A novel implant removal technique by endoscopy.

BACKGROUND: Routine implant removal after fracture healing remains controversial. However, it has been suggested that implant removal should be performed in cases of joint impingement, painful scar adhesion, and implant malposition. Entrance selection is relatively critical in patients with poor soft tissue conditions or sloughing coverage. We propose an innovative technique using endoscopy. METHODS: Consecutive surgeries of endoscopic implant removal performed between 2005 and 2016 by a single experienced arthroscopic surgeon were included. Overall, 73 patients were enrolled; 44 were not eligible for inclusion and were excluded from the study. RESULTS: Twenty-nine patients, including 32 surgical sites, were included. Twenty-four plates and 166 screws were removed using this technique. There were five complications during the follow-up period (range, 0.5 to 104 months; mean, 8.8), including one broken screw, one persistent knee joint contracture, and three wound dehiscence. There were no infections or neurovascular injuries. CONCLUSION: Implant removal using endoscopy is a minimally invasive surgery that ensures that the screw axis does not strip, and treats the intra-articular pathology concomitantly. This innovative technique may be considered as an alternative to the traditional open method in cases with good surgical indications.

Is additional balloon Kyphoplasty safe and effective for acute thoracolumbar burst fracture?

BACKGROUND: Burst fracture is a common thoracolumbar injury that is treated using posterior pedicle instrumentation and fusion combined with transpedicular intracorporeal grafting after reduction. In this study, we compared the outcome of these two techniques by using radiologic imaging and functional outcome. METHODS: Sixty-one patients with acute thoracolumbar burst fracture were operated with kyphoplasty (n = 31) or vertebroplasty (n = 30) and retrospectively reviewed in our institution between 2011 and 2014. All 61 patients underwent surgery within 5 days after admission to the hospital and then followed-up for 12 to 24 months after surgery. RESULTS: Significant improvement was found in the anterior vertebral height (92 ± 8.9% in the kyphoplasty group, 85.6 ± 7.2% in the vertebroplasty group, p < 0.01) at 1 month post-operatively and (89 ± 7.9% in the kyphoplasty group, 78 ± 6.9% in the vertebroplasty group, p < 0.01) at the 24-month follow-up. Significant improvement was also observed in the kyphotic angle (1.2 ± 0.5° in the kyphoplasty group, 10.5 ± 1.2° in the vertebroplasty group, p < 0.01) at 1 month post-operatively and (5.4 ± 1.2° in the kyphoplasty group, 11.5 ± 8.5° in the vertebroplasty group, p < 0.01) at the 24-month follow-up. Both operations led to significant improvement of the patients' pain and the Oswestry disability index (p < 0.01). Cement leakage was noted in 29% of patients after kyphoplasty and 77% of patients after vertebroplasty (p < 0.01). Only one implant failure (3.3%), which required further surgical intervention, was reported in the vertebroplasty group. CONCLUSIONS: Reduction with additional balloon at the fractured site is better than indirect reduction only by posterior instrumentation. The better reduction of kyphotic angle and the lower cement leakage rate in the kyphoplasty group indicate that additional balloon kyphoplasty is safe and effective for acute thoracolumbar burst fracture.

Surgical treatment of syndesmotic diastasis: emphasis on effect of syndesmotic screw on ankle function.

Fifty-two consecutive adult patients with syndesmotic diastasis (SD) were treated with closed anatomical reduction and stable fixation by a trans-syndesmotic cancellous screw. A short leg splint was prescribed for a six week postoperative period. Treatment outcomes of syndesmotic screw removal at various time points were studied and compared (group 1 at six weeks, group 2 at three months and group 3 at an average of nine months). Recurrence of SD, incidence of syndesmotic screw breakage and ankle function were compared among the three groups. Recurrence of SD occurred in 15.8% (3/19) of patients in group 1, 15.0% (3/20) in group 2 and 0% (0/13) in group 3 (p = 0.054). Breakage of the syndesmotic screw occurred in three patients within three months (group 2, 15.0%) and in two patients beyond three months (group 3, each at six and 12 months, 15.4%). None of the group 1 patients experienced screw breakage (p = 0.034). Forty-three patients (82.7%) were classified as having satisfactory outcomes. Ankle function did not significantly differ among the three groups (p = 0.191), with or without syndesmotic screw breakage (p = 0.343) and with or without SD recurrence (p = 0.218). In conclusion, restriction of daily activity for at least three months is required to prevent recurrence. Removal of the syndesmotic screw at six weeks may prevent its breakage but increases the risk of recurrence. Over an average follow-up of 19 months, SD recurrence does not lead to deterioration in ankle function.

Tension band wiring for olecranon fractures: relative stability of Kirschner wires in various configurations.

BACKGROUND: To assess clinical and functional outcomes as well as the relative stability of various configurations of tension band wiring approaches for treating olecranon fractures, a retrospective cohort study was conducted. METHODS: Seventy-seven consecutive adult patients with 78 olecranon fractures were treated using tension band wiring techniques in three different configurations. The configurations differed in the location of the ends of Kirschner wires with the following locations being used: in the proximal ulnar canal, through the anterior ulnar cortex, and in the distal ulnar canal. RESULTS: Based on average follow-up of 2.76 years (range, 1.1-5.5 years), all three techniques achieved high union rates and low complication rates. However, the Kirschner wires in the first technique allowed proximal pin migration with elbow irritation as compared with the second and the third techniques (p = 0.001, 0.03, respectively). CONCLUSIONS: Placement of the ends of Kirschner wires in the proximal ulnar canal should be avoided whenever possible. Because placement of the ends of Kirschner wires through the anterior ulnar cortex may produce serious complications as reported in medical literature, placement of the ends of Kirschner wires in the distal ulnar canal may be the most effective approach.

Exchange nailing for aseptic tibial shaft nonunion: emphasis on the influence of a concomitant fibulotomy.

BACKGROUND: Exchange nailing is reported to have a high success rate for aseptic tibial nonunions. However, sample sizes in all series in the literature were small, and the influence of a concomitant fibulotomy was not evaluated. METHODS: Fifty-four aseptic tibial shaft nonunions for 1.2 approximately 4.3 (mean, 2.4) years were treated with exchange nailing. Indications for this technique included an aseptic nonunion of the tibial shaft with an inserted intramedullary nail and < 2 cm of shortening. A fibulotomy was performed in a nonunion with poor shaft alignment, which concomitantly required manipulation to correct. The success rate of exchange nailing was determined, and whether a concomitant fibulotomy affected the success rate was evaluated. RESULTS: Forty-seven nonunions were followed-up for 1.1 approximately 6.9 (mean, 3.8) years, and all nonunions healed. The union rate was 100% (47/47), and the average period required to achieve union was 4.7 (3.0 approximately 7.5) months. The average union periods between the fibulotomy and non-fibulotomy groups did not statistically differ (4.6 vs. 4.8 months, p = 0.61). There were no significant complications in either group. CONCLUSIONS: Exchange nailing is an excellent technique to treat aseptic nonunions of the tibia. It can be considered the treatment of choice for all indicated cases. A concomitant fibulotomy has minimal influence on the success rate. It can be performed when the shaft alignment needs correction.

Surgical treatment of acute complete acromioclavicular dislocation: comparison of coracoclavicular screw fixation supplemented with tension band wiring or ligament transfer.

BACKGROUND: Treatment of acute complete acromioclavicular (AC) dislocation is still controversial. Both non-surgical and surgical methods have been reported with similar results. In addition, once surgical treatment is chosen, a satisfactory surgical technique has not been developed yet. METHODS: Sixty consecutive patients who sustained 60 acute complete AC dislocations were treated using coracoclavicular (CC) screw fixation supplemented with tension band wiring for the AC joint (n = 30) or coracoacromial (CA) ligament reconstruction (n = 30), respectively. The operating times, functional outcomes, and complications were compared. RESULTS: Twenty-nine patients with tension band wiring (group 1) and 27 patients with CA ligament reconstruction (group 2) were followed-up for 12-47 (mean, 23.6) months. The operating time was 34-57 (mean, 46.3) minutes in group 1 verse 52-93 (mean, 83.4) minutes in group 2 (p < 0.001). The percentage of satisfactory outcomes was 86.2% in group 1 verse 88.9% in group 2 (p = 0.30). Loss of reduction of the AC joint was 13.8 % (4/29) in group 1 verse 3.7% in group 2 (1/27, p = 0.17). Patients who received tension band wiring treatment had a higher rate of unsatisfactory outcomes when loss of reduction of the AC joint occurred (p = 0.01). CONCLUSIONS: Once surgical methods are chosen in patients with acute complete AC dislocation, CC screw fixation supplemented with tension band wiring for the AC joint or CA ligament reconstruction achieved similar satisfactory rates. However, patients who received the former had relatively shorter operating times.

Ipsilateral femoral neck and shaft fractures treated with Russell-Taylor reconstruction intramedullary nails.

BACKGROUND: Ipsilateral femoral neck and shaft fractures are rare injuries and the treatment is complicated and versatile. No single device has been considered absolutely superior to others. METHODS: Fifteen combined fractures in 15 patients were treated with Russell-Taylor reconstruction intramedullary nails (recon nails). Twelve surgeries were performed within 24 hours of trauma and the other 3 were delayed for 4-7 days due to associated life-threatening injuries. Postoperatively, protected weight bearing was permitted as early as possible. RESULTS: The median operating time was 250 minutes (range 125-430 min) and median blood loss was 300 ml (range 100-600 ml). Thirteen patients were followed-up for a median of 22 months (range 13-45 months). The union rates for neck and shaft fractures were 84.6% and 69.2% respectively. The median union times were 3.0 months for neck fractures and 8.5 months for shaft fractures. CONCLUSIONS: Recon nails are alternative acceptable devices to treat combined fractures. However, the stability of neck fixation may be insufficient and restriction of vigorous activity is suggested to avoid fixation failure.