of preimplantation risk assessment, three dimensional alignment of the implant, information on minimum distance from the granulation, implant angle and distance from neighboring structures.5.
Purpose
Few studies have investigated the risk factors for implant removal after treatment for spinal surgical site infection (SSI). Therefore, there is no firmly established consensus for the management of implants. We aimed to investigate the incidence and risk factors for implant removal after SSI managed with instrumentation, and to examine potential strategies for avoiding implant removal.Methods
Following a survey of seven spine centers, we retrospectively reviewed the records of 55 patients who developed SSI and were treated with reoperation, out of 3967 patients who had spinal instrumentation between 2003 and 2012. We examined implant survival rate and applied logistic regression analysis to assess the potential risk factors for implant removal.Results
The overall rate of implant retention was 60% (33/55). A higher implant retention rate was observed for posterior cervical surgery than for posterior-thoracic/lumbar surgery (100 vs. 49%, P < 0.001). On univariate analysis, significant risk factors for implant removal included greater blood loss, delay of reoperation, and delay of intervention with effective antibiotics. Multivariate analysis revealed that a delay in administering effective antibiotics was an independent and significant risk factor for implant removal in posterior-thoracic/lumbar surgery (odds ratio 1.17; 95% confidence interval 1.02–1.35, P = 0.028).Conclusions
Patients with SSI who underwent posterior cervical surgery are likely to retain the implants. Immediate administration of effective antibiotics improves implant survival in SSI treatment. Our findings can be applied to identify SSI patients at higher risk for implant removal.6.
Purpose
The aim of this study is to understand how many anchor sites are necessary to obtain maximum posterior correction of idiopathic scoliotic curve and if the alloy of instrumentation, stainless steel or titanium, may have a role in the percent of scoliosis correction.Methods
We reviewed 143 consecutive patients, affected by AIS (Lenke 1–2), who underwent a posterior spinal fusion with pedicle screw-only instrumentation between 2002 and 2005. According to the implant density and alloy used we divided the cohort in four groups.Results
All 143 patients were reviewed at an average follow-up of 7, 2 years, the overall final main thoracic curve correction averaged 61.4%, whereas the implant density within the major curve averaged 71%. A significant correlation was observed between final% MT correction and preoperative MT flexibility and implant density.Conclusions
When stainless steel instrumentation is used non-segmental pedicle screw constructs seem to be equally effective as segmental instrumentations in obtaining satisfactory results in patients with main thoracic AIS. When the implant alloy used is titanium one, an implant density of ≥60% should be guaranteed to achieve similar results.7.
Di Martino Alberto Papalia Rocco Albo Erika Cortesi Leonardo Denaro Luca Denaro Vincenzo 《European spine journal》2015,24(7):810-825
Purpose
The alignment at the cervical spine has been considered a determinant of degeneration at the adjacent disc, but this issue in cervical disc replacement surgery is poorly explored and discussed in this patient population. The aim of this systematic review is to compare anterior cervical fusion and total disc replacement (TDR) in terms of preservation of the overall cervical alignment and complications.Methods
A systematic review of the current literature was performed, together with the evaluation of the methodological quality of all the retrieved studies.Results
In most of the retrieved studies, a tendency towards a more postoperative kyphotic alignment in TDR was reported. The reported mean complication rate was of 12.5 % (0–66.2 %). Complications associated with cervical prosthesis included heterotopic ossification, device migration, mechanical instability, failure, implant removal, reoperations and revision.Conclusions
Even though cervical disc arthroplasty leads to similar outcomes compared to arthrodesis in the middle term follow-up, no evidence of superiority of cervical TDR is available up to date. We understand that the overall cervical alignment after TDR tends towards the loss of lordosis, but only longer follow-up can determine its influence on the clinical results.8.
Purpose
Aim of this study is to compare late degenerative MRI changes in a subset of patients operated on with ACDF to a second subset of patients presenting indication to ACDF but never operated on.Methods
Patients from both subgroups received surgical indication according to the same criteria. Both subgroups underwent a cervical spine MRI in 2004–2005 and 10 years later in 2015. These MRI scans were retrospectively evaluated with a cervical spine ageing scale.Results
Comparing the two subset of patients both suffering from clinically relevant single-level disease returns no statistically significant difference in the degenerative condition of posterior ligaments, presence of degenerative spondylolisthesis, foraminal stenosis, diameter of the spinal canal, Modic alteration, and intervertebral discs degeneration at 10-year follow-up.Conclusions
The adjacent segment degeneration represents, in the present cohort, a result of the natural history of cervical spondylosis rather than a consequence of fusion.9.
Daisuke Inoue Tamon Kabata Toru Maeda Yoshitomo Kajino Takashi Yamamoto Tomoharu Takagi Takaaki Ohmori Hiroyuki Tsuchiya 《European journal of orthopaedic surgery & traumatology : orthopedie traumatologie》2016,26(6):591-598
Background
Initial fixation is a key factor in the success of cementless THA using a tapered wedge stem. The purpose of this study was to use three-dimensional templating software to examine the correlation between quantitative contact state and important clinical radiological outcomes, specifically stem subsidence, stress shielding, and cortical hypertrophy.Methods
We conducted a retrospective consecutive review of 75 hips in 70 patients over a minimum 3-year follow-up period. X-rays and CT scans were investigated to assess preoperative planning, quantify the contact state of implant and femur, and assess stem alignment, stem subsidence, stress shielding, and cortical hypertrophy. We evaluated the correlation between radiological outcomes and three-dimensional quantitative contact state according to Gruen Zone in each Dorr classification.Results
Density mapping indicated that stem subsidence increased postoperatively if the stem had less cortical contact in the middle to distal portion of the implant in terms of initial fixation. Cases having too much cortical contact in the distal portion of the implant tended to have increased stress shielding. We found no correlation between cortical hypertrophy and the contact state of implant and femur.Conclusions
Density mapping with three-dimensional templating software can be useful in predicting stem subsidence and stress shielding following cementless THA with a tapered wedge stem. Further analysis is required to accurately depict the correlation between cortical hypertrophy and the contact state.10.
Juergen Götz Johannes Beckmann Ingo Sperrer Clemens Baier Silvia Dullien Joachim Grifka Franz Koeck 《International orthopaedics》2016,40(7):1441-1446
Purpose
Modified postural stability after retaining the posterior cruciate ligament (PCL) in total knee arthroplasty is still discussed controversially. The objective of this study was to evaluate whether a PCL-retaining implant design should be preferred over a PCL-substituting implant design regarding postural stability in one-leg stance and clinical outcome.Methods
Forty patients underwent total knee arthroplasty, 20 of them with a cruciate-retaining (CR) and 20 of them with a cruciate-substituting (PS) implant system. Postural stability was analysed 6 months postoperatively in one-leg stance using the Biodex Balance System. In addition, the Western Ontario and McMaster Universities Arthritis Index (WOMAC) and Knee Society Score were completed.Results
This study shows that there is no significant difference in postural stability between CR and PS) implant systems with PS implants showing better results in WOMAC score.Conclusions
In case it is necessary to use a PS implant, no negative influence on postural stability is to be expected compared to a CR implant.11.
S. Reinhardt 《Der MKG-Chirurg》2016,9(2):101-106
Background
In many cases incorrect positioning of implants in the vertical plane can only corrected only by explantation, especially in the aesthetic zone; however, what vertical implant position is correct in order to achieve stable long-term aesthetic and functional results in the anterior and posterior dentition?Material and methods
In order to answer this question the results of the 9th European Consensus Conference (EuCC) from March 2014 in Cologne under the leadership of the European Association of Dental Implantologists (BDIZ EDI) and a recent literature review were included.Results
The results are discussed with respect to the resorption behavior of implants under conditions of varying depths of implant insertion.12.
13.
Background
Surgical correction of severe and rigid cervical kyphosis with chin-on-chest deformity poses significant challenges to both the patient and surgeon once surgery is considered as the treatment of choice.Objectives
This article presents the current concepts of corrective surgery for patients with severe and rigid cervical kyphosis.Material and methods
Narrative review and report of clinical experience.Results
The treatment of severe cervical kyphosis indicates a dedicated deformity assessment, the analysis of regional and global imbalance, the identification of spinal sagittal plane compensation mechanisms, detailed radiographic and clinical planning of corrective surgery, and the meticulous performance of surgical correction. Most recent large-scale studies serve as evidence for the benefit of surgical correction and outline the complications that need to be targeted during and after surgery.Conclusion
Surgical correction of severe cervical kyphosis can be a pleasant and life-changing event for the disabled patient.14.
Yoshinori Ishii Hideo Noguchi Junko Sato Nobukazu Ezawa Shin-ichi Toyabe 《European journal of orthopaedic surgery & traumatology : orthopedie traumatologie》2016,26(5):537-543
Background
The purpose of this study was to assess changes in the three-dimensional (3D) load-bearing mechanical axis (LBMA) preoperatively and at 3 weeks and more than 1-year follow-up after total knee arthroplasty (TKA), and effects of the degree of constraint in the anteroposterior (AP) direction because of the retention of the posterior cruciate ligament (PCL) and the implant design on the changes in LBMA.Methods
We evaluated 157 knees from 131 patients, including 79 knees that received meniscal-bearing-type (PCL-retaining) and 78 knees that received rotating-platform-type (PCL-substituting) prostheses. Quantitative 3D computed tomography was used to assess changes in the location of the pre- and postoperative LBMA at the tibial plateau level.Results
Changes in the 3D axis were mainly found from medial to lateral and posterior to anterior in both implant designs with no significant differences. Change in the mediolateral (ML) direction was improved soon after TKA, but change in the AP direction improved more gradually over time. The different constraints in the AP direction because of the retention of the PCL and different implant designs did not affect the changes in the LBMA.Conclusions
The LBMA in the AP direction more than 1 year postoperatively, as well as the LBMA in the ML direction at 3 weeks, appears to shift toward the location found in normal knees after TKA, regardless of the type of prosthetic constraint. These changes may be an important factor that influences the periarticular knee bone mineral density which load bearing may be related to.Level of evidence
Level II, Prognostic study.15.
Ahmed Hamed Kassem Abdelaal Norio Yamamoto Katsuhiro Hayashi Akihiko Takeuchi Shinji Miwa Ahmad Fawaz Morsy Yoshitomo Kajino Hiroyuki Tsuchiya 《Journal of orthopaedics and traumatology》2016,17(3):255-259
Background
The linea aspera is the rough, longitudinal crest on the posterior surface of the femoral shaft. Most orthopedic surgeons depend on the linea aspera as an intraoperative landmark identifying the true posterior aspect of the femur. We investigated the position of the linea aspera to verify whether the surgeon can rely on this accepted belief.Material and method
One hundred and thirty-three femora from 73 patients were evaluated. Four CT cuts were done of the mid femur, and we measured the angle of rotation of the linea aspera at each cut.Results
The linea aspera was externally rotated in most femora evaluated; average angles of rotation were 15.4°, 14°, 11.7°, and 11.5° at 10, 15, 20, and 25 cm from the intercondylar line, respectively. The angle of rotation of the linea aspera was positively correlated with femoral neck anteversion angle and negatively with age.Conclusion
The linea aspera is exactly posterior in a minority of individuals, while it is externally rotated to varying degrees in the majority of individuals. The degree of rotation was positively correlated with femoral neck anteversion angle, and negatively with age. To avoid implant malrotation, accurate estimation of the rotation angle should be determined preoperatively.Level of evidence
Level IV.16.
Luca Denaro Umile Giuseppe Longo Alberto Corrado Di Martino Nicola Maffulli Vincenzo Denaro 《BMC musculoskeletal disorders》2017,18(1):552
Background
Even though internal fixation has expanded the indications for cervical spine surgery, it carries the risks of fracture or migration, with associated potential life threatening complications. Removal of metal work from the cervical spine is required in case of failure of internal fixation, but it can become challenging, especially when a great amount of scar tissue is present because of previous surgery and radiotherapy.Case presentation
We report a 16 year old competitive basketball athlete who underwent a combined anterior and posterior approach for resection of an osteosarcoma of the sixth cervical vertebra. Fourteen years after the index procedure, the patient eliminated spontaneously one screw through the intestinal tract via an oesophageal perforation and developed a severe dysphagia. Three revision surgeries were performed to remove the anterior plate because of the great amount of post-surgery and post-irradiation fibrosis.Conclusions
Screw migration and oesophageal perforation after cervical spine surgery are uncommon potentially life-threatening occurrences. Revision surgery may be challenging and it requires special skills.17.
Keyvan Mostofi Reza Karimi Khouzani 《European journal of orthopaedic surgery & traumatology : orthopedie traumatologie》2016,26(7):805-808
Background
The incidence of cervical disc herniation is estimated about 5.5/100,000, and they lead to surgical intervention in 26 %. Cervical disc herniation causes radiculopathy, which defines by radicular pain and sensory deficit and maybe weakness following the path of the affected nerves. Classically, cervical radiculopathy is expected to follow its specific dermatome—C4, C5, C6, C7 and C8. We investigate patients who present with discrepancy between classical radiculopathy and imaging findings in the daily practice of our profession.Methods
We reviewed the medical records of 102 patients with cervical radiculopathy, caused by cervical disc herniation. All patients had surgery.Results
We found an apparent discrepancy between clinical and radiological findings, patients complained of radiculopathy on one side, and magnetic resonance imaging (MRI) scan or CT scan finding on the other side in ten patients (10.2 %). We did not found any other abnormalities in preoperative and post-operative period. All patients underwent cervical diskectomy via anterior approach. Six weeks after surgery eight patients (80 %) recovered completely, and 3 months after all ten patients (100 %) had been relieved totally.Comparison with existing method
The aim of this paper is review of this medical concept and management of radiculopathy in patients with this discrepancy. As far as we know, the subject has not yet been touched in this light in medical literature.Conclusion
The discrepancy between clinical radiculopathy and disc herniation level on MRI or on CT scan is not rare. Management of this discrepancy requires further investigation to avoid missing diagnosis and treatment failure.18.
Purpose
This study aimed to evaluate the clinical and radiological results in patients with unstable Denis type B thoracolumbar burst fractures treated by modified one-stage posterior/anterior combined surgery.Methods
Thirty-one patients with unstable Denis type B thoracolumbar burst fractures were enrolled in this study. The patients underwent one-stage posterior/anterior combined surgery with posterior instrumentation using pedicle screws and anterior monosegmental reconstruction utilizing titanium mesh cages. The mean follow-up period was 38.3 months. Clinical outcomes, radiological parameters, and treatment-related complications were assessed.Results
The mean age of the patients was 36.4 years. The mean operative time and blood loss were 230 min and 645 ml, respectively. The VAS pain score was significantly improved after surgery, and the improvement was maintained until the final follow-up. In 23 patients with neurologic dysfunction, 20 (87 %) patients had improvement after surgery. By the final follow-up, 27 patients had returned to work; 18 of the 27 patients returned to a similar job. The mean sagittal kyphosis was corrected from 21.2° preoperatively to 2.5° postoperatively, which increased slightly to 4.3° at the final follow-up. Minimal subsidence and tilt of the titanium mesh cage were observed during the follow-up period. Solid bony fusion was achieved in all patients. One patient developed a posterior surgical site infection, which was resolved by antibiotic treatment and surgical debridement.Conclusion
Modified one-stage posterior/anterior combined surgery for Denis type B unstable thoracolumbar burst fractures can produce good clinical and radiological outcomes.19.
Objective
Coracoacromial ligament release to widen the subacromial space, resection of the anterior undersurface of the acromion and, if needed, caudal exophytes at the acromioclavicular joint.Indications
All types of outlet impingement after 3 months of conservative treatment.Contraindications
Impingement syndrome with instability/muscular imbalance, massive rotator cuff tear, unstable os acromionale, posterior–superior impingement, joint infection, freezing phase of a secondary frozen shoulder.Surgical technique
Lateral decubitus position with traction device for the arm. Diagnostic arthroscopy of the glenohumeral joint via standard portals. With arthroscope moved to the subacromial space, bursectomy, electrosurgical release of coracoacromial ligament, resection of acromial hook through standard posterior portal.Postoperative management
Physiotherapy or self-exercises on postoperative day 1, pain-adapted analgesia to avoid shoulder stiffness.Results
Several studies present positive long-term results compared to conservative treatment (and open acromioplasty) for partial rotator cuff tears and for elderly patients. With a 20-year follow-up, successful results have been achieved for all patients with isolated impingement syndrome.20.