Posterior deltoid-sparing approach for displaced inferior or posterior glenoid fossa fractures: technical note and case series.

Scapular surgery has usually been performed through the posterior Judet approach. This approach allows access to the entire posterior scapular body, but causes significant soft tissue damage and detaches the deltoid muscle. To date, there has been no clinical study of a deltoid-preserving approach to access the joint for displaced postero-inferior glenoid fractures (Ideberg type II or Ib). We describe an easy and less invasive approach to the postero-inferior glenoid fossa.

Efficacy and safety of oblique posterior endplate resection for wider decompression (trumpet-shaped decompression) during anterior cervical discectomy and fusion.

OBJECTIVE: Anterior cervical discectomy and fusion (ACDF) provides a limited workspace, and surgeons often need to access the posterior aspect of the vertebral body to achieve sufficient decompression. Oblique resection of the posterior endplate (trumpet-shaped decompression [TSD]) widens the workspace, enabling removal of lesions behind the vertebral body. This study was conducted to evaluate the efficacy and safety of oblique posterior endplate resection for wider decompression. METHODS: In this retrospective study, 227 patients who underwent ACDF for the treatment of cervical myelopathy or radiculopathy caused by spondylosis or ossification of the posterior longitudinal ligament and were followed up for ≥ 1 year were included. Patient characteristics, fusion rates, subsidence, and patient-reported outcome measures, including the neck pain visual analog scale (VAS) score, arm pain VAS score, and Neck Disability Index (NDI), were assessed. Patients who underwent TSD during ACDF (TSD group) and those who underwent surgery without TSD (non-TSD group) were compared. RESULTS: Fifty-seven patients (25.1%) were included in the TSD group and 170 patients (74.9%) in the non-TSD group. In the TSD group, 28.2% ± 5.5% of the endplate was resected, and 26.0% ± 6.1% of the region behind the vertebral body could be visualized via the TSD technique. The resection angle was 26.9° ± 5.9°. The fusion rate assessed on the basis of interspinous motion, intragraft bone bridging, and extragraft bone bridging did not significantly differ between the two groups. Furthermore, there were no significant intergroup differences in subsidence. The patient-reported outcome measures at the 1-year follow-up were also not significantly different between the groups. CONCLUSIONS: TSD widened the workspace during ACDF, and 26% of the region posterior to the vertebral body could be accessed using this technique. The construct stability was not adversely affected by TSD as demonstrated by the similar fusion and subsidence rates among patients who underwent TSD and those who did not. Therefore, TSD can be safely applied during ACDF when compressive lesions extend behind the vertebral body and are not limited to the disc space, enabling adequate decompression without disrupting the construct stability.

Clinical Efficacy of the Antibiotic-Loaded Collagen Sponge During Arthroscopic Treatment of Acute Septic Arthritis of the Native Knee.

Background: To completely eliminate an infection, the antibiotic concentration must exceed the minimum inhibitory concentration for the causative pathogens. The antibiotic-loaded collagen sponge (ALCS) has been used to manage an infection through a high local concentration of antibiotics. Purpose: To evaluate the clinical efficacy of ALCS in the arthroscopic treatment of patients with acute septic arthritis of the native knee. Study Design: Cohort study; Level of evidence, 3. Methods: The authors retrospectively reviewed the data for 132 consecutive patients with acute septic arthritis of the knee who underwent arthroscopic debridement between 2013 and 2019. Patients with a history of surgery in the affected joint, concomitant osteomyelitis, or accompanying medical infection were excluded. The study patients were divided into 2 groups based on the use of ALCS during surgery. C-reactive protein (CRP) levels were temporally measured to normalization and the duration of intravenous antibiotic administration was recorded, and the mean length of hospital stay was compared between the groups. Independent t test and chi-square test were performed to assess differences between the groups, and univariate analysis was used to analyze factors affecting recurrence of septic arthritis. Results: Of the 132 patients, 88 were ultimately included in this study; 51 patients were managed without ALCS and 37 were treated with ALCS. There were statistically significant differences between groups in the mean period for CRP-level normalization (15.2 ± 8.2 days [ALCS] vs 26.2 ± 14.7 days [without ALCS]; P = .004), mean duration of intravenous antibiotic use (18.4 ± 7.3 days [ALCS] vs 26.6 ± 16.1 days [without ALCS]; P = .046), and mean length of hospital stay (21.1 ± 11.6 days [ALCS] vs 30.3 ± 18.3 days [without ALCS]; P = .045). The preoperative CRP level was the only significant risk factor for recurrence or treatment failure after single arthroscopic debridement. Conclusion: The results of this study indicated that ALCS was able to reduce the duration of CRP-level normalization, intravenous antibiotic use, and hospitalization in patients who underwent arthroscopic irrigation and debridement for acute septic arthritis of the native knee.

Bowel Injury and Insidious Pneumoperitoneum after Lateral Lumbar Interbody Fusion.

STUDY DESIGN: Retrospective review of prospectively collected cases. PURPOSE: To report bowel injury cases and determine the incidence and risk factors of insidious pneumoperitoneum after lateral lumbar interbody fusion (LLIF). OVERVIEW OF LITERATURE: Minimally invasive LLIF is considered a safe surgical approach with a low risk of complications. Visceral injury after LLIF is rare and, to our knowledge, no studies on pneumoperitoneum after LLIF have been performed. Bowel injury is a catastrophic complication, but the clinical signs may not be apparent. After we encountered two cases of bowel injury after LLIF, we decided to perform computed tomography of the abdomen and pelvis (APCT) after surgery for all patients who underwent LLIF. METHODS: A total of 90 patients underwent APCT within 48 hours of surgery. Medical records were reviewed to determine each patient's age, sex, body mass index, medical and surgical histories, characteristics of LLIF procedures, and subjective symptoms and abnormal findings in the physical examination related to acute abdomen after surgery. Various parameters were compared between patients with and without pneumoperitoneum. RESULTS: Bowel injuries were identified in the first two patients and five patients (5.5%) were diagnosed with pneumoperitoneum only on APCT. We found that the greater the number of fused segments, the higher the incidence of postoperative bowel injury and/or pneumoperitoneum. The incidence was significantly high when the L2-3 level was included in the LLIF surgery. CONCLUSIONS: Pneumoperitoneum after LLIF indicates damage to the peritoneum and the presence of bowel injury that may lead to peritonitis. However, it is difficult to distinguish pneumoperitoneum and/or bowel injury from general abdominal pain after surgery because patients may present with a wide range of symptoms. We recommend that APCT be routinely performed after LLIF surgery in order to promptly identify pneumoperitoneum and bowel injury.

Three-dimensional measurement of the course of the radial nerve at the posterior humeral shaft: An in vivo anatomical study.

PURPOSE: Iatrogenic radial nerve injury caused by surgical exposure of the humerus is a serious complication. We aimed to describe the course of the radial nerve at the posterior humeral shaft using a three-dimensional (3D) reconstruction technique by utilizing computed tomography (CT) images of living subjects. We hypothesized that the course of the radial nerve in the posterior aspect of the humeral shaft would be reliably established using this technique and the measurements would have satisfactory intraobserver/interobserver reliabilities. METHODS: This in vivo anatomical study utilized 652 upper extremity CT angiography images from 326 patients. A 3D modeling of the humerus and radial nerve was performed. We evaluated the segment of the radial nerve that lays directly on the posterior aspect of the humeral shaft and measured its proximal point, mid, and distal points. The shortest distances from the olecranon fossa to these points were defined as R1, R2, and R3, respectively. The relationships between these parameters and humeral length (HL) and transcondylar length (TL) were evaluated, and the intraobserver/interobserver reliabilities of these parameters were measured. RESULTS: The HL was 293.6 mm, and TL was 58.64 mm on average. The R1 measured 159.2 (range 127.1-198.2) mm, R2 was 136.6 (105.7-182.5), and R3 was 112.8 (76.8-150.0) mm on average (p < .001). The intraobserver/interobserver reliabilities ranged from 0.90 to 0.98. CONCLUSION: The course of the radial nerve at the posterior aspect of the humeral shaft can be reliably established using the 3D reconstruction technique, and all measurements had excellent intraobserver/interobserver reliability.

Feasibility of CaO-SiO2-P2O5-B2O3 Bioactive Glass Ceramic Cage in Anterior Cervical Diskectomy and Fusion.

BACKGROUND: CaO-SiO2-P2O5-B2O3 bioactive glass ceramic (BGC) is known to chemically bond with bones by forming a hydroxyapatite layer and inducing osteoblastic differentiation. This study was conducted to compare the clinical outcomes, radiographic outcomes, and safety of a CaO-SiO2-P2O5-B2O3 BGC cage in anterior cervical diskectomy and fusion (ACDF) with those of an allograft interbody spacer. METHODS: A total of 63 patients who underwent 2-level ACDF to treat degenerative cervical radiculopathy/myelopathy were reviewed. Results from 26 patients who were recruited prospectively using CaO-SiO2-P2O5-B2O3 BGC as a cage material (BGC group) were compared with a historical control group of 37 patients who underwent surgery using an allograft (allograft group). Fusion rates, subsidence, and adjacent segment degeneration were compared between the groups. Demographic data, fusion rates, visual analog scale (VAS) scores for neck or arm pain, Neck Disability Index (NDI) scores, and complications were also compared. RESULTS: Fusion rates were 88.5% when assessed by interspinous motion and 92.3% when assessed by intragraft bone bridging in the BGC group at 12-month follow-up. The neck pain or arm pain VAS scores and NDI scores significantly improved in both groups. No material-related complications were observed in the BGC group, such as graft resorption and breakage. Fusion rates, subsidence, neck pain or arm pain VAS scores, and NDI scores did not significantly differ between the BGC and allograft groups. CONCLUSIONS: CaO-SiO2-P2O5-B2O3 BGC cage was effective and safe when used in ACDF, conferring a high fusion rate and favorable clinical outcomes similar to those of the allograft.

Closure of Persistent, Small, Posterior Elbow Soft Tissue Defects Using a Rotation Flap: A Retrospective Study.

Treating soft tissue defects occurring over the posterior elbow is challenging. PURPOSE: This study aimed to evaluate the long-term outcomes of using rotation flaps for soft tissue defects over the posterior elbow. METHODS: A retrospective study was conducted among patients who had sustained posterior elbow defects and underwent rotation flap under local anesthesia between January 2, 2011, and December 31, 2014. Patient inclusion criteria stipulated the soft tissue defect had to be small (<12 cm2), was the result of wound dehiscence following posterior approach surgery immediately following trauma, and had failed to heal using nonsurgical treatment or primary closure. Patients with an active infection, malignancies, a defect of any etiology other than trauma, or incomplete operative data were excluded. Patient demographics, medical history, operative reports, and outcomes were abstracted. Flap failure and surgical complications were monitored for a minimum of 2 years after surgery. Range of motion (ROM; 0˚ to normal 130˚) and Mayo Elbow Performance Scores (MEPS) were evaluated and recorded before surgery and after 2 years' follow-up and included evaluating pain, ROM, stability, and daily function. Patient, wound, surgical, and wound healing variables were compared between the flap survival and flap failure/complication groups using Mann-Whitney U and chi-squared tests. The Wilcoxon signed-rank test was used to compare pre- and postoperative MEPS and elbow ROM. RESULTS: Thirty (30) patients (13 male, 17 female; mean age 55 ± 15.6 [range 19-74] years) had complete records. Eighteen (18) flaps were created using the transolecranon approach, and 12 rotation flaps involved an olecranon fracture; 24 flaps survived and 6 patients experienced flap failure/complications (wound dehiscence or infection). Mean procedure duration was 25.6 ± 10.1 minutes. All defects were located over the olecranon with exposed bone or hardware. Mean defect size was 7.4 cm2 ± 2.9 cm2, the average defect duration was 60.4 (range 31-89) days, average time to wound healing was 21.9 ± 11.5 days, and mean follow-up time was 29.4 (range 24-56) months. All flaps successfully survived without recurrence. Mean pre- and postoperative MEPS were significantly different (56.4 vs. 90.2 points; P <.001). ROM did not differ significantly between mean preoperative range (extension 9.8˚ ± 3.2˚ and flexion 116.7˚ ± 10.2˚) and mean final follow-up range (extension 9.6˚ ± 2.6˚ and flexion 118.5˚ ± 11.3˚; P = .459). CONCLUSION: Rotation flap surgery performed under local anesthesia may offer a simple and safe option in the treatment of small (<12 cm2) trauma-related defects over the posterior elbow. More research is needed to develop evidence-based guidelines for optimal approaches to posterior elbow soft tissue defect closure techniques.

How Does Ossification of Posterior Longitudinal Ligament Progress in Conservatively Managed Patients?

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The aim of this study was to elucidate the progression of ossification of the posterior longitudinal ligament (OPLL) in conservatively managed patients and determine its risk factors SUMMARY OF BACKGROUND DATA.: Although several studies have demonstrated how OPLL progresses after laminoplasty or fusion, its progression in conservatively managed patients remains unclear. METHODS: The vertical length of the ossified mass and its thickness at each segment were evaluated on sagittal computed tomography images. Patients with vertical growth >2 mm were included in the vertical progression group. Segments with a thickness progression >1 mm were classified as thickness progressed segments, and patients who had at least one progressed segment were included in the thickness progression group. Based on the characteristics at each disc level, the ossified mass at each segment was classified into four types: type 1, no disc space involvement; type 2, involving the disc space, but not crossing; type 3, crossing the disc space, but not fused; and type 4, completely fused. RESULTS: The progression of ossified mass was observed in younger patients (P < 0.01) and in C2-C3 involvement (P < 0.01) cases. Moreover, progression in both directions was observed more frequently in the mixed-type OPLL (P < 0.01). Progression occurred most often in type 3 segments (72.0%, P < 0.01). In type 3 segments, thickness progression was found more frequently in segments with segmental range of motion (ROM) ≥5° (55.6% vs. 27.8%, P = 0.04). The proportion of segments whose initial thickness was >5 mm was significantly higher among progressed segments (60.0% vs. 35.2%, P = 0.03). CONCLUSION: Young age, C2-C3 involvement, and mixed-type OPLL are risk factors for OPLL progression. Segments with morphology of crossing the segment, but without fusion (type 3), segmental ROM ≥5°, and initial thickness >5 mm need special attention. LEVEL OF EVIDENCE: 3.

Supracondylar process syndrome: two cases of median nerve neuropathy due to compression by the ligament of Struthers.

The supracondylar process is a beak-shaped bony process on the anteromedial aspect of the distal humerus. The ligament of Struthers is a fibrous band extending from the tip of the process to the medial epicondyle. The median nerve and brachial artery pass under the ligament of Struthers and consequently can be compressed, causing supracondylar process syndrome. As a rare cause of proximal median nerve entrapment, supracondylar process syndrome is triggered when the median nerve is located in the superficial or deep layer of the ligament of Struthers as a result of anatomical variation. The supracondylar process can be easily detected on X-ray images obtained in oblique views but may not be identified in only anteroposterior or lateral views. In this article, we present 2 cases of supracondylar process syndrome and describe the process of diagnosis and treatment and results of a literature review.