Minimally invasive surgery technique for unstable pelvic ring fractures with severe vertical shear displacement: A retrospective study.

BACKGROUND: Unstable pelvic fractures, especially vertical shear fractures, require surgery for correct reduction, rigid fixation, and improved postoperative outcomes. Herein, we assess the effectiveness of our minimally invasive procedure for the management of unstable pelvic fractures. HYPOTHESIS: We hypothesized that this procedure would be useful for the management of unstable pelvic fractures. PATIENTS AND METHODS: This study included 28 patients with unstable pelvic fractures (vertical shear injuries; AO types C1-3) treated using minimally invasive surgery for spinopelvic fixation (MIS-SP) between 2014 and 2020 (mean follow-up time, 15 months). The MIS-SP requires four percutaneous pedicle screws and four iliac screw insertions. Subsequently, reduction and fixation are performed. RESULTS: The mean preoperative displacement of the posterior pelvic elements in craniocaudal correction was 17.6 (range, 9.0-32.2) mm. The mean length of the craniocaudal reduction was 16.5 (8.1-30.1) mm, with a mean reduction rate of 93.5% (78%-100%). The mean length of the mediolateral reduction was 11.3 (3.9-19.6) mm, with a mean reduction rate of 87.3% (76%-100%). DISCUSSION: Our novel reduction and fixation procedure is a powerful, minimally invasive option for the treatment of unstable pelvic ring fractures. LEVEL OF EVIDENCE: III.

Can a true perforator flap survive on venous blood? A case report of anterolateral thigh true perforator flap supplied by antegrade venous inflow.

In some cases of degloving injury, as a result of multiple venous anastomoses formed on the peripheral and proximal sides, the detached flap skin did survive, though with patchy necrosis. On the basis of this experience, the skin and soft-tissue defects after removing skin cancer were closed with an anterolateral thigh true perforator flap, measuring 4 × 5 cm in size, which is nourished by venous blood. The subcutaneous vein on the peripheral side of the defect was anastomosed to the perforator artery, and the veins on the proximal side of the defects were anastomosed to the concomitant veins of the perforator. After surgery, to ensure a sufficient blood flow to the flap, the affected limb was positioned lower than the heart for 1 week. To prevent microthrombus in the perforator branch and the flap, preventive anticoagulant therapy was performed. The transplanted flap had marked cyanosis for a few days, but turned pinkish on the sixth day after surgery. The flap survived completely. As opposed to venous flaps reported in the past, the physiologic direction of blood flow of the flap is from arteries to veins, and it is nourished exclusively by venous blood. If a flap is small, and there are no appropriate recipient vessels nearby, this method could serve as a favorable alternative.

Risk factors for lumbosacral plexus palsy related to pelvic fracture.

STUDY DESIGN: A retrospective study. OBJECTIVE: We assessed risk factors for lumbosacral plexus palsy related to pelvic fracture that can be evaluated during the acute injury phase with diagnostics such as computed tomography (CT). SUMMARY OF BACKGROUND DATA: Many patients with pelvic fracture are in vital shock, with polytrauma and loss of consciousness, making an accurate neurologic examination very difficult in the emergency room. METHODS: This study included 22 patients who had AO classification type B or C pelvic fractures. The 22 patients had 27 posterior osteoligamentary lesions. The average injury severity score (ISS) was 27.5 (range, 16-50). Age, sex, ISS, suicidal jump, longitudinal displacement, sacral transverse fracture, pubic fracture, lumbar transverse process fracture, type of pelvic fracture (AO), and type of sacral fracture (Denis) were examined for a correlation with the lumbosacral plexus palsy. Using coronal reconstruction CT, we considered a 10 mm or greater displacement at the sacrum or sacroiliac joint to be a longitudinal displacement. Transverse sacral fracture was diagnosed by sagittal reconstruction CT. RESULTS: Of the 22 patients, 5 (22.7%) had lumbosacral plexus palsy (8 of 27 pelvic fractures) detected during treatment. The incidence of lumbosacral plexus palsy was not related to age, sex, ISS. Incidence of palsy was significantly higher when the patient's affected side had longitudinal displacement. Patients who had made a suicidal jump or had a sacral transverse fracture also had a significantly higher risk for lumbosacral plexus palsy. Palsy was not related to the type of pelvic fracture (AO) or sacral fracture (Denis). CONCLUSION: In this study, longitudinal displacement of the pelvis, transverse sacral fracture, and trauma from a suicidal jump were risk factors for lumbosacral plexus palsy. These risk factors were helpful in our examination of patients who had severe pelvic fracture with loss of consciousness.

Cervical cord injury in patients with ankylosed spines: progressive paraplegia in two patients after posterior fusion without decompression.

STUDY DESIGN: Case report and clinical discussion. OBJECTIVE: To describe technical pitfall to treat 2 cervical cord injuries, including dislocations in patients with ankylosed spine due to diffuse idiopathic skeletal hyperostosis (DISH) or ossification of the posterior longitudinal ligament (OPLL). SUMMARY OF BACKGROUND DATA: DISH and OPLL are disease processes similar in pathology, which can lead to unexpected fractures due to low-energy trauma. In reported cases of fracture of the ankylosed spine in patients with DISH or OPLL, increasing lever arm and a grossly unstable fracture occurred. However, the actual surgical intervention for these fractures and spinal cord injuries was not discussed. METHODS: We report 2 cervical cord injuries, including dislocations in patients with ankylosed spine due to DISH or OPLL. RESULTS: Two patients underwent posterior fusion without decompression; however, postoperative progressive paraplegia still occurred. There were 3 points in common: these patients had ankylosed spines due to DISH or OPLL; they were elderly and had spinal canal stenosis; and after undergoing posterior fusion without decompression, their bilateral, lower extremity palsies worsened after surgery. Cervical alignment was slightly different after posterior fusion, and this change concentrated in one segment because adjacent vertebral bodies were ankylosed, and thus, immoveable. Additionally, this stress caused infolding of the ligamentum flavum with resultant spinal cord compression. CONCLUSION: In these cases, we recommend posterior fusion and decompression such as laminoplasty to avoid worsening palsy.

Deep venous thrombosis in patients with acute cervical spinal cord injury in a Japanese population: assessment with Doppler ultrasonography.

BACKGROUND: Deep venous thrombosis (DVT) and pulmonary thromboembolism are major complications in patients with acute spinal cord injury. The incidence of DVT in patients with a spinal cord injury has ranged from 5% to 26% in several countries; however, the incidence in Japan is unknown. METHODS: We retrospectively assessed 52 patients with acute cervical spinal cord injury. According to the American Spinal Injury Association Impairment Scale (AIS) at admission, 17 patients were grade A, 15 grade B, 17 grade C, and 3 grade D. These patients were assessed for a DVT using color Doppler ultrasonography (US) regardless of whether they were symptomatic. As standard protocol, we perform Doppler US 5 days after injury; however, this retrospective research included patients who were assessed 2-13 days after injury. RESULTS: In this study, 11 of 52 (21%) patients had DVT. Three patients had DVT of the right leg, six of the left leg, and two of bilateral legs. There were two proximal-type DVTs and nine distal-type DVTs. No patients had a symptomatic thrombopulmonary embolism. In all, 10 of 41 (24%) men had DVT and 1 of 11 (9%) women had DVT (P = 0.26). A total of 7 of 32 (22%) patients who had complete motor palsy (AIS A or B) had DVT, and 4 of 20 (20%) with incomplete motor palsy (AIS C or D) had DVT (P = 0.58). DVT was found 2-13 days after injury. CONCLUSIONS: In this study of the Japanese population, 11 of 52 (21%) patients with acute cervical spinal cord injury had DVT. Several studies showed there were no differences in the incidence of DVT between patients with complete or incomplete palsy, and our study showed the same results. Many asymptomatic patients had DVT, so asymptomatic patients should not be neglected.

Clinical accuracy of 3D fluoroscopy-assisted cervical pedicle screw insertion.

OBJECT: Cervical pedicle screw (PS) misplacement leads to injury of the spinal cord, nerve root, and vertebral artery. Recently, several investigators reported on the usefulness of a spinal navigation system that improves the accuracy of PS insertion. In this study, the authors assessed the accuracy of cervical pedicle, lateral mass, and odontoid screw insertions placed using a 3D fluoroscopy navigation system, the Iso-C3D unit. METHODS: In this prospective analysis of the authors' initial 50 cases of 3D fluoroscopy-assisted cervical screw insertion, the authors inserted 176 PSs, 58 lateral mass screws, and 5 odontoid screws into the C1-7 vertebrae. They placed screws using intraoperative acquisition of data by the isocentric C-arm fluoroscope and a computer navigation system. They obtained postoperative fine-cut CT scans in all patients and assessed the accuracy of screw insertion. RESULTS: A PS (>or= 3.5 mm) could be inserted into 24 (63%) of 38 pedicles at the level of C-3, 18 (53%) of 34 pedicles at C-4, 30 (65%) of 46 at C-5, 33 (80%) of 41 at C-6, and 43 (100%) of 43 at C-7. Of 176 PSs inserted into vertebrae between C-2 and C-7, 171 screws (97.2%) were classified as Grade 1 (no pedicle perforation), and 5 screws (2.8%) were classified as Grade 2 (screw perforation of the cortex by up to 2 mm). Clinically significant screw deviation in the present study was considered Grade 3 (screw perforation of the cortex by > 2 mm), and this occurred in 0% of the placements. CONCLUSIONS: In this study, the authors were able to correctly insert cervical PSs using the 3D fluoroscopy and navigation system.