Management of urosymphyseal fistula and pubic bone osteomyelitis: Description of a new surgical technique by cystectomy, urinary diversion and pelvic filling flap by unilateral pedicled myocutaneous vertical rectus abdominus muscle flap.

Pubic bone osteomyelitis is a rare infection, mostly related to urinary fistula. The published data about the medical or surgical management of this type of infection is relatively poor. In this case study of three patients, we describe our surgical technique for the management of urosymphyseal fistula complicated with pubic bone infection using pelvic filling flap by unilateral pedicled myocutaneous vertical rectus abdominus muscle flap. The first patient had the pelvic space filled with omentum flap. Unfortunately, the patient presented, postoperatively, an enteric fistula resulting from intestine incarceration on the resected bone. Considering this failure, the next two cases, have benefited from a Taylor flap to protect the peritoneal cavity by covering the residual pubic bone. Early complications were pyelonephritis and anemia (Clavien-Dindo 2), but no repeat surgery was required afterwards. The hospital stay for both cases were 26- and 12-days contrary to the first case who was hospitalized for 180-days. In conclusion, despite our limited experience in managing complicated urosymphyseal fistula, Taylor's flap, mainly used for gynecological or rectal surgery, might be a good reproducible solution for the surgical management of this kind of fistula with pubic debridement. It allows to protect the peritoneal cavity with fewer postoperative complications.

Percutaneous balloon calcaneoplasty versus open reduction and internal fixation (ORIF) for intraarticular SANDERS 2B calcaneal fracture: Comparison of primary stability using a finite element method.

INTRODUCTION: Fractures of the calcaneus are common, with 65% being intra-articular, which can lead to a major impairment of the patient's quality of life. Open reduction and internal fixation with locking plates can be considered as gold-standard technique but has a high rate of post-operative complications. Minimally invasive calcaneoplasty combined with minimally invasive screw osteosynthesis is largely drawn from the management of depressed lumbar or tibial plateau fractures. The hypothesis of this study is that calcaneoplasty associated with minimally invasive percutaneous screw osteosynthesis presents biomechanical characteristics comparable with conventional osteosynthesis. MATERIALS AND METHODS: Eight hind feet were collected. A SANDERS 2B fracture was reproduced on each specimen, while four calcanei were reduced by a balloon calcaneoplasty method and fixed with a lateral screw, four others were manually reduced and fixed with conventional osteosynthesis. Each calcaneus was then segmented for 3D finite element modeling. A vertical load was applied to the joint surface in order to measure the displacement fields and the stress distribution according to the type of osteosynthesis. RESULTS: Analyses of the intra-articular displacement fields showed lower overall displacements in calcaneal joints treated with calcaneoplasty and lateral screw fixation. Better stress distribution was found in the calcaneoplasty group with lower equivalent joint stresses. These results could be explained by the role of the PMMA cement as a strut, enabling better load transfer. CONCLUSION: Balloon Calcaneoplasty combined with lateral screw osteosynthesis has biomechanical characteristics at least comparable to locking plate fixation in the treatment of SANDERS 2B calcaneal joint fractures in terms of displacement fields and stress distribution under the premise of anatomical reduction.

Stand-alone kyphoplasty in recent thoracolumbar split fractures: A series of 36 patients reviewed at 19months.

INTRODUCTION: Spinal fractures with a split component present specific bone union problems (pseudarthrosis). The purpose of this study was to assess the rate of pseudarthrosis after stand-alone percutaneous kyphoplasties and analyze clinical and radiographic parameters that are predictive of its efficacy in thoracolumbar spine fractures with a split-type of injury. HYPOTHESIS: Stand-alone kyphoplasty results in satisfactory bone union of the treated vertebral body despite the diastasis of fracture fragments. MATERIALS AND METHODS: A retrospective single-center study of 36 patients with posttraumatic monosegmental thoracolumbar vertebral fractures, that were classified as either Magerl A2 or A3.2, without any neurologic deficits. Patients were treated with percutaneous kyphoplasty and PMMA bone cement. The assessment included both clinical (visual analog pain scale [VAS] and Oswestry disability index) and radiographic (pseudarthrosis, fracture gap, disk incarceration, vertebral height and length, and vertebral and regional kyphosis) criteria. RESULTS: A total of 36 patients (mean age 58years) were included, with a mean follow-up of 19.1months. Five of these patients (14%) had a pseudarthrosis. The fracture gap was significantly greater in these patients than in those who had bone union preoperatively (+3.94 mm, p<0.001) and at the last follow-up consultation (+9.3 mm, p<0.001). There was an association between the incarceration of adjacent disks located above (p=0.008) and below (p=0.003) the fracture site and the pseudarthrosis. The mean VAS decreased significantly on the first postoperative day (p<0.001) and remained lower than the initial assessment until the last follow-up (p<0.001). DISCUSSION: Stabilization by stand-alone kyphoplasty produces good clinical and radiographic results for split fractures, provided that the extent of the fragment diastasis has been carefully assessed preoperatively to prevent the risk of pseudarthrosis. LEVEL OF EVIDENCE: IV; retrospective.

Assessment of the impact of pharmacist-led intervention with antibiotics in patients with bone and joint infection.

OBJECTIVES: The management of patients with bone and joint infections (BJIs) is complex. To improve this care, we carried out pharmaceutical actions in the orthopedic unit, including pharmacist-led-intervention (PLI) for patients requiring prolonged antibiotics. Few data exist regarding patient compliance, adherence and knowledge in cases of BJI. Data on hospital readmission are likewise limited, even though it is considered as a major determinant of clinical impact. The aim of this study was to assess the effectiveness of PLI regarding six-month readmissions. PATIENTS AND METHODS: Patients were assigned to two groups, both receiving standardized care. Two periods were compared: control group (CG) without PLI and interventional group (IG) with PLI throughout. The analysis was based on patient records and included: proportion of rehospitalizations at 6 months for infectious causes, reasons for antibiotic dose modification or antibiotic switch after 6 weeks, and descriptive analysis of data on pharmaceutical interventions in care pathways. RESULTS: Analysis was performed on 164 patients: 105 CG (64 %) patients and 59 IG (36 %) patients. There were no significant differences between IG and CG in patients' socio-demographic characteristics, infectious factors and antibiotic regimens. Amongst the CG patients, 23 were readmitted (22 %) versus 3 patients in the IG (5 %), (p = 0.002). There were significantly fewer treatment changes after 6 weeks (28.6 % versus 15.3 %, p = 0.05) for IG patients. CONCLUSION: In this retrospective survey, our results suggest a positive impact of PLI on 6-month readmission for all causes in BJI patients. These results need to be confirmed in a multicentric study.

Percutaneous surgery with balloon for tibial plateau fractures, results with a minimum of 5 years of follow-up.

Tibial plateau fracture is a frequent entity for which surgical management is difficult both surgically and postoperatively, with multiple complications and often delayed recovery. The challenge lies in the anatomical reduction of the joint, the limitation of complications and the rapid functional recovery. Tuberoplasty appears to be an innovative technique that meets current expectations. The objective is to evaluate the reliability of tuberoplasty in reducing surgical risks and improving postoperative clinical results. This single-centre retrospective study included 30 patients with depressed tibial plateau fractures who underwent tuberoplasty from September 2011 to March 2014. Reduction analysis was performed by comparing pre-operative and post-operative depression from computed tomography (CT) data. Clinical outcomes were assessed by measuring flexion joint ranges, time to weight-bearing, KOOS questionnaire and a pangonogram. The mean depression was 7.4mm pre-operatively and 2.6mm [0;9] post-operatively, with 47% (14/30) having a residual depression of 2mm or less. Mean flexion at 6 weeks was 103° [30; 130]. Partial and total weight-bearing were allowed on day 47 [3; 150] and day 58 [20; 150], respectively. The mean KOOS score was 25.43 [1.15; 62.30] at a minimum of 5 years after surgery and the mean axis was 176.54° [172; 180]. There was one case of thrombophlebitis and one sensory-motor deficit in the common fibular nerve territory. The reduction of the tibial plateau observed in our study from tuberoplasty is in line with the literature results obtained from a conventional approach. Our results indicate that tuberoplasty is stable in the long term, has good functional results and early recovery with few complications. This preliminary study presents results that need to be investigated in a prospective randomised double-blind study.

Professional Status of Persistent Spinal Pain Syndrome Patients after Spinal Surgery (PSPS-T2): What Really Matters? A Prospective Study Introducing the Concept of "Adapted Professional Activity" Inferred from Clinical, Psychological and Social Influence.

Persistent Spinal Pain Syndrome Type 2 (PSPS-T2) represents a main cause of work disruption. Beyond its societal consequences, occupational inactivity is responsible for a major decrease in physical/mental health in individuals but remains poorly analyzed. We designed a study to prospectively examine Professional Status (PS) evolution and its association with key bio-psychological markers. Data from 151 consecutively included working-age PSPS-T2 patients were analyzed to determine the proportion of professional inactivity and the relationships between PS and Social Gradient of Health (SGH), Numeric Pain Rating Scale (NPRS), EuroQol 5-Dimensional 5-Level (EQ-5D-5L), Oswestry Disability Index (ODI), Hospital Anxiety and Depression Scale (HADS), and Fear-Avoidance Belief Questionnaire work subscale (FABQ-W). Despite optimized medical management, 73.5% of PSPS-T2 patients remained inactive after 1 year of follow-up/p = 0.18. Inactive patients presented a low SGH/p = 0.002, higher NPRS/p = 0.048, lower EQ-5D-5L/p < 0.001, higher ODI/p = 0.018, higher HADS-D/p = 0.019 and higher FABQ-W/p < 0.001. No significant mediation effect of FABQ-W on SGH consequences regarding PS was observed in our structural model/p = 0.057. The link between unemployment and bio-psycho-social pain dimensions appears bidirectional and justifies intense collaboration with social workers. Optimizing therapeutical sequencing towards personalized professional plans implies restoring "Adapted Physical Function" as an initial goal, and tailoring an "Adapted Professional Activity", matching with patient expectations and capabilities, as a final objective.

Persistent Spinal Pain Syndrome Type 2 (PSPS-T2), a Social Pain? Advocacy for a Social Gradient of Health Approach to Chronic Pain.

The Social Gradient of Health (SGH), or position in the social hierarchy, is one of the major determinants of health. It influences the development and evolution of many chronic diseases. Chronic pain dramatically affects individual and social condition. Its medico-economic impact is significant and worldwide. Failed Back Surgery Syndrome or Persistent Spinal Pain Syndrome type 2 (PSPS-T2) represents one of its most fascinating and disabling conditions. However, the influence of SGH on PSPS-T2 has been poorly explored. We designed a prospective multicentric study (PREDIBACK study) to assess the SGH prevalence, and to examine its association with medical and psychological variables, in PSPS-T2 patients. This study included 200 patients to determine the SGH association with pain (NPRS), Quality of life (EQ-5D-5L), kinesiophobia (FABQ-Work), catastrophism (CSQ), and functional capacity (ODI). Around 85.3% of PSPS-T2 patients in our study had low SGH. Low SGH patients had a higher FABQ-Work and CSQ-Catastrophizing score than high SGH patients (p < 0.05). High SGH patients have a higher ODI score than low SGH patients (p < 0.10). Our results suggest that SGH is a relevant factor to guide prevention, research, and ultimately intervention in PSPS-T2 patients and could be more widely transposed to chronic pain.

Vertebral balloon kyphoplasty versus vertebral body stenting in non-osteoporotic vertebral compression fractures at the thoracolumbar junction: a comparative radiological study and finite element analysis (BONEXP study).

OBJECTIVE: To compare radiologically balloon kyphoplasty (BKP) and vertebral compression fracture (VCF) expansion and corroborate with a finite element (FE) analysis. The principle of BKP is to stabilize VCF by restoring vertebral body anatomy using bone expansion and cement filling. More recently, vertebral body stenting (VBS) has been developed to reduce the loss of vertebral height observed after balloon deflation. METHODS: A retrospective, monocentric and continuous study of 60 non-osteoporotic fractures of the thoracolumbar junction treated by vertebral bone expansion was carried out over three years. The main endpoint was radiological correction of vertebral kyphosis (VK) at 3 months. The other studied parameters were vertebral height, index of Farcy, index of Beck, cement leakages and their location. A FE model was developed to analyze effects linked to the stent during cement injection, specifically throughout the risk of cement leakage evaluation. RESULTS: After three months, average reduction of VK was 4.73° ± 4.8° after BKP, and 4.63° ± 2.7° after VBS. There was no difference between the two techniques, but cement leakage was significantly greater with BKP (41.7%) than with VBS (4.2%). FE analysis showed substantial changes of the cement flow orientation in the presence of a stent. CONCLUSION: BKP and VBS offer comparable expansion with no added value of VBS in non-osteoporotic VCF reduction. VBS technique appears to prevent cement leakage due to its mesh architecture hindering the leaking process. In counterpart, such balloon expansion is likely to require higher pressure to deploy the stent. This could be an important parameter to take into account in young patients with high bone density.

Acrylic kyphoplasty in recent nonosteoporotic fractures of the thoracolumbar junction: a prospective clinical and 3D radiologic study of 54 patients.

STUDY DESIGN: Prospective clinical and radiological study. OBJECTIVES: To evaluate the impact of stand-alone acrylic kyphoplasty in the treatment of recent traumatic fractures of the thoracolumbar spine in young patients. SUMMARY OF BACKGROUND DATA: The management of fractures of the thoracolumbar spine without neurological deficit remains controversial. For a long time clinicians could only chose between functional treatment, orthopedic treatment, and traditional surgery. The recent advent of minimally invasive surgical techniques is an interesting alternative. MATERIALS AND METHODS: Fifty-four patients with a mean age of 45.8±18.2 years and who had recently sustained a fracture of the thoracolumbar junction were enrolled into the study. Balloon kyphoplasty was performed using acrylic cement. Radiologic assessments (computed tomography scans) and clinical assessments (including Visual Analog Scale and Oswestry Disability Index scores) were used to determine kyphoplasty success and measure patient recovery over 2 years. RESULTS: Kyphoplasty reduced mean vertebral kyphosis from 12.8±5.0 degrees at trauma to 8.2±5.1 degrees at 2-year follow-up. Mean vertebral kyphosis was corrected by -5.7±4.7 degrees (P=0.0001) at the point of first verticalization, with no significant change at the 2-year follow-up visit (+1.1±4.3 degrees, P=0.1058). Kyphoplasty significantly augmented the height of the 6 anterior and intermediate segments. Maximum mean augmentation of intermediate vertebral height after 6 months was (11.6%±15.5%, P<0.0001). Patients tolerated the procedure well and 56% of them returned to work 3 months after kyphoplasty. CONCLUSION: Kyphoplasty is safe and effective in the correction of nonosteoporotic fractures of the thoracolumbar junction in young patients, and remains stable for at least 2 years postsurgery.

The relationship between clinical outcomes and the amount of arthroscopic acromial resection.

PURPOSE: In 47 consecutive patients who had a shoulder impingement syndrome treated by arthroscopic subacromial decompression, we compared the functional outcome with the amount of the acromion resection. TYPE OF STUDY: Prospective study. METHODS: The inclusion criteria for patient selection was a chronic impingement syndrome unresolved by conservative treatment with an intact rotator cuff or with an irreparable rupture of the rotator cuff. The assessment was performed with the scoring system of Constant preoperatively and postoperatively. Quantitative measurements of the acromion resection were made by comparing preoperative and postoperative anteroposterior radiographic views, standardized under fluoroscopic control in order to become reproducible and comparable. There were 39 patients (41 shoulders) available for follow-up at 37 months. RESULTS: The condition of the shoulder, concerning pain, motion and activities, was improved at the time of follow-up, the mean gain of the total functional score was 29 points/100. Age, side, activity, duration of pain before procedure and cuff statement had no influence on preoperative and postoperative Constant's score. The difference between preoperative and postoperative measurements of anterior acromion protuberance was significant. There was no correlation between the amount of the acromion resection and the improvement of Constant's score (P =.84). CONCLUSIONS: The origin of impingement syndrome is multi-factorial, and efficiency of arthroscopic decompression may not be only due to the amount of acromion resection. From these results and a literature review, this study analyzes several morphologic factors, which could explain the good results of arthroscopic subacromial decompression in impingement syndrome.

Biomechanical study and digital modeling of traction resistance in posterior thoracic implants.

STUDY DESIGN: Posterior implants were used to test the resistance of seven human thoracic spines to traction, and results were compared with those of a digital study. OBJECTIVES: To compare the use of hook and screw fixation methods for posterior thoracic surgery in a study supplemented by a digital analysis using the finite-element method. SUMMARY OF BACKGROUND DATA: The maximum break strength of pedicular screws on bone has already been studied several times. Far fewer studies have investigated the stresses that may be applied to pedicular and laminar hooks or compared these hooks with pedicular screws in the thorax. METHODS: For this study, seven human thoracic spines were used, identifying 49 groups of two vertebrae each. The assemblies used a bolt in the medullary cavity. The central diameter of this bolt could be varied using tubes to suit the individual medullary cavity, spreading the stresses over the entire centrum during traction. The assembly was placed on an Instron machine. Vertical traction was applied up to the maximum break strength, that is, the strength recorded at the top of the traction curve read out directly on the Instron machine. Traction speed in all the tests was 5 mm per minute. Four pedicular screws and two pedicular-laminar clips were used alternately. In these tests, 25 values were obtained with hooks and 24 with screws. The group with screw fixation was tested in two halves, with 12 tests using 4-mm diameter screws and 12 tests using 5-mm diameter screws. For the digital study, the vertebra model comprised nearly 63,000 nodes and 14,000 elements. Elastic field calculations were carried out using the Abaqus finite-element calculation method. RESULTS: Each time pedicular-laminar traction was used, the pedicles broke at the base. Where screws were used, a medial fissure was found at the base of the pedicle. For the hooks, the maximum break strength was 1150 +/- 388 N. It was 820 +/- 418 N when 4-mm diameter screws were used and 1395 +/- 435 N when 5-mm screws were used. The most fragile vertebrae were found to be at T5-T6 and T7-T8. The screw-instrumented model showed that stresses were concentrated at the medial part of the pedicle, inside the medullary cavity. Use of a long screw did not lead to noticeable stress reduction. The hook-instrumented model showed that the stresses were greatest in the lower part of the pedicles. CONCLUSIONS: Screw fixation is the most appropriate from a mechanical point of view. During tests, however, screw fixation falls short of its promises. This leads to the hypothesis that in most cases screws pull out because the bony anchoring of the pedicle screwing fails. Screws are less effective if their anchoring in the pedicles cannot be guaranteed, which is probably the reason for their relative weakness. Screw diameter should be chosen according to the size of each pedicle. The findings showed that hooks impose additional stresses on the vertebrae.