A Sternum-Disk Distance Method to Identify the Skin Level for Approaching a Surgical Segment without Fluoroscopy Guidance during Anterior Cervical Discectomy And Fusion

STUDY DESIGN: A retrospective review of prospectively collected data. PURPOSE: To introduce the sternum-disk distance (SDD) method for approaching the exact surgical level without C-arm guidance during anterior cervical discectomy and fusion (ACDF) surgery and to evaluate its accuracy and reliability. OVERVIEW OF LITERATURE: Although spine surgeons have tried to optimize methods for identifying the skin level for accessing the operative disk level without C-arm guidance during ACDF, success has rarely been reported. METHODS: In total, 103 patients who underwent single-level ACDF surgery with the SDD method were enrolled. The primary outcome measure was the accuracy of the SDD method. The secondary outcome measures were the mean SDD value at each cervical level from the cranial margin of the sternum in the neutral and extension positions of the cervical spine and the inter- and intra-observer reliability of the SDD outcome determined using repeated measurements by three orthopedic spine surgeons. RESULTS: The SDD accuracy (primary outcome measure) was indicated in 99% of the patients (102/103). The mean SDD values in the neutral-position magnetic resonance imaging (MRI) were 108.8 mm at C3–C4, 85.3 mm at C4–C5, 64.4 mm at C5–C6, 44.3 mm at C6–C7, and 24.1 mm at C7–T1; and those in the extension-position MRI were 112.9 mm at C3–C4, 88.7 mm at C4–C5, 67.3 mm at C5–C6, 46.5 mm at C6–C7, and 24.3 mm at C7–T1. The Cohen kappa coefficient value for intra-observer reliability was 0.88 (excellent reliability), and the Fleiss kappa coefficient value for inter-observer reliability as reported by three surgeons was 0.89 (excellent reliability). CONCLUSIONS: Based on the results of the present study, we recommend performing ACDF surgery using the SDD method to determine the skin level for approaching the surgical cervical segment without fluoroscopic guidance.

Feasibility Study of Free-Hand Technique for Pedicle Screw Insertion at C7 without Fluoroscopy-Guidance

STUDY DESIGN: Retrospective interventional study. PURPOSE: To introduce a free-hand pedicle screw (PS) insertion technique without fluoroscopic guidance in the C7 vertebra and evaluate the procedure's feasibility and radiologic outcomes. OVERVIEW OF LITERATURE: Although PS insertion at C7 has been recognized as a critical procedure in posterior cervical fusion surgery, conventional techniques for C7 PS have several limitations. METHODS: Thirty two patients (64 screws) who underwent PS insertion in C7 with the novel technique were included in this study. Postoperative clinical and radiological outcomes were evaluated. Special attention was paid to the presence of any problems in the screw position including cortical breaches of the PS and encroachment of the PS into the spinal canal or the vertebral foramen. This novel technique for PS insertion in C7 without fluoroscopy guidance had three key elements. First, the ideal PS entry point was chosen near the C6-7 facet joint using preoperative images. Second, the convergent angle distance was measured at axial computed tomography (CT) imaging, which defined the distance between the tip of C7 spinous process and the extended line passing through the pedicle axis from the ideal entry point. Third, the cranial-caudal angle distance was measured in sagittal CT images, which defined the distance between the tip of the C7 spinous process and the extended line passing through the pedicle axis. RESULTS: Cortical breach on postoperative CT images was observed in three screws. All violated only the lateral wall of the affected pedicle. The breached screws occurred in the initial five cases. Postoperative neurologic deterioration was not observed in any patient, regardless of cortical breaching. CONCLUSIONS: The novel technique successfully allows for C7 PS to be placed and is associated with a low rate of cortical breach.

Repair Using Conventional Implant for Ruptured Annulus Fibrosus after Lumbar Discectomy: Surgical Technique and Case Series

STUDY DESIGN: A retrospective review of annulus fibrosus repair (AR) using a novel technique with a conventional implant. PURPOSE: The purpose of this study was to present the feasibility and clinico-radiological outcomes of a novel AR technique using a conventional implant to minimize recurrence following a lumbar discectomy (LD). OVERVIEW OF LITERATURE: Conventional repair techniques to prevent recurrence following LD have several drawbacks. The AR surgical technique has received little attention as an adjunct to LD. METHODS: A total of 19 patients who underwent novel AR following LD, and who were available for follow-up for at least three years, were enrolled in this study. Several variables, including the type and size of disc herniation, and the degree of disc degeneration, were evaluated preoperatively. Postoperatively, the presence of clinical and radiological recurrence of disc herniation was evaluated from pain intensity and functional statuses, as well as an enhanced L-spine magnetic resonance imaging at the final follow-up. The presence of a peripheral hollow rim and inserted anchor mobilization were also evaluated during the follow-up. RESULTS: During follow-ups, there were no recurrences of disc herniation or complications, including neurovascular complications. Pain and functional disability improved significantly after surgery, and the improvement was maintained throughout the three-year follow-up period. No mobilization or implant peripheral hollow rim was observed during the follow-up. CONCLUSIONS: This study examined the feasibility of a novel and easily available annulus implant technique following LD. These results suggest performing AR with this technique may be a valuable alternative for optimizing outcomes, if the procedure is performed in proper candidates.

Arthroscopic Resection of Volar Ganglion of the Wrist Joint

PURPOSE: To evaluate the results of arthroscopic resection of volar ganglion of the wrist. MATERIALS AND METHODS: Nine patients who had arthroscopic resection of volar ganglion of wrist were evaluated. Using 3-4 poral as a viewing portal, volar ganglion was debrided through the radioscaphocapitate (RSC) ligament and long radiolunate (LRL) ligament using a resector inserted from the 1-2 or 4-5 portal. We evaluated the incidence of relapse, the time to postoperative disappearance of pain, surgical complications, and intra-articular derangements. RESULTS: Eight patients had synovitis around radial styloid process. Three patients had capsular tear between RSC ligament and LRL ligament. There was no relapse at an average follow-up of 15 months. The pain felt during daily activities subsided at 2.5 months after operation in 9 patients. One patient had partial injury of the median nerve causing persistent paresthesia. All were satisfied for the postoperative scars. CONCLUSION: Arthroscopic resection is a reliable option with good cosmetic results for the treatment of volar ganglion of the wrist.

Management of the Posttraumatic Neuralgia of the Peripheral Nerve by External Neurolysis

PURPOSE: To evaluate the results of the external neurolysis of the scarred peripheral nerves present with the posttraumatic neuralgia refractory to the conservative treatment for at least 6 months with or without vein wrapping and/or free fat graft to prevent scar reformation. MATERIALS AND METHODS: In 8 patients with posttraumatic neuralgia of the peripheral nerve unresponsive to conservative treatment for at least 6 months, only neurolysis was done in 6 cases. Vein wrapping with free fat graft was concomitantly added after neurolysis in one case and free fat graft was added in the other case. The inclusion criteria were neuralgia felt anatomically along the affected nerve, positive Tinel sign at the scarred site and aggravation of pain with passive motion of the adjacent joint. Affected were digital nerves (two cases), ulnar nerve at the wrist (one case), median nerve (one case), peroneal nerve around knee (one case), posterior tibial nerves (two cases) and plantar nerve (one case). Patients were assessed for the disappearance of neuralgia and Tinel sign and subjective satisfaction with VAS (no pain, 0 and no change or aggravated, 10 compared to contra-lateral side) RESULT: Neuralgia was absent in four cases and persisted in four cases. Average VAS was 5.8 (0~10). According to the degree of the scarred surroungings, neuralgia was persisted after only neurolysis in four cases of the severely scarred 5 cases, but in one case having free fat graft added, neuralgia was absent. In partially scarred two cases, neurolysis with or without additional procedures (free fat graft and vein wrapping) brought the same result of VAS. In one case of good surroundings, neuralgia was absent after neurolysis. Tinel sign was absent in 4 cases where neuralgia had disappeared. CONCLUSION: Prevention of re-adhesion after neurolysis seems to be very important to yield good results. Vein wrapping and/or free fat grafting may be effective methods to be applicable if the adjacent tissue looks scarred

Improvement of the Elbow Function with Early Mobilization and Rigid Fixation of Coronoid Fracture by Tension Band Technique

PURPOSE: We wanted to evaluate the surgical results of early mobilization after rigid fixation of small coronoid fracture using the tension band technique MATERIALS AND METHODS: Eight cases of coronoid fracture were fixed with the tension band technique and using K-wire and wire through the medial approach. All the cases were Regan-Morrey type 2. According to O'Driscoll, they were classified as 5 cases of the tip type (subtype 2) and 3 cases of the anteromedial type (1 case of subtype 2, and 2 case of subtype 3). The associated collateral ligament injuries (6 cases) and radial head/neck fractures (4 cases) were managed simultaneously. After immobilization for 5~7 days, active ROM exercise with a fitted hinge brace started and continued till postoperative 6 weeks. The patients were assessed for pain, ROM and functional disability using the Mayo elbow performance score (MEPS) at an average of 11 months (range: 6~28 months). The ulnar nerve symptoms were also investigated. RESULTS: We observed solid union in all the coronoid fractures without hardware failure. An average of 2.2 wires (range: 2~4) were used. The mean extension was 3degrees (range: 0degrees~25degrees), the mean flexion was 137degrees (range: 130degrees~140degrees), the mean pronation was 69degrees (range: 45degrees~90degrees) and the mean supination was 78degrees (range: 45degrees~90degrees). The mean MEPS was 96 (range: 65~100). Ulnar nerve symptoms occurred at postoperative one day and persisted in one patient with the terrible triad of taking radial head excision and residual medial instability. CONCLUSION: The tension band technique uses easily obtained, economic K-wires and the wire was strong enough to permit early elbow ROM exercise and the technique might improve the elbow function. It was especially useful for fixation of multiple small fragments.

Management of the Comminuted Fractures of the Ulnar Head and Neck Combined with Distal Radius Fractures by Darrach Procedure and Tenodesis of Extensor Carpi Ulnaris

PURPOSE: To evaluate the surgical results of distal radioulnar fractures managed by open reduction and internal fixation for the fractures of the distal radius and excision of the fractured fragments and ECU tenodesis for the comminuted fractures of ulnar head and neck. METHODS: Six cases of combined fractures of the distal radius and ulna were enrolled. Distal radius fractures were fixed by ORIF with AO locking plate without bone graft. The comminuted fragments of distal ulnar head and neck were excised and the tenodesis using half strip of ECU was added to stabilize the proximal ulnar stumps. After immobilization for 6 weeks, active ROM exercise started. The change of radial inclination and volar tilt, the ulnar shift and collapse of carpal bone and ulnar impingement were investigated with simple X-ray. Patients were assessed with residual subjective symptoms and modified Mayo wrist score (MMWS). All were female and average age was 68(58~75) years. Average follow up was 23(10~50) months. RESULTS: Resting pain was absent in all patients but heavy lift made them feel weakness and discomfort intermittently. All patients returned to the normal daily activities except one patient handicapped by hemiplegia. The average range of motion and grip power was 89% and 85% compared to the contralateral side respectively. The average MMWS was 87(75~95). The postoperative loss of the reduction of the distal radius was not observed in follow up X-ray. CONCLUSION: ORIF of distal radius fractures associated with the excision of the distal ulnar fragments and stabilization procedure using half strip of ECU may be one good method for the treatment of the fractures of the distal radius combined with the comminuted distal ulnar fractures difficult to be managed by ORIF. The intermittent weakness felt in this method made it not suitable in young active patient doing heavy work. AO locking plate was strong enough to maintain reduction until bone union.

Surgical Treatment of the Fracture of the Scapular Body

PURPOSE: We wanted to evaluate the results of surgical treatment for fracture of the scapular body MATERIALS AND METHODS: The subjects of this study were seven patients with fracture of the scapular body and all these patients were managed surgically. We considered the operative indications as being 100% translation of the lateral border, or 25 degrees of angular deformity of the glenoid, or 1cm medialization or the variant of the double disruption of the superior scapular suspensory complex. There were five males and two females, and their ages ranged between 40 and 58 years (mean age: 49) with average follow up of 11 months (6~24 months). Two patients sustained multiple fractures of the ribs and spines. The surgical results were evaluated according to the subjective satisfaction, the UCLA score and the Korean shoulder score. RESULTS: The mean UCLA score was 29 (17~33) and the mean Korean shoulder score was 86 (63~94). The self assessment for subjective satisfaction was 7.7 (4~9). There were two complications; one case of screw pull-out without the loss of the fracture fixation and the other case with screw penetration of the glenoid cavity. CONCLUSION: Surgical treatment may be effective for the management of severely displaced fracture of the scapular body in order to prevent the impairment of the shoulder function caused by the altered glenohumeral and scapulothoracic kinematics.