Acute Ankle Diastasis Injuries Treated with Dynamic, Static Fixation or Anatomic Repair: A Meta-Analysis and Systematic Review of Comparison Studies.

BACKGROUND: Acute ankle diastasis injuries are complex and debilitating. These injuries occur when the syndesmotic complex becomes compromised. Treatments of acute syndesmotic injuries include static fixation with screws, dynamic fixation with an elastic device, or anatomic repair of the damaged ligament. However, there is disagreement over which method is most effective. The primary purpose of this study was to compare the 3 treatment methods for acute syndesmotic injuries. METHODS: A systematic literature search was conducted on Embase and PubMed. Studies that compared at least 2 groups with relevant American Orthopaedic Foot & Ankle Society (AOFAS), Visual Analog Scale (VAS), reoperation rate, and complication (implant failure, implant irritation, and infection) data were analyzed. Statistical analysis for this study was performed using Review Manager 5.4, with a standard p-value of ≤0.05 for statistical significance. RESULTS: Twenty-one studies including a total of 1,059 patients (452 dynamic, 529 static, and 78 anatomic) were included for analysis. Dynamic fixation had significantly higher mean AOFAS scores at 3 months postoperation by 5.12 points (95% confidence interval [CI], 0.29-9.96, p = 0.04) as well as at 1 year postoperation by 4.64 points (95% CI, 1.74-7.55, p = 0.002) than static fixation. Anatomic repair had significantly higher AOFAS scores at 6 months postoperation by 3.20 points (95% CI, 1.06-5.34, p = 0.003) and 1 year postoperation by 1.86 points (95% CI, 0.59-3.14, p = 0.004) than static fixation. Dynamic fixation had significantly higher AOFAS scores at 6 months postoperation by 2.81 points (95% CI, 0.76-4.86, p = 0.007), 12 months postoperation by 3.17 points (95% CI, 0.76-5.58, p = 0.01), and at 2 years postoperation by 5.56 points (95% CI, 3.80-7.32, p < 0.001) than anatomic repair. Dynamic fixation also had a lower VAS score average (favorable), only significant at 12 months postoperation, than static fixation by 0.7 points (95% CI -0.99 to -0.40, p < 0.001). Anatomic repair did not have significant difference in VAS scores compared with static fixation. Anatomic repair had significantly lower VAS scores at 12 months postoperation by 0.32 points (95% CI -0.59 to -0.05, p = 0.02) than dynamic fixation. Dynamic fixation had significantly less implant failures (odds ratio [OR], 0.13, 95% CI, 0.05-0.32, p < 0.001) than static fixation. Anatomic repair was not significantly different from static fixation in the complication metrics. Dynamic fixation and anatomic repair were not significantly different in the complication metrics either. Dynamic fixation had a significantly lower reoperation rate than static fixation (OR, 0.23, 95% CI, 0.09-0.54, p < 0.001). Anatomic repair did not have a significantly different reoperation rate compared with static fixation. However, dynamic fixation had a significantly lower reoperation rate than anatomic repair (OR, 4.65, 95% CI, 1.10-19.76, p = 0.04). CONCLUSION: Dynamic fixation seems to demonstrate superior early clinical outcomes. However, these advantages become negligible in the long term when compared with alternative options. Dynamic fixation is associated with a lower risk for complications, specifically seen with the decrease in implant failures. This method also presents a significantly lower reoperation rate compared with the other treatment approaches. Apart from showing improved early clinical outcomes in comparison with static fixation, anatomic repair did not have significant distinctions in other metrics, including complications or reoperation rate. LEVEL OF EVIDENCE: Level III. See Instructions for Authors for a complete description of levels of evidence.

Systematic review of periprosthetic tibia fracture after total knee arthroplasties.

AIM: To investigate the known incidences, treatment options, and related outcomes of periprosthetic tibia fractures after total knee arthroplasty (TKA). METHODS: A literature search was done to identify studies that fit the inclusion criteria. The database search yielded 185 results, which were further reduced by the exclusion criteria to 13 papers, totaling 157 patients that met these criteria. Incidence rates of the different types of periprosthetic tibia fractures were determined and their treatments were subsequently analyzed based on the fracture's subclass, with patient outcomes being overall favorable. RESULTS: Of the 144 documented patients, 54 (37.5%) had a subclass C fracture, which are frequently seen in revision arthroplasties or when using cement intraoperatively. The fractures of subclasses A and B occur postoperatively. There were 90 subclass A and B fractures with incidences of 18.75% and 43.75% respectively. When broken down by type, 62 (55.36%) were type 1, 24 (21.4%) were type 2, 24 (21.4%) were type 3, and 2 (1.8%) were type 4. Furthermore, from the studies that included origin of injury, the types were further classified as having non-traumatic or traumatic origins. Type 1 had 78% (40/51) non-traumatic origin and 22% (11/51) traumatic origin. Fifteen fractures were type 2, but 5 were falls and 1 through a motor vehicle accident, giving a trauma causation of 40% (6/15). Of the 24 type 3 fractures, 12 were falls and 2 vehicular accidents, leading to a trauma causation of 58% (14/24). CONCLUSION: Type 1 fractures were the most common. Subclass A was treated with locking plates, B required a revision TKA, and C was treated intraoperatively or nonoperatively.

Quantitative changes in the cervical neural foramen resulting from axial traction: in vivo imaging study.

BACKGROUND CONTEXT: Cervical traction has a long history as a method of conservative treatment for cervical spine diseases. However, information on quantitative changes in the cervical neural foramen resulting from axial traction in vivo is lacking. PURPOSE: To quantitatively evaluate the changes in the neural foramen of the cervical spine during axial traction in vivo. STUDY DESIGN: A prospective radiographic analysis of the cervical neural foramen of adult volunteers. PATIENT SAMPLE: Fifteen healthy volunteers (10 men, 5 women) without any history of cervical spine disease. OUTCOME MEASURES: The changes in cervical cross-sectional foraminal areas and heights were measured. METHODS: Cervical magnetic resonance (MR) images of the volunteers were taken at the neutral position and were reconstructed in the oblique plane perpendicular to the long axis of each neural foramen from the C2-3 to the C6-7 level. The changes in the neural foraminal dimensions at incremental axial traction forces (0, 5, 10, and 15 kg) were analyzed. RESULTS: After each 5-kg incremental increase in traction weight, there was a significant (p value less than .05) increase in area and height of the intervertebral foramen compared with the position in which no weight was applied. There was an average increase of 5.81%, 16.56%, and 18.9% in the foraminal area and an average increase of 3.75%, 8.67%, and 10.43% in foraminal height compared with the position with no weight at traction of 5, 10, and 15 kg, respectively. There was no statistically significant difference for the increase in foraminal area and height from 10 to 15 kg of traction (p value greater than .05). CONCLUSIONS: There was a significant increase in intervertebral foraminal area and height after each 5-kg increment in traction weight compared with the position in which no weight was applied. From 10 to 15 kg of traction, there was no significant change in the foraminal area and height.

Evaluation of skull thickness and insertion torque at the halo pin insertion areas in the elderly: a cadaveric study.

BACKGROUND CONTEXT: The halo skeletal fixator provides the most rigid type of immobilization of all the orthoses that stabilize the cervical spine. Sometimes with older patients (>70 years old), the pin penetrates the cortical and cancellous bone of the skull and enters the intracranial space, which can result in serious complications such as brain injury, infection, hematoma, and loss of cerebrospinal fluid from the subarachnoid space. Currently, there is a lack of relevant literature that examines these concerns. PURPOSE: To evaluate the thickness of the outer table, diploe, and inner table at the anterolateral and posterolateral pin insertion areas of the skull in elderly cadavers by using computed tomography (CT) scans. In addition, insertion torques at the four standard pin insertion areas was determined by applying halo pins at incremental torque in an effort to suggest safe torque levels for the anterolateral and posterolateral pins. STUDY DESIGN/SETTING: A human cadaveric anatomical and biomechanical study relating to thickness and insertion torques at standard pin areas in the elderly. PATIENT SAMPLE: Twenty-one elderly cadaveric skull specimens. OUTCOME MEASURES: Thickness of cortices (tables) and diploe of skull and insertion torque at halo pin insertion areas. METHODS: Aquarius Image software at the CT scanner's TeraRecon Aquarius Workstation was used to make the necessary skull thickness measurements at the pin insertion areas. Six, 8, 12, 18, and 36 inch lb of torque were used to determine penetration of the pins through the inner table at each of the four locations (two anterolateral and two posterolateral). RESULTS: The mean anterolateral thickness was 7.36+/-1.57 mm. The average thickness of the outer table, diploe, and inner table were 2.24+/-0.44 mm, 1.52+/-0.41 mm, and 3.59+/-1.70 mm, respectively. The mean posterolateral thickness was 9.47+/-1.12 mm. The average thickness of the outer table, diploe, and inner table were 4.32+/-0.92 mm, 1.88+/-0.35 mm, and 3.27+/-1.21 mm, respectively. No pin penetration was seen at the traditional 8 inch lb of insertion torque in both the anterolateral and posterolateral pin insertion areas. Eighteen inch lb of torque resulted in penetration in 90.48% (19/21) and in 85.71% (18/21) of specimens in the left anterolateral and right anterolateral pin insertion areas, respectively. No penetration was seen even at 36 inch lb of torque in 80.95% (17/21) of the cadavers in both the left and right posterolateral pin insertion areas. CONCLUSIONS: The current study supported previous research that 8 inch lb of torque is safe for application of halo pins in the elderly. The posterolateral skull is thicker and stronger than the anterolateral skull. The safe maximum torque is 8 inch lb for anterolateral pin insertion area and 18 inch lb for the posterolateral pin insertion area.

Changes of pulmonary function for patients with osteoporotic vertebral compression fractures after kyphoplasty.

One of the consequences of osteoporotic vertebral compression fractures (OVCFs) is progressive collapse of the fractured osteoporotic vertebral body. This can lead to spinal kyphosis that may cause restriction of respiratory function. The balloon kyphoplasty procedure can reduce kyphosis and relieve the pain. There are few studies that have appropriate data and follow-up to evaluate the effect of deformity correction on pulmonary function after the kyphoplasty procedure. The current study explores changes of pulmonary function of 30 older women who suffered from OVCFs in the thoracolumbar segment after kyphoplasty. After kyphoplasty was performed on these women, thoracic kyphotic angle, local kyphotic angle, pain scores, and pulmonary function parameters-vital capacity, inspiratory capacity, residual volume, functional residual capacity, total lung capacity, forced vital capacity (FVC), and maximum voluntary ventilation (MVV) were measured. All measurements were taken before, 3 days after, and 1 month after the kyphoplasty. The height of the vertebral body was restored, the local kyphotic angle was improved, and pain scores were significantly decreased after kyphoplasty. FVC and MVV were significantly increased 3 days after the procedures; whereas only MVV had gone on to improve 1 month later. The decreased values of pain scores had a remarkably positive correlation with the percentage of improvement of FVC (r=0.536) and MVV (r=0.614) measured 3 days after kyphoplasty. In patients with OVCFs, kyphoplasty could partially improve their impaired lung function.

Preservation of the spinous process-ligament-muscle complex to prevent kyphotic deformity following laminoplasty.

BACKGROUND CONTEXT: Long-term results of patients treated with conventional laminoplasty have shown a significant number of patients complicated with kyphotic deformity. The authors hypothesize that by maintaining the spinous process-ligament-muscle complex (SPLMC) during laminoplasty, followed by postoperative muscle strengthening exercises, the formation of kyphosis can be decreased. PURPOSE: To evaluate the incidence of kyphosis in a select patient group undergoing laminoplasty with preservation of the SPLMC followed by neck strengthening exercises. STUDY DESIGN/SETTING: A midterm retrospective study of 30 patients following laminoplasty with preservation of the SPLMC. PATIENT SAMPLE: Thirty consecutive patients with cervical myelopathy attributable to multilevel cervical spinal stenosis underwent laminoplasty with preservation of the SPLMC from April 1998 to July 2002. OUTCOME MEASURES: Preoperative and postoperative Japanese Orthopedic Association (JOA) scores, Guigui angles, and axial symptoms were measured. METHODS: Thirty patients with multiple-level cervical myelopathy were studied. Fourteen had a normal lordotic curve, whereas 16 had a straight curve. All these patients underwent laminoplasty with preservation of the SPLMC. For the first 6 months, isometric neck muscle exercises were performed. After this time, the intensity of the exercises was gradually increased. RESULTS: The average preoperative JOA score was 5.8+/-1.4. Mean JOA score at 3.8 years follow-up was 13.6+/-2.1. The recovery ratio was 69%. All 14 presurgical lordotic curves remained lordotic. Fourteen of the 16 straight spines improved to a lordotic configuration. Using the Guigui method, the preoperative lordotic angle was corrected by approximately 9 degrees (mean preoperative of 9.89+/-1.13 degrees, mean postoperative of 18.66+/-1.85 degrees), and the preoperative straight angle was corrected by approximately 15 degrees (mean preoperative of 0.91+/-2.14 degrees, mean postoperative of 15.88+/-1.71 degrees). CONCLUSIONS: Laminoplasty with preservation of the SPLMC followed by appropriate postoperative muscle exercises may be an encouraging way to maintain or restore the physiological curve and prevent kyphotic deformity at a medium term follow-up.

Reconstruction of comminuted posterior wall fractures using the buttress technique: a review of 32 fractures.

Fractures of the posterior wall are the most common of the acetabular fractures. The aim of this study was to assess the medium-term results of reconstruction of comminuted posterior wall fractures of the acetabulum by using the buttress technique. This is a retrospective review conducted at a level 1 trauma centre. Thirty-two patients (25 men, 7 women, mean age 41 years, range 14-80 years) with comminuted posterior wall fracture of the acetabulum underwent reconstruction of the posterior wall during the period of July 1998 to February 2004. The average follow-up was 43 months (range 24-70 months). Clinical evaluation was based on modified Merle d'Aubigne and Postel scoring. Radiographic evaluation was according to criteria developed by Matta. The postoperative reduction was graded as anatomical in 28 patients (88%) and imperfect in 4 patients (12%). The clinical outcome was excellent in 11 (34% ), very good in 9 (28%), good in 4 (12%), fair in 3 (9%) and poor in 5 (15%). Radiological grading at the final follow-up was excellent 12 (37%), good 11 (34%), fair 4 (12%) and poor 5 (15%). Reconstruction of comminuted posterior wall acetabular fractures by buttress technique can be expected to produce good results. It can provide a stable fixation of the posterior wall amenable to early range of motion and weight bearing.

How the increase of the cervical disc space height affects the facet joint: an anatomy study.

STUDY DESIGN: In vitro study on the effect of increasing the height of the cervical disc space on the facet joint. OBJECTIVES: To demonstrate how facet joint articulation is affected by increasing the cervical disc space height. SUMMARY OF BACKGROUND DATA: A surgeon attempts to increase the disc space and inserts a larger artificial disc than normal in order to keep the intervertebral foramen open and the prosthesis stable. However, it is hypothesized by the current authors that this procedure could have an adverse effect on the facet joints. METHODS: Computerized tomography images passing through the disc space and the center of the C4-C7 facet joints (sagittal plane) were obtained from 15 cadaveric cervical spine specimens. A 1-mm incremental increase to a total 5 mm in disc space height was performed to simulate the changes seen in disc replacement. The change in the facet joint articulation overlap and space in the sagittal plane at normal and each displacement was measured. RESULTS: Each 1-mm incremental increase in disc space at C4-C5 translated to a decrease in the facet joint articulation overlap in the sagittal plane by approximately 8%. The mean facet joint space increased approximately 0.8 mm. At the C5-C6 and the C6-C7 levels, the articulation overlap decreased by approximately 7% and the facet joint space increased approximately 0.8 mm. CONCLUSIONS: There is a significant decrease of the facet joint articulation overlap in the sagittal plane and an increase in the facet joint space following an increase in the cervical disc space. The inappropriate increase of the disc space height may result in facet joint subluxation and could lead to the accelerated failure of the artificial disc.