Suture augmentation of acromioclavicular and coracoclavicular ligament reconstruction for acute acromioclavicular dislocation

The objective of this report was to introduce a new suture augmentation of coracoclavicular (CC) and acromioclavicular ligament reconstruction for acute Rockwood grade III to V acromioclavicular dislocations.From January 2015 to January 2019, 43 patients with Rockwood III to VI acute acromioclavicular dislocations were retrospectively reviewed. For comparison, another series of 28 patients treated with double Endobutton technique from January 2011 to December 2014 were reviewed. A P < .05 was considered statistical significance.The mean follow-up period of the 2 series were 39.69 ± 7.42 months (range, 24–54 months) and 37.86 ± 8.23 months (range, 26–48 months) (P > .05), respectively. There were significant differences regarding CC space (11.62 ± 2.54 mm vs 16.78 ± 5.53 mm; P < .05), CC reduction loss (5.56 ± 4.73 mm vs 26.25 ± 4.42 mm; P < .05), and acromioclavicular space (6.89 ± 1.87 mm vs 7.95 ± 2.37 mm; P < .05). There were significant differences regarding the disabilities of the arm, shoulder, and hand questionnaire (3.3 ± 2.8 vs 5.32 ± 4.37; P < .05) and University of California–Los Angeles shoulder rating scale (31.19 ± 2.48 vs 29.24 ± 2.48; P < .05). The excellent to good percentages were 100% (n = 32) and 85% (n = 23), respectively.In conclusion, the suture augmentation of acromioclavicular and CC ligament reconstruction is a reliable technique for acute acromioclavicular dislocation with minimal complications.Type of study/level of evidence: Therapeutic IIa.     

Bilateral Shoulder Dysfunction Related to the Lung Resection Area After Thoracotomy

This study aimed to investigate the mobility, pain, and disability of the shoulders after different pulmonary surgical procedures.It is a cross-sectional prospective study. A total of 38 patients who underwent lung surgery via thoracotomy (mean age = 57 ± 10 years) were evaluated in the preoperative period, and first and second postoperative days were assessed for range of motion of shoulder; pain intensity; and application of the Shoulder Pain and Disability Index questionnaire. This study compared the 3 days of evaluation, and the subgroups according to the resection area (biopsy/nodulectomy, lung segmentectomy and lobectomy).There was a decrease of flexion (153° ± 16°–98° ± 23°), abduction (151° ± 20°–126° ± 38°), and increased Shoulder Pain and Disability Index (2.4–44.3) in the shoulder ipsilateral to surgery from the preoperative to the first postoperative day (P < 0.05). There was a greater loss of ipsilateral flexion and abduction in the lobectomy subgroup (P < 0.05), and decreased abduction of the contralateral shoulder in the lung segmentectomy and lobectomy subgroups (P < 0.05).After pulmonary surgery, there is bilateral impairment in shoulder range of motion, with greater limitation on ipsilateral shoulder, and larger resections.     

Comparison of the fixation ability of headless compression screws and locking plate for metacarpal shaft transverse fracture

Metacarpal shaft fractures are common hand fractures. Although bone plates possess strong fixation ability, they have several limitations. The use of headless compression screws for fracture repair has been reported, but their fixation ability has not been understood clearly.This study aimed to compare the fixation ability of locked plate with that of headless compression screw for metacarpal fracture repair.A total of 14 artificial metacarpal bones (Sawbones, Vashon, WA, USA) were subjected to transverse metacarpal shaft fractures and divided into 2 groups. The first group of bones was fixed using locked plates (LP group), whereas the second group was fixed using headless compression screws (HC group). A material testing machine was used to perform cantilever bending tests, whereby maximum fracture force and stiffness were measured. The fixation methods were compared by conducting a Mann–Whitney U test.The maximum fracture force of the HC group (285.6 ± 57.3 N, median + interquartile range) was significantly higher than that of the LP group (227.8 ± 37.5 N; P < .05). The median of the HC group was 25.4% greater. However, no significant difference in stiffness (P > .05) was observed between the HC (65.2 ± 24.6 N/mm) and LP (61.7 ± 19.7 N/mm) groups.Headless compression screws exhibited greater fixability than did locked plates, particularly in its resistance to maximum fracture force.     

Treatment of Severely Displaced Radial Neck Fractures in Children With Percutaneous K-wire Leverage and Closed Intramedullary Pinning

To evaluate the efficacy and safety of percutaneous K-wire leverage (PKWL) reduction and closed intramedullary pinning (CIMP) for the treatment of pediatric radial neck fractures.From June 2010 to December 2013, a total of 50 children with Judet III and IV radial neck fractures were treated at our hospital. Manual closed reduction was first attempted to reduce the radial neck fractures. Upon successful closed reduction or the radial neck–shaft angle was reduced to <45°, radial intramedullary pinning or CIMP was performed for fixation. Unsuccessful manual reduction was corrected using percutaneous K-wire leverage and CIMP. The injured arm was fixed at the functional position using plaster for 4 to 6 weeks.Sixteen patients were treated with manual closed reduction and CIMP (group A). Percutaneous K-wire leverage and CIMP were performed for 30 patients (group B). Another 4 patients were treated with open reduction and CIMP (group C). Groups B and C showed no significant difference in the radial neck–shaft angle, fracture displacement, and angle/displace ratio (P > 0.05), but were significantly larger than group A in the radial neck–shaft angle and fracture displacement (P < 0.05). Group A and B had significantly shorter operation time than group C (58.4 ± 14.5 minutes, 55.2 ± 11.2 minutes, versus 81.4 ± 7.5 minutes, P < 0.05). Forty-five patients were followed up for a mean of 2 years. Bone union was achieved in all patients within a mean time of 4.1 months. The patients treated with manual reduction or percutaneous leverage reduction showed excellent results. Three patients, however, treated with open reduction showed 10 to 20° limitation in range of motion of the elbow. No other complications were seen.Percutaneous K-wire leverage and CIMP are safe and effective for the treatment of pediatric Judet III and IV radial neck fractures.     

Minimally invasive approach with external fixator for intra-articular calcaneal fractures in children

Calcaneal fractures are rare in pediatric population, with more displaced intra-articular fractures encountered due to the increasing number of high-energy trauma. Operative interventions are gaining popularity because of the unsatisfactory outcomes of traditional conservative methods. This study investigated the clinical outcomes of a minimally invasive technique using the sinus tarsi approach and external fixator in the treatment of intra-articular calcaneal fractures in pediatric patients.Patients who underwent open reduction between January 2010 and January 2018 at our institute were included in this study and reviewed retrospectively. Radiological and clinical parameters were all recorded and analyzed.Overall, 29 patients were included in the study, including 23 boys and 6 girls (10.2 ± 2.2 years old). The average follow-up was 29.5 months postoperatively (range, 26–72 months). Bohler angle was 15.2 ± 3.3° preoperatively, and 34.0 ± 3.8° postoperatively (P < .001); Gissane angle was 101.8 ± 6.2 degrees preoperatively, and 129.7 ± 6.2° postoperatively (P < .001). The average length of incision was 3.4 ± 0.7 cm. At the last follow-up, all patients showed satisfactory clinical outcomes and the score was 90.0 ± 2.3 according to American Orthopedic Foot and Ankle Society Scale.Minimally invasive approach with external fixator is an effective method for treating displaced intra-articular calcaneal fractures in pediatric patients, with a lower incidence of wound-related complications and good cosmetic outcomes.     

Reconstruction of large bone defect using autogenous fibular strut and iliac bone graft for revision total elbow arthroplasty

The stability and longevity of the prosthesis after revision total elbow arthroplasty (TEA) are greatly influenced by the reconstruction of bone defects around the distal humerus and proximal ulna. This study evaluated the clinical and radiological results of reconstruction of a large bone defect using an autogenous fibular strut and iliac bone graft in revision TEA.This retrospective study reviewed 10 patients who underwent revision TEA with autogenous fibular strut and iliac corticocancellous bone graft between March 2007 and May 2016. Range of motion (ROM), Visual Analog Scale (VAS), and Mayo Elbow Performance Score were used to evaluate clinical outcomes at the final follow-up. Plain radiographs were reviewed for bone union and the presence of re-loosening or for the presence of peri-prosthetic fractures.At the final follow-up, the ROMs of the elbow was 102.5° (range, 90–120°) from extension to flexion, 60.0° (range, 40–80°) in pronation, and 58.5° (range, 35–80°) in supination. The mean preoperative VAS and Mayo Elbow Performance Score were 5.1 and 46.5, and theses scores were improved to 2.6 and 79.0, at the final follow-up (P < .05). Union of the grafted bone with the distal humerus was achieved at an average of 4.5 months (range, 3–6 months). Re-osteolysis recurred in 2 cases, and additional surgery for bone grafting was performed in 1 case.Autogenous fibular strut bone grafting is an effective technique when revision TEA has large bone defects around the prosthesis resulting in a relatively stable prosthesis fixation and good union rate with a satisfactory clinical outcome after TEA revision.     

Therapeutic efficacy of arthroscopy-assisted transosseous fixation with the Versalok suture anchor for tibial eminence fractures in adults

To investigate the clinical outcomes of arthroscopy-assisted transosseous fixation of tibial eminence fractures with the Versalok suture anchor in adults.A total of 23 adult cases of tibial eminence fractures treated between June 2016 and March 2019 were retrospectively analyzed. The results of the preoperative drawer test and Lachman test were positive. Radiography and computed tomography were performed before and after the procedure. Magnetic resonance imaging was performed in every patient after admission. Arthroscopy-assisted fracture reduction and Orthocord high-strength suture fixation with two Versalok anchors were performed in all the patients. The International Knee Documentation Committee scale and the Lysholm Knee Scoring Scale were used to evaluate outcomes during the follow-up period. Additionally, the KT-2000 knee stability test was performed.At the final follow-up, all the fractures had proceeded to bony union and no wound infection was observed. The average Lysholm Knee Score of the affected knees was 93.1 (range, 90–98), which was not significantly different from that of the healthy knees (t = 0.732, P = .132). Based on the International Knee Documentation Committee scale results, 21 patients were graded as normal and the other 2 patients were graded as nearly normal. The KT-2000 test showed that the anterior displacement of the affected side and the healthy side was less than 3.6 mm in all cases.The outcomes indicated firm fixation and good fracture healing with minimal trauma. Thus, arthroscopy-assisted transosseous fixation with Versalok suture anchors for adult tibial eminence fractures seems to have satisfactory clinical outcomes.     

Treatment of Aseptic Necrosis of the Lunate Bone (Kienb?ck Disease) Using a Nickel–Titanium Memory Alloy Arthrodesis Concentrator: A Series of 24 Cases

Avascular necrosis of the lunate bone (Kienböck disease) is caused by loss of blood supply of the bone. This study aimed to evaluate the efficacy and safety of a novel nickel–titanium (Ni–Ti) memory alloy arthrodesis concentrator in the treatment of this disease.A consecutive 24 patients with stage IIIb aseptic lunate necrosis were treated with scapho-trapezio-trapezoeid (STT) arthrodesis using a Ni–Ti arthrodesis concentrator from August 2008 to December 2012. Wrist pain, grip strength, carpal height, and scapholunate angle were measured and compared before and after the surgery. The wrist functions were evaluated using the Mayo scale.Patients were followed up for a mean of 12 months (range, 6–24 months). Grip strength of the affected side was significantly improved after the surgery (18 ± 4.74 kg vs. 30.21 ± 7.14 kg, P < 0.0001). Wrist pain score was significantly decreased from 5.88 ± 0.9 to 0.5 ± 0.51 (P < 0.0001). Carpal height and Mayo score were also significantly increased after the surgery (P < 0.0001). Scapholunate angle was significantly decreased after the surgery (68.38 ± 7.28° vs. 49.91 ± 4.28°, P < 0.0001). No implant breakage, loose implant, wound infection, or nonunion occurred.STT arthrodesis is effective for the treatment of stage IIIb lunate necrosis. The Ni–Ti memory alloy arthrodesis concentrator is a convenient tool for STT arthrodesis with excellent and reliable results.     

The comparison of Nice knots and traditional methods as an auxiliary reduction-fixation technique in pre-contoured locking plate fixation for comminuted Robinson type 2B clavicle fracture: A retrospective study

Open reduction and pre-contoured locking plate fixation is a popular treatment option for displaced midshaft clavicle fracture. Lag screw and cerclage are 2 main intraoperative techniques to reduce and fix fragments. However, both lag screw and metallic cerclage have disadvantages. The doubled-suture Nice knot has been reported in many areas of orthopedic surgery for its effectiveness. This study aims to compare the outcomes of comminuted mid-shaft clavicle fractures reduced by Nice knots vs traditional techniques (lag screw or/and metallic cerclage) when bridged with pre-contoured locking plates.We retrospectively reviewed 101 patients (65 females and 36 males) diagnosed with midshaft clavicle fractures with at least one wedge fragment reduced by either Nice knots or traditional methods and bridged with pre-contoured locking plates between December 2016 and April 2019. Operation time, functional outcomes, pain, patient satisfaction, fracture healing, and complications were assessed at a follow-up of 12 to 40 months.The mean age of all the patients was 50.8 years. There were 52 and 49 patients in the Nice knot group and traditional group respectively, and no differences between 2 groups were found in general patient characteristics, fracture type, follow up and injury-to-surgery duration. The Nice knot group had significant less operation time (P < .01) than the traditional group (mean and standard deviation [SD], 78.6 ± 19.0 compared with 94.4 ± 29.9 minutes, respectively). For healing time, functional score, pain, satisfaction and complications, there were no significant differences between groups, despite the Nice knot group had slightly better results.Both Nice knots and traditional methods treated for comminuted Robinson type 2B clavicle fractures were effective and safe. And the Nice knots seemed to be superior with significant less operation time.     

Treatment of tibial plateau fractures involving the posterolateral column using the extended anterolateral approach

To summarize the surgical technique and clinical effects of the extended anterolateral approach for the treatment of Schatzker type II and Schatzker type V/VI involving the posterolateral column tibial plateau.From January 2015 through December 2018, 28 patients with tibial plateau fractures involving the posterolateral column were included in the study. Among them, 16 patients were Schatzker type II treated using an extended anterolateral approach with lateral tibial locking compression plate fixation. Twelve patients were Schatzker type V or VI treated using an extended anterolateral combined with a medial approach using lateral tibial locking compression plate plus medial locking compression plate fixation. All cases were followed up for 15 to 31 months, with an average follow-up of 22.5 ± 3.7 months. During the follow-up, the tibial plateau angle (TPA), lateral posterior angle (PA) and Rasmussen radiological criteria were used to evaluate the effect of fracture reduction and fixation; the Hospital for Special Knee Surgery score and the range of motion were used to evaluate knee function. Additionally, the Lachman and knee Valgus (Varus) stress tests were used to evaluate anteroposterior and lateral stability of the knee.All fractures healed. At the 12-month follow-up, the Schatzker type II group revealed a mean TPA of 86.38 ± 3.92°, a mean PA of 7.43 ± 2.68°, and a mean Rasmussen radiological score of 16.00 ± 2.06 points. The Schatzker type V/VI group showed a mean TPA of 84.91 ± 3.51°, a mean PA of 9.68 ± 4.01°, and a mean Rasmussen radiological score of 15.33 ± 2.99 points. During the 1-year follow-up, when the postoperative PA was re-measured, the TPA and Rasmussen score of the 2 groups did not change significantly (P > .05). At the last follow-up, the Schatzker type II group showed a knee flexion angle of 110° to 135° and a mean HHS score of 88.37 ± 10.01 points. The Schatzker type V/VI group revealed a knee flexion angle of 100° to 130° and a mean HHS score of 82.17 ± 10.76 points. Additionally, up to the last follow-up, the Lachman and knee Valgus (Varus) stress test results of the 2 groups were negative. No complications were found.The extended anterolateral approach is a good choice to treat tibial plateau fractures involving the posterolateral column.     

Minimally invasive pedicle screw fixation,including the fractured vertebra,combined with percutaneous vertebroplasty for treatment of acute thoracolumbar osteoporotic compression fracture in middle-age and elderly individuals: A prospective clinical study

To evaluate the feasibility, efficacy, and safety of minimally invasive pedicle screw (MIPS) fixation, including the fractured vertebra, combined with percutaneous vertebroplasty (PVP) for the treatment of acute thoracolumbar osteoporotic compression fracture in middle-age and elderly individuals.Between January 2016 and August 2019, a total of 30 patients, with a mean age of 69.4 years (range, 58–75 years), who experienced thoracic or lumbar fracture without neurological deficits, underwent the MIPS procedure combined with PVP. Preoperative and postoperative pain were assessed using a visual analog scale and Oswestry Disability Index. Cobb angles and anterior column height were measured on lateral radiographs before surgery and at 3 days, 1, 3, and 6 months, and 1 and 2 years at final follow-up after surgery.All patients underwent surgery successfully, with a mean follow-up of 18.2 ± 5.7 months (range, 12–45 months). Mean preoperative visual analog scale score decreased from 7.3 ± 2.2 to 1.4 ± 0.3 at the final follow-up (P < .05). Mean preoperative Oswestry Disability Index decreased from 84.2 ± 10.3 to 18.8 ± 7.5 (P < .05) at the final follow-up. The Kyphosis angle of operative segment was improved from preoperative (21.38 ± 1.68)° to (4.01 ± 1.38)° 3 days postoperatively and (5.02 ± 1.09)° at final follow-up (P < .05). The anterior vertebral height was improved from preoperative (49.86 ± 6.50)% to (94.01 ± 1.79)% 3 days postoperatively and (91.80 ± 1.88)% at final follow-up (P < .05). No significant changes in vertebral body height restoration were observed during 2 years of follow-up after surgery. In addition, there were no instrumentation failures or complications in any of the patients.MIPS, including the fractured vertebra, combined with PVP, was a reliable and safe procedure, with satisfactory clinical and radiological results for the treatment of thoracolumbar osteoporotic compression fracture in patients without neurological deficits.     

Biomechanical comparison between double-plate fixation and posterior plate fixation for comminuted olecranon fracture using two triceps screws in synthetic bone model

Background:Although preventing triceps fragment displacement is essential for treating an olecranon fracture, we frequently encounter situations in which only a few screws can be fixed to the triceps fragment. The aim of this study was to compare the stability of double-plate fixation and posterior plate fixation for olecranon fractures when the triceps fragment was small and only 2 screws could be inserted.Methods:A composite ulna model was used to simulate olecranon fracture. Four groups were formed consisting of double-plate and posterior plates with cortical and locking screws. The cyclic loading test was conducted for 500 cyclic loads of 5 to 50 N on a specimen to measure micromotion and displacement of the gap caused by light exercise. The load-to-failure test was performed by applying a load until fixation loss, defined as when the fracture gap increased by 2 mm or more or catastrophic failure occurred, to measure the maximum load.Results:Eight samples per group were tested through the pilot study. All groups were stable with a micromotion of <0.5 mm. However, the mean micromotion showed significant differences between the 4 groups (P < .001, Table ​Table1Table1 ). In the mean micromotion during exercise, posterior plating with cortical screws was the most stable (0.09 ± 0.02 mm) while double-plating with cortical screws was the most unstable (0.42 ± 0.11 mm). At the maximum load, posterior plating with locking screws was the strongest (205.3 ± 2.8 N) while double-plating with cortical screws was the weakest (143.3 ± 27.1 N). There was no significant difference in displacement after light exercise between the groups.Table 1Mean gapping and displacement in the cyclic loading test.

Clinical Characteristics and Surgical Outcomes in Patients With Intermittent Exotropia: A Large Sample Study in South China

The clinical characteristics and surgical outcomes in a large sample of patients with intermittent exotropia (IXT) as well as an analysis of risk factors associated with surgical failures are presented in this article. Data from IXT patients who received surgical management at the Eye Hospital, in the Zhongshan Ophthalmic Center, of Sun Yat-Sen University, China from January 2009 to December 2013 were reviewed retrospectively. Included within this analysis were data from pre- and postoperative ocular motility, primary alignment, and binocular vision.A total of 1228 patients with IXT were reviewed. Males (50.4%) and females (49.6%) were nearly equally represented in this sample. Thirty-two patients (2.6%) had a family history of strabismus. The mean age at onset was 6.77 ± 6.43 years (range 7 months –48.5 years), mean duration at presentation was 7.35 ± 6.68 years (range 6 months–47 years), and mean age at surgery was 13.7 ± 8.8 years (range 3–49 years). The mean refractive error was −0.84 ± 2.69 diopter in the right eye and −0.72 ± 2.58 diopter in the left eye. Amblyopia (4.2%), oblique muscle dysfunction (7.0%), and dissociated vertical deviation (4.7%) were also present in these patients. The most common subtype of IXT was the basic type (88.1%). Orthophoria was observed in 80.5% of patients and the ratios of surgical undercorrection and overcorrection were 14.7% and 4.8%, respectively, as determined with a mean follow-up time of 7.8 ± 3.7 months. When combining ocular alignment with binocular vision as the success criteria, the success rate decreased to 35.6%. Multivariate risk factor analysis showed that only the loss of stereoacuity (P = 0.002) was associated with a poor outcome. There were no differences in the long-term results between bilateral lateral rectus recession and unilateral lateral rectus recession with medial rectus resection.Most IXT patients displayed normal vision, with few having positive family histories, amblyopia, oblique muscle dysfunction, and dissociated vertical deviation. The most common subtype of IXT was the basic type. Long-term surgical results were less favorable when sensory status was included in the criteria for success. Patients with stereoacuity loss were at an increased risk for poor outcomes.     

Biomechanical Evaluation of Interfragmentary Compression At Tibia Plateau Fractures In Vitro Using Different Fixation Techniques: A CONSORT-compliant article

Reliable osteosynthesis of intraarticular fractures depends on lasting interfragmentary compression. Its amount differs in the applied fixation method. The interfragmentary compression of cancellous and cortical lag screws and angle stable locking plates was quantified in an osteoporotic and non-osteoporotic synthetic human bone model.A split fracture of the lateral tibia plateau (AO/OTA type 41-B1.1) was mimicked by an osteotomy in right adult synthetic human tibiae with hard or soft cancellous bone. Specimens were fixed with either two 6.5 mm cancellous, four 3.5 mm cortical lag screws, or 3.5 mm LCP proximal lateral tibia plate preliminary compresed by a reduction clamp (n = 5 per group). A pressure sensor film was used to register the interfragmentary compression. One-way analysis of variance (ANOVA) with Bonferroni post hoc correction was performed for statistical analysis (p < 0.05).Interfragmentary compression under reduction clamp was 0.59 ± 0.12 MPa in the non-osteoporotic and 0.55 ± 0.14 MPa in the osteoporotic group. The locking plate itself maintained the compression in non-osteoporotic (0.53 ± 0.11 MPa) and osteoporotic bone (0.50 ± 0.14 MPa). Four 3.5 mm cortical lag screws provided a compression of 1.69 ± 0.65 MPa in non-osteoporotic bone, being not significantly different to the osteoporotic bone group (1.43 ± 0.47 MPa, P = 1.0). Two 6.5 mm cancellous lag screws showed a significantly higher compression in non-osteoporotic (2.1 ± 0.59 MPa) compared to osteoporotic (0.77 ± 0.21 MPa, P < 0.01) bone.Angle stable locking plates maintained the compression preliminarily applied by a reduction clamp. Two 6.5 mm cancellous lag screws are especially suited for non-osteoporotic bone, whereas four 3.5 mm cortical screws exhibited comparable compression in both bone qualities.     

Three-Dimensional Reconstruction Modeling of the Spatial Displacement,Extent and Rotational Orientation of Undisplaced Femoral Neck Fractures

The purpose of this study was to employ a new three-dimensional (3D) reconstruction and modeling method to measure displacement of undisplaced femoral neck fractures (Garden stages I and II). We also aimed to evaluate the effectiveness of the Garden classification for determining the displacement of undisplaced femoral neck fractures.A total of 120 consecutive patients with undisplaced femoral neck fractures were enrolled between 2012 and 2014, including 60 within the Garden I group and 60 within the Garden II group. The displacements of the femoral head center (d1) and the lowest point of the fovea capitis femoris (d2) and rotational displacement of the femoral head (α) in the 3D model were measured with 3D computed tomography reconstruction and modeling. Five observers, trauma surgeons, were asked to found the centers of the femoral heads and the deepest points of the foveae. The intraobserver and inter-observer agreements were calculated using Fleiss’ kappa.The inter-observer and intra-observer kappa values were 0.937 and 0.985, respectively. Current method has good reliability. We discovered that many participants in our study had been misclassified by an anterior–posterior radiograph as having an “incomplete” fracture. In incomplete fracture of Garden stage I group, the average displacements d1 and d2 were 3.69 ± 1.77 mm and 14.51 ± 1.91 mm, respectively. The mean α was 4.91° ± 2.49°. For impacted fracture of Garden stage I, significant spatial displacement in the impacted fractures was observed (d1: 6.22 ± 3.36 mm; d2: 10.30 ± 5.73 mm; and α: 17.83° ± 10.72°). Similarly, significant spatial displacement was observed among the Garden stage II group (d1: 7.16 ± 4.58 mm; d2: 12.95 ± 8.25 mm; and α: 18.77° ± 9.10°). There was no significant difference in α, d1, and d2 between impacted fracture and Garden stage II groups (P > 0.05). However, significant differences were found between incomplete fracture and Garden stage II groups (P < 0.05).Our findings suggest that 3D reconstruction and modeling may be a better tool for assessing femoral neck fractures than the Garden classification. Undisplaced femoral neck fractures showed variable degrees of displacement and were not undisplaced, stable fractures. Garden classification for undisplaced femoral neck fractures has certain limitations.     

Vascular Dysregulation in Normal-Tension Glaucoma Is Not Affected by Structure and Function of the Microcirculation or Macrocirculation at Rest: A Case–Control Study

In normal-tension glaucoma (NTG), optic nerve damage occurs despite a normal intraocular pressure. Studies implicating systemic blood pressure or, more recently, arterial stiffness in the pathophysiology of NTG have produced conflicting results. Our aim was to investigate whether NTG is associated with alterations in the macrocirculation or microcirculation, cardiac function, and peripheral and central hemodynamics.Thirty patients with NTG (mean age 65 years, range 46–79) and 33 healthy subjects (mean age 67 years, range 42–79) matched for age and sex were included in the study. Exclusion criteria (for both cases and controls) were history of cardiovascular disease, diabetes mellitus, severe hypertension, and hypercholesterolemia. Aortic stiffness was measured using carotid–femoral pulse wave velocity (PWV), central hemodynamics using carotid artery applanation tonometry, and diameter, stiffness, and intima-media thickness (IMT) of the carotid and femoral artery using echo-tracking. Total peripheral resistance index (TPRI) was derived from mean arterial pressure and cardiac index, measured using ultrasound.There were no statistically significant differences in arterial structure nor function between NTG patients and age and sex-matched controls. NTG versus controls, respectively: brachial blood pressure 126 ± 15/77 ± 8 versus 127 ± 16/76 ± 7 mm Hg, P = 0.81; carotid–femoral PWV 9.8 ± 2.1 versus 10.1 ± 1.9 m/s, P = 0.60; TPRI 1833 ± 609 versus 1779 ± 602 dyne.s/cm⁵/m², P = 0.79; and carotid IMT 0.65 ± 0.14 versus 0.68 ± 0.13 mm, P = 0.39.This study could not show an association of NTG with altered IMT, arterial stiffness, total peripheral resistance, cardiac output, and peripheral or central hemodynamics at rest. Although the majority of these NTG patients do exhibit symptoms of vascular dysregulation, in the present study this was not translated into alterations in the microcirculation or macrocirculation at rest.     

Leukocyte Activation in Obese Patients: Effect of Bariatric Surgery

The rising prevalence of obesity is a major global health problem. In severe obesity, bariatric surgery (BS) allows to obtain a significant weight loss and comorbidities improvement, among them one of the factors is the thrombotic risk. In this observational study, we measured indices of leukocyte activation in severely obese patients as markers of increased thrombotic risk in relation with serum markers of inflammation before and after BS.Frequency of polymorphonuclear neutrophil-platelet (PLT) and monocyte (MONO)-PLT aggregates as well as of tissue factor (TF) expressing MONOs was measured in the peripheral blood of 58 consecutive obese patients and 30 healthy controls. In 31 of the 58 obese patients, data obtained at the enrollment were compared with those obtained at 3, 6, and 12 months after BS.Compared with healthy controls, obese patients showed a higher frequency of polymorphonuclear leukocyte (PMNL)-PLT aggregates (7.47 ± 2.45 [6.82–8.11]% vs 5.85 ± 1.89 [5.14–6.55]%, P = 0.001), MONO-PLT aggregates (12.31 ± 7.33 [10.38–14.24]% vs 8.14 ± 2.22 [7.31–8.97]%, P < 0.001), and TF expressing MONOs (4.01 ± 2.11 [3.45–4.56]% vs 2.64 ± 1.65 [2.02–3.25]%, P = 0.002). PMNL-PLT and MONO-PLT aggregate frequency was positively correlated with TF expressing MONOs (R² = 0.260, P = 0.049 and R² = 0.318, P = 0.015, respectively).BS was performed in 31 patients and induced a significant reduction of the body mass index, and waist and hip circumferences. These effects were associated with a significant decrease of PMNL-PLT aggregates at 12 months (7.58 ± 2.27 [6.75–8.42]% vs 4.47 ± 1.11 [3.93–5.01]%, P < 0.001), and a reduction of TF expressing MONOs at 6 (3.82 ± 2.04 [3.07–4.57]% vs 1.60 ± 1.69 [0.30–2.90]%, P = 0.008) and 12 months (3.82 ± 2.04 [3.07–4.57]% vs 1.71 ± 0.54 [1.45–1.97]%, P = 0.001) after BS.These data suggest that leukocyte-PLT aggregate formation and MONO activation represent an important mechanism underlying the increased thrombotic risk of obese patients. We also show that BS is effective in normalizing these inflammatory indices.     

Anterior Lumbar Interbody Fusion for Degenerative Discogenic Low Back Pain: Evaluation of L4–S1 Fusion

The treatment of degenerative discogenic pain is controversial, and anterior lumbar fusion for the treatment of degenerative discogenic low back pain has also been a controversial topic for over a generation.The aim of this systematic review was to evaluate the outcome of different anterior lumbar fusion levels for degenerative discogenic low back pain.In this study, we performed a clinical outcome subgroup analysis. The outcomes of 84 consecutive patients who underwent anterior lumbar interbody fusion from 2004 to 2009 were reviewed. The operative time, intraoperative blood loss, hospital stay, Oswestry Disability Index (ODI), visual analog scale (VAS) results, and complication rate were recorded separately.Medical indications were degenerative disc disease (73.8%), postdiscectomy disc disease (16.1%), and disc herniation (9.5%). Patients with severe spondylolysis or disc degeneration, with more than 3 or multilevel lesions, were excluded.The mean operative time was 124.5 ± 10.9 min (range 51–248 min), the mean intraoperative blood loss was 242.1 ± 27.7 mL (range 50–2700 mL), the mean hospital stay was 3.9 ± 1.1 days (range 3–6 days), the mean preoperative VAS score was 7.5 ± 1.4, and the mean preoperative ODI score was 60.0 ± 5.7. At the 1-year follow-up, the mean postoperative VAS score was 3.3 ± 1.3 and the mean postoperative ODI score was 13.6 ± 3.4 (P < 0.05). L4–L5 disc fusion led to better clinical results than 2-level L4–L5/L5–S1 disc fusion. Additionally, the 2-level fusion of L4–L5/L5–S1 had better clinical results than the L5–S1 disc fusion at both the 1 and 2-year postoperative follow-ups regarding the VAS score and the ODI score. The rate of complications was more frequent in the 2-level L4–L5/L5–S1 group (27.3%) (group C) than in the L4–L5 group (9.1%) (group A) and the L5–S1 group (12.5%) (group B). There was no difference between the L4–L5 group (9.1%) and the L5–S1 group (12.5%). A venous tear occurred during surgery and was successfully repaired in 6 of the 84 patients. Also, out of the 84 patients, 6 were found with pseudarthrosis during the follow-up, and these patients underwent a spinal fusion with instrumentation, with a posterior approach after a mean of 1 year. The complications secondary to the surgical approach were persistent abdominal pain (1/84, 1.2%) and wound dehiscence (1/84, 1.2%).Anterior lumbar interbody fusion for L4–L5 had better clinical results than the 2-segmental L4–L5/L5–S1 disc fusion, and the 2-segmental L4–L5/L5–S1 disc fusion had better clinical results than the L5–S1 disc fusion. Also, the 2-segmental L4–L5/L5–S1 disc fusion had a higher complication rate (27.3%), but there was no difference between the L4–L5 group (9.1%) and the L5–S1 group (12.5%).     

Management of Giant Splenic Artery Aneurysm: Comprehensive Literature Review

To provide an overview of the medical literature on giant splenic artery aneurysm (SAA).The PubMed, Medline, Google Scholar, and Google databases were searched using keywords to identify articles related to SAA. Keywords used were splenic artery aneurysm, giant splenic artery aneuryms, huge splenic artery aneurysm, splenic artery aneurysm rupture, and visceral artery aneurysm. SAAs with a diameter ≥5 cm are considered as giant and included in this study. The language of the publication was not a limitation criterion, and publications dated before January 15, 2015 were considered.The literature review included 69 papers (62 fulltext, 6 abstract, 1 nonavailable) on giant SAA. A sum of 78 patients (50 males, 28 females) involved in the study with an age range of 27–87 years (mean ± SD: 55.8 ± 14.0 years). Age range for male was 30–87 (mean ± SD: 57.5 ± 12.0 years) and for female was 27–84 (mean ± SD: 52.7 ± 16.6 years). Most frequent predisposing factors were acute or chronic pancreatitis, atherosclerosis, hypertension, and cirrhosis. Aneurysm dimensions were obtained for 77 patients with a range of 50–300 mm (mean ± SD: 97.1 ± 46.0 mm). Aneurysm dimension range for females was 50–210 mm (mean ± SD: 97.5 ± 40.2 mm) and for males was 50–300 mm (mean ± SD: 96.9 ± 48.9 mm). Intraperitoneal/retroperitoneal rupture was present in 15, among which with a lesion dimension range of 50–180 mm (mean ± SD; 100 ± 49.3 mm) which was range of 50–300 mm (mean ± SD: 96.3 ± 45.2 mm) in cases without rupture. Mortality for rupture patients was 33.3%. Other frequent complications were gastrosplenic fistula (n = 3), colosplenic fistula (n = 1), pancreatic fistula (n = 1), splenic arteriovenous fistula (n = 3), and portosplenic fistula (n = 1). Eight of the patients died in early postoperative period while 67 survived. Survival status of the remaining 3 patients is unclear. Range of follow-up period for the surviving patients varies from 3 weeks to 42 months.Either rupture or fistulization into hollow organs risk increase in compliance with aneurysm diameter. Mortality is significantly high in rupture cases. Patients with an evident risk should undergo either surgical or interventional radiological treatment without delay.     

Prediction of loss of correction after hemiepiphysiodesis for the alignment of lower limb angular deformities

Guided growth by temporary hemiepiphysiodesis (HEPD) is established for the alignment of lower limb angular deformities. This retrospective cohort study was designed to assess the effect of HEPD in idiopathic coronal plane deformities around the knee and on the frontal knee joint line orientation, and to test the frontal knee joint line as predictive means for recurrence.Fourty-four patients (78 deformities: valgus n = 64, varus n = 14) were enrolled in the retrospective observational study. Mechanical axis deviation, mechanical lateral distal femoral angle, and mechanical medial proximal tibial angle were assessed prior to surgery and during follow-up. The facultative frontal knee joint line angle (FKJLA) was used as predictive tool. Cases of remaining growth potential (n = 45/78) after implant removal were followed to assess rebound deformity.Pre-operative angles of the mechanical axis were corrected average 9.0 months after HEPD. Pre-operative assessment of the frontal knee joint line revealed a mean of 3.9° in valgus, and –1.0° in varus deformities. At time of complete deformity correction, mean FKJLA was –0.2° in valgus, and –0.8° in varus deformities. Mean shift of FKJLA was significantly higher after singleHEPD compared to combiHEPD (P < .001). Patients having an unphysiological FKJLA (>/<0°–3°) after correction of mechanical axis had a significantly higher risk of rebound deformity (P = .01). Regression analysis showed a 60.5% higher risk of rebound deformity per each degree deviating from the FKJLA physiological range. Age, gender, or body mass index had no impact.Temporary HEPD offers great potential for the correction of the mechanical axis and the frontal knee joint line. An unphysiological change of the frontal knee joint line is associated with a high risk of recurrent angular deformities. CombiHEPD instead of singleHEPD seems to be safer to prevent detrimental frontal knee joint line shift.Level of Evidence: Retrospective comparative therapeutic study, Level III.