Predisposing factors for chronic syndesmotic instability following syndesmotic fixation in ankle fracture: Minimum 5-year follow-up outcomes

BackgroundThis study aimed to identify risk factors for chronic syndesmotic instability following syndesmotic fixation.MethodsWe performed a retrospective review of consecutive patients who had sustained ankle fractures requiring syndesmotic fixation. Patients available for a minimum 5 years of follow-up were classified into 2 groups according to the presence of syndesmotic instability. Statistical binary logistic regression analyses were performed to investigate the significance of various risk factors. Functional outcomes were assessed using the FAOS.ResultsIn total, 166 patients who met the study inclusion criteria underwent analysis. The overall postoperative instability rate was 20.5%, which was significantly affected due to BMI (p = 0.018; OR 6.72), and concomitant posterior malleolar fracture (p = 0.032, OR 2.77). The mean scores in the syndesmotic instability (SI) group were significantly lower than those in the no syndesmotic instability (NSI) group (p = 0.021).ConclusionsObesity and concomitant posterior malleolar fracture were significant risk factors for postoperative syndesmotic instability.     

Bony Protuberances on the Anterior and Posterior Clinoid Processes Lead to Traumatic Internal Carotid Artery Aneurysm Following Craniofacial Injury

Traumatic intracranial aneurysms are rare, comprising 1% or less of all cerebral aneurysms. The majority of these aneurysms arise at the skull base or in the distal anterior and middle cerebral arteries or their branches following direct mural injury or acceleration-induced shearing force. We present a 50-year-old patient in whom subarachnoid hemorrhage (SAH) was developed as a result of traumatic aneurysm rupture after a closed craniofacial injury. Through careful evaluation of the three-dimensional computed tomography and conventional angiographies, the possible mechanism of the traumatic internal carotid artery trunk aneurysm is correlated with a hit injury by the bony protuberances on the anterior and posterior clinoid processes. This traumatic aneurysm was successfully obliterated with clipping and wrapping technique. The possibility of a traumatic intracranial aneurysm should be considered when patient with SAH demonstrates bony protuberances on the clinoid process as a traumatic aneurysm may result from mechanical injury by the sharp bony edges.     

Unexpected Seizure Attack in a Patient with Spinal Metastasis Diagnosed as Posterior Reversible Encephalopathy Syndrome

Seizure is a foreseeable risk in patients with brain lesion. However, seizure during treating non-brain lesion is not a familiar situation to neurosurgeon. Posterior reversible encephalopathy syndrome (PRES) is a relatively common situation after systemic chemotherapy. The aim of this study is to make neurosurgeons aware of this potential medical problem. A 52-year-old woman with advanced gastric cancer, presented with low back pain due to spinal metastasis at the 4th lumbar vertebra. Ten cycles of chemotherapy with FOLFOX (5-Fluoruracil/Oxaliplatin) had been completed 23 days ago. Two days before the planned operation, a generalized tonic clonic seizure occurred. She did not have a history of hypertension or seizure. The seizure was stopped with lorazepam 4mg. The brain magnetic resonance (MR) imaging showed high signal changes in both parieto-occipital lobes on the T2-weighted images, and these were partially enhanced, suggesting PRES. The surgery was preceded by treatment with an antiepileptic drug. The MR images, taken 1.5 months after the seizure, showed that the lesion was no longer present. At 3 month follow-up, no additional seizure attack occurred without any seizure medication. The possibility of a seizure attack should be considered if the patient has a history of chemotherapy.     

Evaluation of a CT-based technique to measure the transfer accuracy of a virtually planned osteotomy

Accurate transfer of a preoperatively planned osteotomy plane to the bone is of significance for corrective surgery, tumor resection, implant positioning and evaluation of new osteotomy techniques. Methods for comparing a preoperatively planned osteotomy plane with a surgical cut exist but the accuracy of these techniques are either limited or unknown. This paper proposes and evaluates a CT-based technique that enables comparing virtual with actual osteotomy planes. The methodological accuracy and reproducibility of the technique is evaluated using CT-derived volume data of a cadaver limb, which serves to plan TKA osteotomies in 3-D space and to simulate perfect osteotomies not hampered by surgical errors. The methodological variability of the technique is further investigated with repeated CT scans after actual osteotomy surgery of the same cadaver specimen. Plane displacement (d_err) and angulation errors in the sagittal and coronal plane (β_err, γ_err) are measured with high accuracy and reproducibility (d_err = −0.11 ± 0.06 mm; β_err = 0.08 ± 0.04°, γ_err = −0.03 ± 0.03°). The proposed method for evaluating an osteotomy plane position and orientation has a high intrinsic accuracy and reproducibility. The method can be of great value for measuring the transfer accuracy of new techniques for positioning and orienting a surgical cut in 3-D space.     

Anatomic structures at risk in anteroposterior screw fixation of posterior malleolar fractures: A cadaver study

IntroductionPercutaneous anterior-posterior (AP) screw is an option for posterior malleolus fracture fixation when the fracture fragment can be reduced indirectly by the mean of ligamentotaxis. However, anterior anatomic structures could be injured during screw placement.Materials and methodsEleven below-knee cadavers were employed for the placement of AP screws in an attempt of fixing assumed Haraguchi Type-I posterior malleolar fractures. Three entry points were selected as medial to the anterior tibial tendon (ATT), lateral to the ATT, and lateral to the extensor digitorum longus (EDL). Three AP screws were placed under guidance of fluoroscopy. After dissection, measurements were made (mm) from each screw to nearby structures. Distances were calculated and damage to structures was documented.ResultsMean, minimum, and maximum distances from the medial screw to the greater saphenous vein, TA, EHL, anterior tibial artery (ATA), and deep peroneal nerve (DPN), were 18.1 (12–25) mm, 2.0 (0–5) mm, 13.6 (9–20) mm, 16.6 (9–25) mm, and 20.1 (12–27) mm. From the middle screw to the ATA, DPN, TA, EHL, and EDL, were 1.2 (0–3) mm, 4.9 (3–9) mm, 3.8 (1–7) mm, 0.4 (0–2) mm, and 13.6 (10–18) mm. From the lateral screw to the superficial peroneal nerve (SPN), EDL, DPN, and ATA, were 10.8 (0–16) mm, 1.2 (0–4) mm, 15.9 (11–25) mm, 19 (15–27) mm. The SPN was found partially cut by the lateral screw on 1 specimen.ConclusionsLateral and middle percutaneous AP screw placement put certain anatomic structures at-risk of injury. Medial screw placement did not result in appreciable damage to adjacent structures. Entry point of AP screws should be selected with respect to posterior malleolar fracture and anatomic structures.Level of evidenceIV.     

Approach and treatment of the adult acquired flatfoot deformity

Adult acquired flatfoot deformity (AAFD), embraces a wide spectrum of deformities. AAFD is a complex pathology consisting both of posterior tibial tendon insufficiency and failure of the capsular and ligamentous structures of the foot. Each patient presents with characteristic deformities across the involved joints, requiring individualized treatment. Early stages may respond well to aggressive conservative management, yet more severe AAFD necessitates prompt surgical therapy to halt the progression of the disease to stages requiring more complex procedures. We present the most current diagnostic and therapeutic approaches to AAFD, based on the most pertinent literature and our own experience and investigations.     

Evaluation of titanium release from titanium alloy implants in patients with spinal instrumentation

ObjectiveThis study was performed to investigate the baseline serum titanium levels in patients with short-segment titanium alloy posterior instrumentation and to assess patient-, implant-, and surgery-related factors that might affect the serum titanium level.MethodTwo groups of patients were included in the study. The study group comprised 39 patients who had undergone short-segment posterior instrumentation from January 2013 to June 2016. The control group comprised 11 randomly selected patients who presented to the outpatient clinic with no history of orthopedic surgery. The serum titanium levels and inter-group differences were analyzed.ResultsThe mean serum titanium level was significantly higher in the study group than in the control group. No significant difference was observed between patients with different etiologies, implants used for fusion, numbers of instrumented segments, or postoperative durations.ConclusionThe serum titanium levels of patients with posterior lumbar spinal instrumentation are significantly higher than those of the normal population even after achievement of solid fusion. These levels are not affected by the use of transverse connectors, the use of cages, the operated segments, or the duration of implants.