Effect of low-intensity pulsed ultrasound on posterolateral lumbar fusion of rabbit

Objective:To observe the effect of low-intensity pulsed ultrasound in the posterolateral Lumbar fusion of rabbit.Methods:A total of 48 New Zealand white rabbits were randomly divided into the observation group and control group,including the autogenous iliac observation group.artificial bone observation group,artificial bone control group and autogenous iliac control group according to the different bone grafting.The posterolateral lumbar fusion of rabbits in each group was analyzed and compared.Results:After 4 weeks of treatment using the low-intensity pulsed ultrasound,the fusion in the bone grafting area of observation group was good.There was the relatively dense fusion area between the right transverse process and artificial bone.The left transverse process had been completely fused,with the clear bone trabecula through the fusion area.There was no significant fusion sign in the control group.According to the fusion comparison between two groups,the fusion rale of the observation group was 83.3%and it was significantly higher than the one of the control group(37.5%).Results of the comparison were statistically significant(P<0.05).The number of chondrocytes and the increase in the relative gray-scale in the fusion area of the iliac observation group were significantly higher than ones of the iliac control group(P<0.05).The number of chondrocytes and the increase in the relative gray-scale in the fusion area of the artificial bone observation group were significantly higher than ones of the artificial bone control group(P<0.05).The expression of IL-1.IL-6 and IL-17 4 weeks after the treatment of the observation group was significantly lower than the one of the control group,with the statistical significance(P<0.05).It indicated that the treatment of low-intensity pulsed ultrasound could reduce the expression level of inflammatory factors.Conclusions:The low-intensity pulsed ultrasound can significantly increase the bone grafting fusion rate of the rabbit's posterolateral lumbar fusion.The possible mechanism is that it promotes the lumbar posterolateral endochondral ossification and reduces the inflammatory reaction.

A Seated Single-Person Dial-Test for Posterolateral Corner and Posterior Cruciate Ligament Knee Injuries

Background: Injuries to the posterolateral corner of the knee (PLC) can be difficult to diagnose and are often missed. The prone dial test can be difficult to perform in the acute setting and the supine dial test requires an assistant. Purpose: We present a simple single person seated dial test that can easily be performed in all patients with a suspected diagnosis of PLC injury. Study Design: Case Series. Method: The patient is seated on the edge of the examination couch with their knees flexed over the side and their calves pressed against the couch to reduce any posterior tibial subluxation. The patients’ knees are placed together ensuring the pelvis is square;the knees are at the same level, and the patellae are facing anteriorly. The patients place their hands against the side of their knees and hold their knees together in this position. The examiner then grasps the patient’s feet, approximates the medial malleoli and exerts a lateral rotational force at 30 and 90 degrees of knee flexion. Results: This test has 100% accuracy for diagnosing PLC injury in our institution. Conclusion: We present a sample to use alternative to traditional dial testing that does not require an assistant and also does not require the patient to be prone, thus limiting discomfort in the acute setting.

Treatment of Posterior Malleolus Fracture through Posterolateral Approach

Posterior malleolus fractures are quite common and usually result from rotational ankle injuries. For the management of posterior malleolus fractures, more studies are still required, though it is already well-recognized for medial and lateral structure. Therefore, fracture of posterior malleolus is striking subject of study among orthopedic surgeons. Most orthopedic surgeons recommend fixing the posterior malleolus fracture if it is larger than 25% to 33% of the distal articular surface. Further attention is required for the reduction and fixation of fractures involving posterior malleolus. Several approaches and methods for fixation of posterior malleolus have been defined in the literature. Previously, the most common method of fixation of the posterior malleolus is by indirect reduction and antero-posterior screws, it is minimally invasive, the anterior incision does not allow satisfactory visualization of the fragment, so good anatomical reduction is difficult to achieve thorough this approach. Operative management goals to reach a stable ankle with maximal function, decrease the risk of post-traumatic degenerative changes, and diminish the risk of complication. Nowadays, posterolateral approach is gaining the popularity due to adequate visualization and accurate anatomic reduction.

Comparison of Fusion Rates between Autologous Iliac Bone Graft and Calcium Sulfate with Laminectomy Bone Chips in Multilevel Posterolateral Spine Fusion

Multilevel lumbar fusion usually requires a large quantity of iliac crest bone graft but the supply is usually insufficient, so an alternative bone graft substitute for autograft is needed. This prospective study investigated the efficacy of calcium sulfate by comparing the fusion rates between the experimental material (calcium sulfate pellets with bone chips from laminectomy) and autologous iliac bone graft in long segment (three-or four-level) lumbar and lumbosacral posterolateral fusion. Forty-five patients with degenerative scoliosis or spondylolisthesis received multilevel spine fusion and decompression. The experimental material of calcium sulfate pellets with decompression bone chips was placed on the experimental side and the iliac crest bone graft was placed on the control side. The fusion status was assessed radiographically at three-month intervals, and solid fusion was defined as a clear continuous intertransverse bony bridge at all levels. The average follow-up period was 34.4 months. Twenty-nine (64.4%) patients showed solid fusion on the experimental side and 39 (86.7%) patients on the control side. The overall fusion rate was 86.7%. A statistically significant relation was found between the two sides with the Kappa coefficient of agreement of 0.436. Compared to the control side, the fusion rate of experimental side is significantly reduced (p = 0.014). The fusion ability of autograft is higher than the experimental material in multilevel lumbar posterolateral fusion. However, the overall fusion rate of calcium sulfate pellets is improved, compared with previously reported rates, which suggested that such material may be considered as an acceptable bone graft extender.

Utilizing Wiltse Approach for Minimal Access Posterolateral Lumbar Stabilization

An aggressive separation and prolonged overstretching of the paraspinal muscles in the posterior midline approach during lumbar non fusion dynamic stabilization in cases of spondylolisthesis resulting from pars interarticularis fracture may result in postoperative flat back deformity and intractable chronic pain. It is hypothesized that utilizing Wiltse paraspinal inter-muscular approach for this purpose may result in reduction of operative time, protection of integrity, vascularity, nerve supply and strength of paraspinal muscles, shortening of hospitalization and minimizing development of chronic postoperative back pain. So, I have performed this prospective descriptive study that involved 24 patients having single level lumbar instability at L4-5 or L5-S1 levels. All patients were operated upon using Wiltse minimal access posterolateral surgical technique for non-fusion dynamic stabilization. The final results revealed that males were 66%, females were 33% and ages were 42 ± 6 years. Trauma was reported in 12%. Low back pain and tenderness were reported in 100% and root affection reported in 25%. Plain X-ray and MRI were done in 100% and C.T. was done in 8% of cases. Level L4-5 was affected in 17% while level L5-S1 was affected in 83%. Anterolisthesis “grades 0” was found in 8%, grades 1 in 88% and retrolisthesis in 4% of cases. Operative time was 1 hour ± 10 min., blood loss was 60 ± 20 ml., patients ambulation was after 6 - 8 hours, hospital stay was 12 - 24 hours. None of cases were complicated with infection, screw loosening, or fixation system break. Back pain VAS diminished from 7 preoperative to 5 in 2nd day, then became 4 by 1 week, 3 by 1 month and 0 by 6 months. It was concluded that utilizing Wiltse approach for posterolateral lumbar stabilization minimizes tissue damage and improves the speed of recovery and outcome.

Posterior Lumbar Interbody Fusion versus Posterolateral Fusion in Surgical Treatment of Lumbar Spondylolithesis

Background: The optimal surgical technique for lumbar spondylolithesis remains debated. Although posterior lumbar interbody fusion (PLIF) theoretically offers more advantages than posterolateral lumbar fusion (PLF), the evidence remains inconclusive. Aim: The aim of this study is to compare the clinical and functional outcomes of PLIF versus PLF in patients with lumbar spondylolithesis. Patients and Methods: We enrolled 38 patients with lumbar spondylolithesis (degenerative and isthmic) who underwent PLIF (N = 19) or PLF (N = 19). We collected operative data and performed follow-up for 12 months after the surgery. The collected data were analyzed using the SPSS software to detected significant differences between both groups. Results: The PLF and PLIF groups exhibited similar pre-operative characteristics between both groups in terms of age (p = 0.57), sex (p = 0.73), clinical presentation (p = 1), required levels of fixation (p = 1), pre-operative VAS score (p = 0.43) or muscle weakness (p = 1). However, the PLIF group had significantly more blood loss and longer operative time than the PLF group. Moreover, both groups had similar levels of postoperative pain (up to six months after surgery), and post-operative complications. The rates of arthrodesis were higher in PLIF group than PLF group within six months while no significant difference within 12 months of follow-up. Conclusion: In our comparative study, we achieved comparison between pedicle screw fixation with posterolateral fusion alone (PLF) in compare with pedicle screw fixation with posterior lumbar interbody fusion (PLIF). Results indicate better results of fusion rate in PLIF as regards arthrodesis with slightly more rate of complication than PLF. So we recommend PLIF in cases of lumbar spondylolithesis than PLF.

Bipolar hip arthroplasty using conjoined tendon preserving posterior lateral approach in treatment of displaced femoral neck fractures

BACKGROUND Hip fractures account for 23.8%of all fractures in patients over the age of 75 years.More than half of these patients are older than 80 years.Bipolar hemiarthroplasty(BHA)was established as an effective management option for these patients.Various approaches can be used for the BHA procedure.However,there is a high risk of postoperative dislocation.The conjoined tendon-preserving posterior(CPP)lateral approach was introduced to reduce postoperative dislocation rates.AIM To evaluate the effectiveness and safety of the CPP lateral approach for BHA in elderly patients.METHODS We retrospectively analyzed medical data from 80 patients with displaced femoral neck fractures who underwent BHA.The patients were followed up for at least 1 year.Among the 80 patients,57(71.3%)were female.The time to operation averaged 2.3 d(range:1-5 d).The mean age was 80.5 years(range:67-90 years),and the mean body mass index was 24.9 kg/m^(2)(range:17-36 kg/m^(2)).According to the Garden classification,42.5%of patients were typeⅢand 57.5%of patients were typeⅣ.Uncemented bipolar hip prostheses were used for all patients.Torn conjoined tendons,dislocations,and adverse complications during and after surgery were recorded.RESULTS The mean postoperative follow-up time was 15.3 months(range:12-18 months).The average surgery time was 52 min(range:40-70 min)with an average blood loss of 120 mL(range:80-320 mL).The transfusion rate was 10%(8 of 80 patients).The gemellus inferior was torn in 4 patients(5%),while it was difficult to identify in 2 patients(2.5%)during surgery.The posterior capsule was punctured by the fractured femoral neck in 3 patients,but the conjoined tendon and the piriformis tendon remained intact.No patients had stem varus greater than 3 degrees or femoral fracture.There were no patients with stem subsidence more than 5 mm at the last follow-up.No postoperative dislocations were observed throughout the follow-up period.No significance was found between preoperative and postoperative mean Health Service System scores(87.30±2.98 vs 86.10±6.10,t=1.89,P=0.063).CONCLUSION The CPP lateral approach can effectively reduce the incidence of postoperative dislocation without increasing perioperative complications.For surgeons familiar with the posterior lateral approach,there is no need for additional surgical instruments,and it does not increase surgical difficulty.

Enhanced bone regenerative properties of calcium phosphate ceramic granules in rabbit posterolateral spinal fusion through a reduction of grain size

Osteoinductivity is a crucial factor to determine the success and efficiency of posterolateral spinal fusion(PLF)by employing calcium phosphate(Ca-P)bioceramics.In this study,three kinds of Ca-P ceramics with microscale to nanoscale gain size(BCP-control,BCP-micro and BCP-nano)were prepared and their physicochemical properties were characterized.BCP-nano had the spherical shape and nanoscale gain size,BCP-micro had the spherical shape and microscale gain size,and BCP-control(BAM®)had the irregular shape and microscale gain size.The obtained BCP-nano with specific nanotopography could well regulate in vitro protein adsorption and osteogenic differentiation of MC3T3 cells.In vivo rabbit PLF procedures further confirmed that nanotopography of BCP-nano might be responsible for the stronger bone regenerative ability comparing with BCP-micro and BCP-control.Collectedly,due to nanocrystal similarity with natural bone apatite,BCP-nano has excellent efficacy in guiding bone regeneration of PLF,and holds great potentials to become an alternative to standard bone grafts for future clinical applications.

Surgical resection of a giant thymolipoma causing respiratory failure: A case report

BACKGROUND Thymolipoma is a rare benign tumor arising from the anterior mediastinal thymus and is composed of mature fatty tissue and interspersed nonneoplastic thymic tissue. This tumor accounts for only a small percentage of mediastinal masses, and the majority of them are asymptomatic and found incidentally. To date, fewer than 200 cases have been published in the world literature, of which most excised tumors weighed less than 0.5 kg and the largest weighed 6 kg.CASE SUMMARY A 23-year-old man presented with a complaint of progressive breathlessness for 6mo. His forced vital capacity was only 23.6% of the predicted capacity, and his arterial partial pressure of oxygen and carbon dioxide were 51 and 60 mmHg,respectively, without oxygen inhalation. Chest computed tomography revealed a large fat-containing mass in the anterior mediastinum that measured 26 cm × 20cm × 30 cm in size and occupied most of the thoracic cavity. Percutaneous mass biopsy revealed only thymic tissue without signs of malignancy. A right posterolateral thoracotomy was successfully performed to remove the tumor along with the capsule, and the excised tumor weighed 7.5 kg, which to our knowledge, was the largest surgically removed tumor of thymic origin. Postoperatively, the patient’s shortness of breath was resolved, and the histopathological diagnosis was thymolipoma. No signs of recurrence were observed at the 6-mo follow-up.CONCLUSION Giant thymolipoma causing respiratory failure is rare and dangerous. Despite the high risks, surgical resection is feasible and effective.

Minimally invasive procedures on the lumbar spine

Degenerative disease of the lumbar spine is a common and increasingly prevalent condition that is often implicated as the primary reason for chronic low back pain and the leading cause of disability in the western world. Surgical management of lumbar degenerative disease has historically been approached by way of open surgical procedures aimed at decompressing and/or stabilizing the lumbar spine. Advances in technology andsurgical instrumentation have led to minimally invasive surgical techniques being developed and increasingly used in the treatment of lumbar degenerative disease. Compared to the traditional open spine surgery, minimally invasive techniques require smaller incisions and decrease approach-related morbidity by avoiding muscle crush injury by self-retaining retractors, preventing the disruption of tendon attachment sites of important muscles at the spinous processes, using known anatomic neurovascular and muscle planes, and minimizing collateral soft-tissue injury by limiting the width of the surgical corridor. The theoretical benefits of minimally invasive surgery over traditional open surgery include reduced blood loss, decreased postoperative pain and narcotics use, shorter hospital length of stay, faster recover and quicker return to work and normal activity. This paper describes the different minimally invasive techniques that are currently available for the treatment of degenerative disease of the lumbar spine.

Arthroscopic approach to the posterior compartment of the knee using a posterior transseptal portal

Arthroscopic surgery of the posterior compartment ofthe knee is difficult when only two anterior portals are used for access because of the inaccessibility of the back of the knee. Since its introduction, the posterior transseptal portal has been widely employed to access lesions in the posterior compartment. However, special care should be taken to avoid neurovascular injuries around the posteromedial, posterolateral, and transseptal portals. Most importantly, popliteal vessel injury should be avoided when creating and using the transseptal portal during surgery. Purpose of the present study is to describe how to avoid the neurovascular injuries during establishing the posterior three portals and to introduce our safer technique to create the transseptal portal. To date, we have performed arthroscopic surgeries via the transseptal portal in the posterior compartments of 161 knees and have not encountered nerve or vascular injury. In our procedure, the posterior septum is perforated with a 1.5-3.0-mm Kirschner wire that is protected by a sheath inserted from the posterolateral portal and monitored from the posteromedial portal to avoid popliteal vessel injury.

Study of coronary sinus anatomy during levophase of coronary angiography

BACKGROUND Coronary sinus(CS)imaging has recently gained importance due to increasing need for mapping and ablation of electrophysiological arrhythmias and left ventricular(LV)pacing during cardiac resynchronization therapy(CRT).Retrograde venogram is the current standard for imaging CS and its tributaries.AIM To evaluate CS anatomy during levophase of routine coronary angiography to aid LV lead implantation during CRT.METHODS In this prospective observational study,164 patients undergoing routine coronary angiography for various indications(Chronic stable angina-44.5%,acute coronary syndrome-39.5%,Dilated cardiomyopathy-11%,atypical chest pain-5%)were included.Venous phase(levophase)of left coronary injection was recorded in left anterior oblique-cranial and right anterior oblique-cranial views.Visibility of coronary veins,width and shape of CS ostium,angulations of proximal CS with body of CS were noted.Presence,size,take-off angle and tortuosity of posterolateral vein(PLV),anterior interventricular veins(AIV)and middle cardiac vein(MCV)were also noted.RESULTS During levophase,visibility grade(Muhlenbruch grade)for coronary veins was 3 in 74%and 2 in 26%of cases.Visibility of CS did not correlate with body mass index.The diameter of CS ostium was<10 mm,10-15 mm and>15 mm in 48%,42%and 10%of patients respectively.Proximal CS was tubular in 136(83%)patients and funnel-shaped in 28(17%)patients.Sharp take-off angulation between ostium and body of CS was seen in 16(10%)patients.Two or more PLV were present in 8 patients while PLV was absent in 52(32%)patients.Angle of take-off of PLV with body of CS was favourable(0°-45°)in 65(40%)patients.The angle was 45°-90°in 36 patients and difficult take-off angle(>90°)was seen in 8 patients.Length of PLV reached distal third of myocardium in 84 cases and middle third in 11 cases.There was no tortuosity in 79 cases,a single bend in 29 cases and more than 2 bends in 4 cases.Thirty nine(24%)patients had other veins supplying posterior/Lateral wall of LV.There was a single vein supplying lateral/posterior wall in 31(19%)patients.Diameter of MCV and AIV was significantly larger in patients with absent PLV as compared to patients with a PLV.CONCLUSION Levophase study of left coronary injection is effective in visualization of the CS in almost all patients undergoing coronary angiography and may be an effective alternative to retrograde venogram in patients with LV dysfunction or LBBB.

Surgical Management of Spondylolisthesis by Pedicular Screw Rod System and Postero-Lateral Fusion

Introduction: Incidence of spondylolisthesis in general population is 5% - 7%. No matter what the etiology is, patients usually have significant functional disability. Few studies have investigated the long term effect of posterolateral fusion on functional outcome. Objectives: To study the efficacy of posterolateral fusion in spondylolisthesis especially in terms of functional outcome. Methodology: From July 2010 to June 2012, a total of 86 patients, operated with postero-lateral fusion were followed up and evaluated based on VAS for low back pain, ODI and neurological deficits. Results: Follow up was 83% of original study population (86). Average follow up was 13 months. The mean difference between pre-operative and post-operative VAS at final follow up was 3.5 cms (SD = 2.94);ODI was 28% at 4 months and 36% at 8 months. Claudication pain relieved in all;functional outcome was good in 67%, fair in 27.5% and failed in 5.5%;75% had fusion at an average of 5.5 months. Conclusion: Posteriolateral fusion is still a safe, promising and appealing technique.

Surgical Management of an Unstable Lumbar Fracture-Dislocation—A Case Report

The lumbar spine is the most common sites for fractures because of the high mobility of the lumbar spine. A spinal cord injury usually begins with a sudden, traumatic blow to the spine that fractures or dislocates vertebrae. A 32-year-old man presented to us after traffic accident. In our patient, unstable fracture-dislocation of the lumbar spine at the L2-L3 level due to traffic accident occurred. The vertebral bodies were fractured and the anterior dislocation happened without spinal cord injury. The patient was a candidate for an open reduction and internal fixation surgery. The posterolateral approach was performed. After insertion of all the pedicle screws, the rods were transversally placed on L2-L3-L4 vertebral bodies and tightened. The reduction of the dislocations was carried out by pushing downwards (foreside) L2 and L4 vertebras and upwards (backside) L3 vertebrae, simultaneously. After securing the reduction of the dislocations, the rods were opened and placed along the spinal column and tightened. This technique is more effective when the pedicle of fractured vertebrae is intact.

Comparison of DAA and PLA Approaches for Total Hip Replacement in the Treatment of Femoral Neck Fractures

Objectives: Femoral neck fractures are becoming more common within nowadays. This research is to explore the clinical effect of primary total hip replacement (THA) via direct anterior approach (DAA) and posterolateral approach (PLA) in the treatment of femoral neck fracture. Methods: Retrospective analysis of 100 cases of elderly patients with femoral neck fracture who underwent total hip arthroplasty admitted to Tianyou Hospital affiliated to Wuhan University of Science and Technology from January 2019 to January 2022. 50 patients treated with DAA approach were included in the observation group, and 50 patients treated with PLA approach were included in the control group. The operation indexes, postoperative acetabular abduction angle and anteversion angle, hip joint function, Harris score and complications were compared between the two groups. Result: The length of incision in the observation group was shorter than that in the control group, and the amount of intraoperative bleeding and postoperative hospital stay were shorter than those in the control group (P < 0.05);There was a statistically significant difference between the two groups in the ratio of acetabular abduction angle and its safe zone, and the length difference of both lower limbs (P < 0.05), while there was no statistically significant difference between the two groups in the ratio of acetabular anteversion angle and its safe zone, eccentricity, and its recovery rate (P > 0.05);Harris score of hip joint: 6 months after operation, the anterior approach group was significantly higher than the posterolateral approach group (P < 0.05), and there was no statistical difference between the two groups 12 months after operation (P > 0.05);The total incidence of complications in the observation group was lower than that in the control group, with a statistically significant difference (P Conclusion: DAA and PLA approaches for total hip replacement can restore the hip joint structure of patients with femoral neck fractures and achieve good results, but DAA approach has greater advantages in early postoperative recovery, improvement of hip joint function, small surgical injury, high application value, so it is recommended.

Advances and disputes of posterior malleolus fracture

Objective The objective of this article is to summarize the development of evaluation and treatment of posterior malleolus fracture （PMF）. Data sources Data used in this Study selection Articles were review were mainly from English literature of PubMed data base. ncluded in this review if they were related to the PMF or trimalleolar fracture.

Dual split and dislocation——a variant of Schatzker type-I tibial plateau fracture: A case report

Schatzkter type-I tibial plateau fracture is a split fracture of the lateral tibial plateau in sagittal plane,consequent to valgus impaction caused by low velocity of trauma.However,a deep understanding of the different columns of the tibial plateau and patho-mechanisms of the injury led to the unmasking of atypical fractures around the tibial plateau.We have encountered 2 cases with unusual fracture pattern of the lateral tibial condyle caused by road traffic accidents.The fracture pattern and severity of injury deviate from the original description of Schatzker type 1;in view of dual plane split,there is rotation of the posterolateral column fragment along its sagittal plane plus grade-III medial collateral ligament injury.The patients were initially treated with knee spanning external fixator and after a latency of 5 days,definitive fracture specific fixation was done,combined with repair of grade-III medial collateral ligament injury.At the 6 months follow-up both the patients achieved satisfactory knee functions(knee society score case 1:100 and case 2:92)and returned to their jobs.The severity of fracture pattern and displacement as described should prompt for examination of associated ligament injury.Because of timely diagnosis,early and appropriate care promised an excellent function outcome even in such a severe nature of knee injury.To prompt the description of injury pattern we coined the name"dual split and dislocation"of lateral tibial plateau,as a complex injury variant of split fracture of lateral tibial plateau fracture.

＂Floating popliteus tendon injury＂ in a mutiple-ligament knee injury： one case report and arthroscopy-assisted reconstruction

A patient with both a femoral attachment injury （peel-off injury） and musculotendinous junction avulsion of the popliteus, a so-called ＂floating popliteus tendon injury＂, received arthroscopy-assisted popliteus reconstruction. The injured ligaments were addressed in the same procedure, including mini-open direct repair of the femoral avulsed fibular collateral ligament （FCL）, suture repair of the grade 3 medial collateral ligament （MCL）, and reconstruction of the posterior cruciate ligament （PCL~.