Flexible posterior vertebral tethering for the management of Scheuermann's kyphosis: correction by using growth modulation-clinical and radiographic outcomes of the first 10 patients with at least 3 years of follow-up.

PURPOSE: The present prospective cohort study was intended to present the minimum 3 years' results of flexible posterior vertebral tethering (PVT) applied to 10 skeletally immature patients with SK to question, if it could be an alternative to fusion. METHODS: Ten skeletally immature patients with radiographically confirmed SK, who had flexible (minimum 35%) kyphotic curves (T2-T12), were included. A decision to proceed with PVT was based on curve progression within the brace, and/or persistent pain, and/or unacceptable cosmetic concerns of the patient/caregivers, and/or non-compliance within the brace. RESULTS: Patients had an average age of 13.1 (range 11-15) and an average follow-up duration of 47.6 months (range 36-60). Posterior vertebral tethering (PVT) was undertaken to all patients by utilizing Wiltse approach and placing monoaxial pedicle screws intermittently. At the final follow-up: mean pre-operative thoracic kyphosis and lumbar lordosis improved from 73.6°-45.7° to 34.7°-32.1°. Mean sagittal vertical axis, vertebral wedge angle and total SRS-22 scores improved significantly. A fulcrum lateral X-ray obtained at the latest follow-up, showed that the tethered levels remained mobile. CONCLUSION: This study, for the first time in the literature, concluded, that as a result of growth modulation applied to skeletally immature patients with SK, flexible PVT was detected to yield gradual correction of the thoracic kyphosis by reverting the pathological vertebral wedging process, while keeping the mobility of the tethered segments in addition to successful clinical-functional results. The successful results of the present study answered the role of the PVT as a viable alternative to fusion in skeletally immature patients with SK. LEVEL OF EVIDENCE: IV.

Long-term Clinical and Radiographic Outcomes Following Surgical Treatment for Ankle Fracture-Dislocations: Do poor radiographic outcomes always matter?

Background Ankle fractures constitute 10% of all traumatic fractures in clinical practice. Concurrent tibiotalar dislocations form 21-36% of all ankle fractures. Although mechanism of injury is similar to non-dislocated ankle fractures, fracture-dislocations cause more extensive bone and soft tissue damage. Treatment is a challenge for orthopedic surgeons due to concomitant pathologies. It is associated with malreduction, chronic pain and most importantly, posttraumatic osteoarthritis. We aimed to investigate the relationship between ankle osteoarthritis radiographic stage and clinical outcomes. Methods 27 patients (17 female, 10 male) were included in the study. Records and data were retrospectively analyzed. Clinical status at the final follow-up was evaluated by a single orthopedic surgeon. Range of motion (ROM), American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score, visual analogue scale (VAS) were the clinical parameters that were assessed. Radiological assessment was made by standard anteroposterior [AP], lateral, and mortise views. Pre-operative osseo-ligamentous injury pattern, presence of posterior malleolar fracture, syndesmosis injury and post-operative ankle osteoarthritis were investigated. Results For 27 patients that were evaluated, at the final follow-up, mean AOFAS was 85 ± 8.12, and mean VAS during daily activities was 1.52 ± 0.70. Mean ankle dorsiflexion and plantar flexion were significantly lower on the affected sides (14.07 ± 7.97° and 36.30 ± 6.59°) than on the unaffected sides (28.15 ± 2.82° and 46.30 ± 2.97°), respectively (p < 0.001). No significant difference for inversion and eversion was observed. Twenty-four patients demonstrated radiographic signs of ankle osteoarthritis, and three remained without evidence of osteoarthritis. No significant difference was found among Takakura's stages in any of the variables. Conclusion The results illustrated that although post-traumatic osteoarthritis rate was high for ankle fracture-dislocation patients, surgical treatment achieved excellent functional results. Even if advanced stages of ankle arthritis according to Takakura's classification developed, patients had satisfactory clinical and functional results.

Dorsal Scapholunate Ligament Reconstruction by Using Palmaris Longus Tendon Graft in Chronic Static Scapholunate Dissociations: Does It Yield Favorable Radiographic and Functional Results?

Background Scapholunate (SL) instability is the most common dissociative carpal instability, and the most frequent cause of wrist osteoarthritis (OA), termed as scapholunate advanced collapse (SLAC). The aim of this study was to present the mid-term clinical and radiographic results of dorsal SL ligament reconstruction by utilizing free palmaris longus tendon graft in patients with symptomatic, chronic, static SL dissociation; while assessing the safety and efficacy of this technique, Materials and Methods In total, 42 patients with a mean age of 44.1 (range 26-53) and mean follow-up duration of 69.4 months (range 60-72) with a diagnosis of chronic, static, and reducible SL instabilities with no chondral damage were enrolled. They all underwent dorsal SL ligament reconstruction with the exam same technique. Results At the last follow-up, patients' mean preoperative SL gap improved from 4.7 (range 4-6) to 2.1 (range 2-3), as did SLA from 84 degrees (range 67-101 degrees) to 66 degrees (range 49-72 degrees)( p <0.001 for both). Preoperative mean VAS (visual analog score), DASH (Disabilities of the Arm, Shoulder and Hand), Mayo wrist scores and SF-36 scores showed significant improvements in the last follow-up visit ( p <0.001, for all). No major complications were acquired in either of the patients. Conclusion Dorsal SL ligament reconstruction by using free PL tendon graft was detected to provide successful restoration of the normal carpal alignment together with SL joint stability. This procedure, by significantly reducing pain and improving grip strength was detected to yield significantly improved clinical and functional outcomes, together with high patient satisfaction indicated by improved health-related quality of life (HRQOL) scores. Level of Evidence IV.

Contribution of Multilevel Transformainal Lumbar Interbody Fusion Surgery to Restoration of Lumbar Lordosis in Patients with Degenerative Spine: Comparison of Long and Short Level Fusion.

AIM: To investigate the effect of multilevel transforaminal lumbar interbody fusion (TLIF) procedures in lumbar degenerative spine conditions on the restoration of lumbar lordosis (LL) in patients with short- and long-level fusion, and to examine the associated radiological results. MATERIAL AND METHODS: This retrospective study reviewed patients with degenerative spinal diseases who underwent lumbar fusion using a multilevel TLIF procedure. Patients with three or fewer segments involved in fusion were assigned to the shortlevel fusion group and those with more than three segments involved in fusion were assigned to the long-level fusion group. The anteroposterior and lateral spine radiographs of the patients were used to measure LL, distal lumbar lordosis and radiological parameters. RESULTS: The study included 47 patients who met the inclusion criteria, with a mean age of 60.4 ± 12.2 years. The mean follow-up time of our patients was 18.3 ± 11 months. Thirty-five (74.5%) patients were women and 12 (25.5%) were men. Overall, 12 patients underwent 3-level and 35 patients underwent 2-level TLIF. Long-level fusion was performed in 24 patients and short-level fusion was performed in 23 patients. CONCLUSION: Multilevel TLIF can be used to correct spinopelvic alignment when applied with the appropriate indications and techniques in patients with degenerative spinal disorders. Multilevel TLIF is associated with substantial improvements in LL, distal lumbar lordosis, and SVA (sagittal vertical axis). It also helps to correct the correlation between PI and LL.

Arthroscopic rotator cuff repair performed with intra-articular tranexamic acid: could it provide improved visual clarity and less postoperative pain? A prospective, double-blind, randomized study of 63 patients.

BACKGROUND: Tranexamic acid (TXA) has been widely used in orthopedic surgery with the aim of reducing intraoperative and postoperative bleeding, as well as bleeding-related complications. The purpose of this study was to assess whether intra-articular use of TXA during arthroscopic rotator cuff tear (RCT) repair could improve visual clarity, shorten the duration of the operation, and provide superior pain management as compared with placebo. METHODS: We conducted a prospective, randomized, double-blind, placebo-controlled study. Patients aged ≥18 years with a magnetic resonance imaging-confirmed RCT and a history of failed conservative treatment for ≥6 months were included. Patients with a history of coagulopathy; a history of cardiac, renal, or hepatic disease; a history of conservative treatment for <6 months; and/or acute RCTs were excluded. Visual clarity as the primary outcome was assessed using an arthroscopic visual scale comprising 5 grades-ranging from grade 1, best visual clarity, to grade 5, worst visual clarity (requiring conversion to open surgery)-after the procedure by the operating surgeon every 10 minutes throughout the video of the operation. Secondary outcomes were operative duration and postoperative pain scores. RESULTS: A total of 63 patients with similar demographic data (age and sex) and intraoperative mean arterial pressure were enrolled and randomized into 2 groups: The TXA group comprised 32 patients with a mean age of 56.46 years, and the placebo group comprised 31 patients with a mean age of 57.83 years. The TXA group was reported to have significantly superior visual clarity (mean arthroscopic visual scale score, 1.5 ± 0.5 vs. 2.86 ± 1.7; P < .001), with a significantly higher percentage of grade 1 visual clarity (78.1% vs. 32.2%, P < .001) and a significantly lower percentage of grade 4 visual clarity (0% vs. 3.2%, P = .003). Grade 5 visual clarity was not recorded in any patient in either group. The TXA group showed a significantly shorter operative duration (55.73 minutes vs. 67.26 minutes, P = .001) and superior pain scores at 8 hours (2.3 vs. 3.6, P = .002) and 24 hours (1.6 vs. 2.4, P < .001) postoperatively. No complications were recorded in either group. CONCLUSIONS: This study showed that during arthroscopic rotator cuff repair procedures, intra-articular use of TXA was able to provide superior arthroscopic visual clarity while shortening the total operative duration significantly and providing significantly superior pain management in the first 8 and 24 hours postoperatively as compared with placebo. This study underlines the safety and efficacy of intra-articular TXA use in arthroscopic rotator cuff repair.

Safety, Efficacy, and Cost-Effectiveness of Simultaneous Bilateral Arthroscopic Bankart Repair for Bilateral Shoulder Instability.

Background: Bilateral shoulder instability and Bankart lesions are not rare and frequently require surgical treatment. Bilateral instability may be treated with either a single-stage, simultaneous bilateral Bankart repair or 2-stage surgery. Purpose/Hypothesis: To compare simultaneous bilateral arthroscopic Bankart repair to 2-stage repair in terms of clinical outcomes and hospitalization costs. It was hypothesized that simultaneous repair would provide clinical outcomes similar to those of 2-stage Bankart repair while yielding lower hospitalization costs. Study Design: Cohort study; Level of evidence, 3. Methods: Patients who underwent simultaneous bilateral arthroscopic Bankart repair (group 1) were matched by age, sex, and injury type to control patients who had unilateral Bankart repair (group 2). All patients were operated on by the same surgeon in the same institution between 2007 and 2017 and had a minimum follow-up duration of 24 months. Patients with inflammatory arthritis, metabolic/malignant disease, previous shoulder surgery, a glenoid bone loss ≥25%, or off-track Hill-Sachs lesion were excluded. The 2 groups were compared in terms of pre- and postoperative Western Ontario Shoulder Instability Index (WOSI) scores, hospitalization costs, complications, and recurrent instability. The hospitalization cost of group 2 was multiplied by 2 to create a projection of the estimated cost of 2 sequential unilateral Bankart repairs. Results: The study population comprised 48 patients (38 men [79.17%] and 10 women [20.83%]; mean age, 25.5 years at surgery and 22.75 years at first dislocation). Group 1 included 32 shoulders in 16 patients, while group 2 consisted of 32 shoulders in 32 patients. The mean hospitalization cost (in 2020 US dollars) was $26,010 ± $1455 for group 1 and $33,591 ± $1574 for group 2 (P < .001). Both groups had improved WOSI scores after surgery and achieved similar scores at the latest follow-up. There was 1 redislocation in each group (3.13%). No surgery- or anesthesia-related/medical complications were recorded in either group. Conclusion: For bilateral shoulder instability, clinical outcomes of simultaneous bilateral arthroscopic Bankart repair were similar to those of 2-stage repair; however, lower hospitalization costs were seen after simultaneous bilateral repair compared with 2-stage surgery.

Comparison of clinical outcomes of autologous bone graft versus pronator quadratus pedicled vascularized bone graft in the treatment of scaphoid nonunion.

We aimed to compare the union rate and clinical outcome of autologous bone graft versus pronator quadratus vascularized pedicled muscle flap in treatment of scaphoid nonunion. Forty patients with a diagnosis of scaphoid nonunion who underwent unilateral pseudarthrosis surgery were included in this study. Notably, the scaphoid nonunion was unilateral, and the contralateral wrist was asymptomatic with normal function, per the physical and radiological examinations. Pronator quadratus vascularized pedicled muscle flap was used in 16 patients (group 1), and autologous bone graft was used in 24 patients (group 2). Patients were compared used Scapholunate angles, Natrass carpal height ratio and Mayo wrist score pre and postoperatively. Fifteen of the 16 (93.3%) patients in group 1 and 19 of the 24 (79.2%) patients in group 2 achieved bone union. Four of twelve patients in group 2 with avascular necrosis (AVN) and one of eight in group 1 with AVN were not able to achieve union. The group 2 (34%) had higher nonunion rate than group 1 (12%) in AVN patients. The scapholunat angle was significantly decreased and the Natress ratio was significantly increased postoperatively compared to the preoperative measurement in both group. There was no statistically significant difference in the postoperative measurement. The postoperative Mayo wrist score showed no statistically significant differences between both groups. The pronator quadratus vascularized pedicled muscle flap was superior to non-vascularized bone grafting in the treatment of scaphoid nonunion with AVN. However, management of the patients without avascular necrosis is not requiring the vascularized pedicled muscle flap technique.

Cemented radial head arthroplasty: Does radiographic loosening have an effect on clinical and functional outcomes? Average 10 years' results.

PURPOSE: The aim of this study was to evaluate the possible effect of radiographic loosening on clinical and functional outcomes, while presenting the mid-term radiographic and functional outcomes of cemented, monopolar RHA applied to patients with comminuted radial head fractures. METHODS: We performed a retrospective study by evaluating the records of patients who were diagnosed in a single center with radial head fractures between 2001 and 2013. Twenty-six patients with comminuted radial head fractures with a mean age of 48.9 and a mean follow-up time of 132.2 months were included. The radiographic evaluation was performed by assessing peri-prosthetic radiolucent lines around the stem to evaluate loosening, while the clinical evaluation was performed by utilizing elbow range of motion (ROM), Mayo elbow performance score (MEPS), Oxford elbow score (OES) and quick-DASH scores. RESULTS: 13 patients (Group 1) with peri-prosthetic stem lucency were defined as radiographic loosening (50%), while the remaining 13 patients (Group 2) were not detected to have stem lucency. One patient in group 1 also had concomitant pain and underwent removal of the prosthesis, while 12 patients (92.3%) remained pain-free. On the latest follow-up visit, there was no significant difference between the groups regarding ROM, MEPS, OES and quick-DASH scores. CONCLUSIONS: Within ten years following surgery, half of the patients with radial head prostheses were noted to show radiographic signs of loosening which did not have any major negative effect in terms of clinical-functional outcomes and quality of life, except requiring the removal of the implant in one patient. LEVEL OF EVIDENCE: Level III.

Effect of lengthening speed on the quality of callus and complications in patients with congenital pseudarthrosis of tibia.

PURPOSE: This study aims to evaluate the effect of lengthening speed on the quality of callus and complications during distraction osteogenesis and describe an optimal lengthening speed in patients with congenital pseudarthrosis of tibia (CPT). METHODS: Twenty-seven patients with CPT with a minimum follow-up of 36 months who underwent limb lengthening surgery between 1997 and 2016 with external fixator only were included in this study. All patients underwent lengthening procedures after achieving complete bone union in this study. Regenerate quality is evaluated according to the Li classification on the X-ray taken one month after the end of the distraction period. Complications were noted in post-operative follow-up period. Receiver operator characteristics (ROC) curve analysis was performed to obtain optimal lengthening speed for these patients. RESULT: The mean age at the time of surgery was 5.74 years. The mean lengthening speed was 0.596 mm/day. Follow-up period of 136.14 months with a mean lengthening period of 92.4 days. Mean amount of lengthening was 5.44 cm for patients with CPT. Total rate of callus with good morphological quality was calculated as 66%. According to ROC analysis, optimal cut-off values of lengthening speed for the obtaining good morphological quality callus was 0.564 mm/day for tibial lengthening in CPT. There was a significantly positive correlation between complication rate and lengthening speed for each group. CONCLUSION: We recommend a mean lengthening rate of 0.56mm/day for the lengthening procedures with external fixator in patients with CPT who had complete bone union at the area of pseudarthrosis.

Comparison of clinical and functional outcomes of vertebral body tethering to posterior spinal fusion in patients with adolescent idiopathic scoliosis and evaluation of quality of life: preliminary results.

PURPOSE: This preliminary study was aimed to present the results of the comparison of clinical and functional outcomes of vertebral body tethering (VBT) and posterior spinal fusion (PSF) for the first time in the literature. METHODS: 21 thoracolumbar (T5-L3) VBT patients (VBT group); and 22 age-gender-fusion level and minimum follow-up duration matched thoracolumbar (T3-L3) PSF patients (PSF group) were enrolled. Average FU duration of group 1 and 2 were 37.1/37.8 months (p = 0.33). Patients clinical data together with SRS-22 scores and SF-36 scores were compared. A retrospective, comparative study was undertaken. RESULTS: VBT group was detected to have superior lumbar range of motion; superior anterior-lateral lumbar bending flexibility; superior flexor and extensor endurances of trunk, and superior average motor strength of trunk muscles with high statistical significance. VBT group was also detected to have superior scores regarding life quality, including better average total SRS-22 and better average SF-36 MCS/PCS scores with also high statistical significance. CONCLUSION: This study for the first time in the literature concluded, that in skeletally immature patients with AIS, VBT as a result of the utilization of growth modulation was able to yield significantly superior lumbar range of motion, lumbar anterior and lateral flexibility, trunk flexor-extensor endurance and trunk motor strength as compared to patients who underwent fusion. By yielding significantly superior SRS-22 and SF-36 scores, VBT was detected to provide better life quality and patient satisfaction than fusion. This study concluded hereby, that by applying VBT, spinal motion could be preserved and complications of fusion could be avoided.

Unilateral Posterior Surgery for Severe Osteoporotic Vertebrae Fractures' Sequelae in Geriatric Population: Minimum 5-Year Results of 109 Patients.

OBJECTIVE: This study aimed to evaluate the efficacy and safety of modified posterior vertebral column resection (PVCR) combined with anterior column restoration in elderly patients presenting with thoracic or thoracolumbar osteoporotic fractures with spinal cord compression and severe pain. METHODS: One hundred nine patients with one level thoracolumbar osteoporotic fracture and at least 5 years of follow-up were included. They underwent posterior instrumentation performed with polymethymetachrylate augmented pedicle screws. A modified PVCR (unilateral costotransversectomy+hemilaminectomy) combined with the insertion of an expandable titanium cage for anterior column restoration was undertaken. Patients were evaluated clinically and radiographically. RESULTS: Patients had a mean age of 74.1 and a follow-up duration of 92.3 months. Mean duration of operations, hospital stays, and mean loss of blood were 172.3 minutes, 4.3 days, and 205.4 mL. All of the patients were mobilized immediately after surgery. The mean preoperative local kyphosis angle improved from 39.3° to 4.7° at the last follow-up (p = 0.003). Patients preoperative mean visual analogue score, Japanese Orthopaedic Association, and Oswestry Disability Index scores improved from 7.7/8.6/76.3 to 1.6/26.1/17.4 (p < 0.001 for all), respectively. The average 36-item Short-Form survey physical component summary/mental component summary scores at the last follow-up were 55.1/56.8. A dural tear was detected intraoperatively in 1 patient and repaired immediately. CONCLUSION: Subtotal PVCR combined with the insertion of an expandable titanium cage was detected as a safe and effective method for osteoporotic vertebrae fractures' sequelae in the older population involving spinal cord compression by enabling the decompression of the spinal canal and reconstruction of the resected segment, resulting in significant improvement in clinical and radiographic outcomes.

Double-sided vertebral body tethering of double adolescent idiopathic scoliosis curves: radiographic outcomes of the first 13 patients with 2 years of follow-up.

PURPOSE: In skeletally immature patients with adolescent idiopathic scoliosis (AIS), vertebral body tethering (VBT) as a fusionless minimally invasive treatment option has been shown to correct the deformity by growth modulation. This prospective cohort study aimed to present the minimum 2 years' results of double-sided VBT applied to double curves of 13 skeletally immature patients with AIS. METHODS: Thirteen skeletally immature patients with AIS and double curves were included. All patients were followed up within a brace for at least 6 weeks. A decision to proceed with surgery was established after the detection of curve progression within the brace (> 40° thoracic, > 35° lumbar) with a minimum curve flexibility of 30%. RESULTS: Patients had an average age of 11.8 years, average follow-up duration of 36.4 months (range 24 to 46), average preoperative main thoracic/thoracolumbar or lumbar curve magnitudes of 48.2°/45.3°. An average of 11.8 levels of tethering was undertaken. Thoracic screws were placed thoracoscopically, while mini-thoracotomy/lumbotomy was added for thoracolumbar levels. Postoperatively, an average first erect thoracic/thoracolumbar major curve magnitudes of 17.3°/14.3° were acquired, while they improved to 9.7°/8.2° at the last follow-up. No neurologic or implant-related complications were acquired. CONCLUSION: Double-sided VBT was detected to provide 80% of thoracic (48.2° to 9.7°) and 82% of thoracolumbar-lumbar curve correction (45.3° to 8.2°) as a result of average two years. As being a growth modulating treatment option, double-sided VBT as applied under strict inclusion criteria was shown to be safe and effective for the correction of double curves in skeletally immature patients with AIS, by yielding a gradual, growth-assisted correction of both curves together with the preservation of coronal-sagittal balance without any major complications.

Endoscopic resection of a localized tenosynovial giant cell tumor causing posterior ankle impingement in a 15-year-old athlete: A case report.

Tenosynovial giant cell tumor (TGCT) is a systematically benign but locally aggressive lesion arising from the synovium, tendon sheath or joint bursae. Even in athletes, soft tissue tumors may be the underlying reason or a component of posterior ankle impingement, although the most common mechanism is forceful and repetitive plantar flexion. In this article, we present a case of localized TGCT in a 15-year-old female patient presenting with symptoms of posterior ankle impingement. The preferred technique for treatment was complete local resection via posterior ankle endoscopy. The patient returned to sports at three months and no recurrence was observed on the last follow-up at the first postoperative year. Although rare, soft tissue tumors should be taken into consideration in posterior ankle impingement in athletes. Such benign soft tissue tumors in the posterior ankle can be treated safely and effectively via two-portal posterior endoscopic approach.

Direct vertebral rotation significantly decreases the pullout strength of the pedicle screw: a biomechanical study in adult cadavers.

The pullout strength of the pedicle screws after direct vertebral rotation (DVR) maneuver is not known. This biomechanical study was performed to quantitatively analyze the pullout strength of a pedicle screw after DVR maneuver using human cadaveric vertebrae. Thoracic vertebral bodies from three cadavers were harvested and stripped of soft tissues. Thirty pedicles of 15 vertebrae were separated into two groups after bone mineral density measurements. Polyaxial 5.5 mm pedicle screws with appropriate length were inserted with a freehand technique for each pedicle. One Kirschner wire was inserted to the anterior part of each vertebral corpus the half depth of each corpus was embedded into PVC pipes using polyester paste. In the DVR group, each screw was pulled horizontally with 2 kg (~20 N) load over a screwdriver rigidly attached to the screw, and a DVR maneuver was simulated. The control group did not load with a DVR maneuver. Samples were placed on a universal testing machine and pullout loads were measured. The Mann-Whitney U test was utilized, and the P value <0.05 was considered as statistically significant. In the DVR group, the mean pullout strength was 183.35 N (SD ± 100.12), and in the control group, the mean pullout strength was 279.95 N (SD ± 76.26). Intergroup comparisons revealed that DVR maneuver significantly decreases the pullout strength (P = 0.012). The results of this study confirm that the pullout strength of pedicle screw significantly decreases by approximately 35% when DVR maneuver is applied.

The Impact of the Ligamentous Injury Pattern and Associated Neurovascular Injury on Ultimate Knee Function in Patients with Traumatic Knee Dislocations.

The present study aims to investigate whether there is a relationship between the ligamentous injury pattern and concomitant neurovascular injury with long-term functional outcomes in patients with traumatic knee dislocations (TKDs). A total of 42 patients with TKDs were categorized according to the Schenck's classification based on the pattern of ligamentous injury. Concomitant vascular and neural injuries were recorded. Long-term functional outcomes were assessed using several objective and subjective outcome measures. This retrospective study was conducted in two phases: (1) to analyze the impact of ligamentous injury pattern on functional outcomes of patients with TKDs in the overall study population, by comparing all the variables among Schenck's grades; (2) to determine the impact of concomitant vascular and neural injury on ultimate knee function based on the subgroup analyses. In the overall study statistical differences were determined among each pattern of ligamentous injury in the total range of motion (ROM) and scoring systems (chi-squared test, p = 0.254). The overall rates of vascular and neural injury were 26 and 28%, respectively. In subgroup analyses, 40 patients were divided into three subgroups: group A (isolated concomitant neural injury), group B (isolated concomitant vascular injury), group C (without concomitant major vascular or neural injury). The analysis revealed a significant difference in the total ROM (p = 0.005), flexion measurements (p = 0.004), and the loss of extension (p = 0.003). Group A had the lowest total knee ROM and the mean flexion degrees, as well as the highest loss of extension. Concerning functional scoring systems including the combined Knee Society Score (knee score + function score), Lysholm knee scoring scale, and International Knee Documentation Committee score, subgroup analyses revealed significant differences among the groups (p = 0.001, p < 0.01 for all scores). All the scores were found to be lowest in group A. Evidence from the current study showed that the ligamentous pattern and concomitant neurovascular injury both may have a significant impact on ultimate knee function in patients with TKDs. This is a Level III-retrospective comparative study.

Biomechanical Comparison of Pull-out Strength of Different Cementation and Pedicle Screw Placement Techniques in a Calf Spine Model.

BACKGROUND: We hypothesized that an entire pedicle screw tract cement augmentation has greater strength than traditional techniques. METHOD: Twenty-four fresh frozen calf lumbar spines were randomized into three study groups, each having eight vertebrae: (1) screw cemented after vertebroplasty; (2) fenestrated cemented screw; and (3) cementation of the entire pedicle screw tract. For the right side screws, two pedicle screws were inserted in each vertebra with the standard position in the sagittal plane, whereas the left side screws were placed at a 30° angle craniocaudal plane. From the recorded force-displacement curves, the maximum peak load (failure load) of each screw was determined. The mode of failure was screw stripping at all levels tested. RESULTS: The pull-out strength for standard screw replacement at the sagittal plane was 1843.3 N, 1707.45 N, and 5365.1 N consecutively. The failure load value in the standard position in the sagittal plane in the cementation of the entire pedicle screw tract group was significantly higher than that in the fenestrated cemented screw group and screw cemented after vertebroplasty (p < 0.001 and p < 0.001, respectively). The standard pedicle screw position in the sagittal plane showed a significant pull-out strength than the others (p < 0.001). CONCLUSION: The pull-out strength of the cementation of the entire pedicle screw tract was 2.5 times higher than the others. The pull-out strength of the pedicle screws in malposition obtained the same strength to the standard positions after the augmentation procedure in our study.

Thoracoscopic Vertebral Body Tethering for Adolescent Idiopathic Scoliosis: A Minimum of 2 Years' Results of 21 Patients.

BACKGROUND: Anterior vertebral body tethering (VBT) is a growth modulating and fusionless treatment option that is considered as a new promising method for the management of adolescent idiopathic scoliosis (AIS). This prospective cohort study aimed to present the minimum 2-year results of anterior VBT applied to 21 skeletally immature patients with AIS. METHODS: Twenty-one skeletally immature patients with a diagnosis of AIS were included. A decision to proceed with surgery was established after the detection of curve progression despite the brace (>40 degrees) with a minimum curve flexibility of 30%. RESULTS: Patients had an average age of 11.1 and an average follow-up period of 27.4 months. All patients underwent thoracoscopic placement of thoracic screws, from the convex side of curves. An average of 7.1 levels of tethering was undertaken. Average preoperative major thoracic curve magnitudes improved from 48.2 to 16 degrees on the first erect postoperative x-ray, and to 10 degrees at the last follow-up (P<0.001). Immediate postoperatively, 1 case with chylothorax was detected and treated conservatively, and another case with tether breakage was detected at the third postoperative year and replaced thoracoscopically. No other major complication was acquired. CONCLUSIONS: Anterior VBT as a growth modulating treatment option by allowing the correction of the scoliotic deformity and preserving coronal balance was detected to be a safe and effective option for the surgical treatment of AIS in skeletally immature patients, if applied under strict inclusion criteria. VBT by allowing preservation of spinal segmental motion is yielding promising radiographic results without causing any major complications. LEVEL OF EVIDENCE: Level IV.

Does the Application of Platelet-Rich Fibrin in Anterior Cruciate Ligament Reconstruction Enhance Graft Healing and Maturation? A Comparative MRI Study of 44 Cases.

BACKGROUND: Anterior cruciate ligament (ACL) reconstruction performed with growth factors and activated platelets has been suggested to accelerate tendon ligamentization, leading to earlier return to daily activities and sports. HYPOTHESES: Platelet-rich fibrin (PRF) will result in improved graft maturation and healing as evaluated by magnetic resonance imaging (MRI) in patients undergoing hamstring ACL reconstruction. Hemostatic and analgesic properties of PRF will lead to less postoperative blood loss and pain. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 44 patients with isolated ACL injuries who underwent arthroscopic all-inside anatomic single-bundle ACL reconstruction with semitendinosus tendon graft were enrolled. Group 1 included 23 patients who had PRF sprayed to the surface of the graft; group 2 included 21 patients for whom no PRF was used. Patients were discharged after 24 hours and examined for hemarthrosis that needed to be aspirated. MRI was performed at the fifth postoperative month. A blinded radiologist evaluated graft maturation according to its signal intensity and the presence of synovial fluid at the tunnel-graft interface. RESULTS: PRF-treated grafts demonstrated lower MRI signal intensity and less fluid in the graft-tunnel interface as compared with controls for the entire length of the graft. The mean full-length MRI signal intensities were 9.19 versus 16.59 (P = .047) for groups 1 and 2, respectively. Subgroup analysis of the semitendinosus grafts demonstrated a signal intensity of 11.57 versus 23.98 (P = .044) for the proximal third, 9.53 versus 13.83 (P = .237) for the midbody, and 6.48 versus 11.98 (P = .087) for the distal third. Synovial fluid at the graft-tunnel interface was detected in 1 patient in group 1 (4.3%) and 3 patients in group 2 (14.3%; P < .001). Patients in group 1 had significantly less hemarthrosis that needed to be aspirated (P = .003), while postoperative analgesia requirements were similar in both groups (P = .08). No clinical benefit of PRF could be demonstrated in clinical outcomes. CONCLUSION: Application of PRF led to superior graft integration and maturation in the proximal third of the ACL graft. There was no significant difference in MRI signal intensity in the midbody or distal tibial graft. Application of PRF also resulted in significantly lower rates of postoperative hemarthrosis that needed to be aspirated.

Conservative Versus Operative Treatment of Stable Thoracolumbar Burst Fractures in Neurologically Intact Patients: Is There Any Difference Regarding the Clinical and Radiographic Outcomes?

STUDY DESIGN: Nonrandomized, retrospective, comparative, and single-center trial. OBJECTIVE: The aim of this study is to compare the long-term clinical and radiographic results of thoracolumbar burst fractures in neurologically intact patients, treated surgically or nonsurgically with the aim to optimize their management. SUMMARY OF BACKGROUND DATA: There is an ongoing controversy regarding the treatment of thoracolumbar burst fractures (TLBF) (A3, A4) in neurologically intact patients. Surgical treatment as well as conservative treatment methods are advised to this specific group of patients, while contrasting results exist in the literature. METHODS: Forty-five neurologically intact patients with TLBF (A3 or A4) (2010-2016) were included. Twenty-one patients with a mean age of 34.3 and a mean follow-up period of 63.1 months were treated surgically with short segment posterior fixation (group 1), while 24 patients with a mean age of 45.7 and a mean follow-up period of 67.1 months were treated conservatively (group 2) with thoracolumbosacral orthesis. RESULTS: At the final follow-up groups 1 and 2 had an average segmental kyphosis of 4.09°/11.65° (P = 0.027), an average loss of kyphosis of 2.04°/4.03° (P = 0.038), an average loss of anterior/posterior vertebral body height of %12.89/%2.84/%17.94/%7.62 (P = 0.027/ P = 0.03), a median JOA score of (16.6/16.75) (P = 0.198), a median ODI score of (11.7/12.1) (P = 0.25), a median VAS score of (1.9/2.3) (P = 0.3), SF-36 PCS of (56.74/56.67) (P = 0.25), SF-36 MCS of (55.47/55.5) (P = 0.3), mean durations of hospital stay of 9-11 days (P = 0.3), respectively. CONCLUSION: While there is an ongoing controversy regarding the management of stable thoracolumbar burst fractures in neurologically intact patients in the literature, this study concluded that surgical management of stable thoracolumbar burst fractures in neurologically intact patients provided better radiolographic outcomes, despite the result, that the difference between surgically and nonsurgically treated patients in terms of clinical outcome parameters and quality of life was not statistically significant. LEVEL OF EVIDENCE: 3.