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Introduction: Posterior tibial plateau fractures (PTPF) have a high impact on functional outcome and the optimal treatment strategy is not well established. The goal of this study was to assess the relationship between trauma mechanism, fracture morphology and functional outcome in a large multicenter cohort and define possible strategies to improve the outcome. Methods: An international retrospective cohort study was conducted in five level-1 trauma centers. All consecutive operatively treated PTPF were evaluated. Preoperative imaging was reviewed to determine the trauma mechanism. Patient reported outcome was scored using the Knee injury and Osteoarthritis Outcome Score (KOOS). Results: A total of 145 tibial plateau fractures with posterior involvement were selected with a median follow-up of 32.2 months (IQR 24.1-43.2). Nine patients (6%) sustained an isolated posterior fracture. Seventy-two patients (49%) sustained a two-column fracture and three-column fractures were diagnosed in 64 (44%) patients. Varus trauma was associated with poorer outcome on the 'symptoms' (p = 0.004) and 'pain' subscales (p = 0.039). Delayed-staged surgery was associated with worse outcome scores for all subscales except 'pain'. In total, 27 patients (18%) were treated with posterior plate osteosynthesis without any significant difference in outcome. Conclusions: Fracture morphology, varus trauma mechanism and delayed-staged surgery (i.e. extensive soft-tissue injury) were identified as important prognostic factors on postoperative outcome in PTPF. In order to assess possible improvement of outcome, future studies with routine preoperative MRI to assess associated ligamentous injury in tibial plateau fractures (especially for varus trauma) are needed. (c) 2021 Elsevier B.V. All rights reserved.

Although infra-acetabular screws have been used for anterior and posterior column transfixation, a screw penetrating the hip joint can result in harmful complications. However, the most accurate intraoperative radiologic imaging tool for identifying articular penetration has not been established. The purpose of the present study was, therefore, to evaluate the consistency with which standard pelvic radiographs compared with computed tomography (CT) can be used for demonstrating articular penetration. This retrospective review was performed between January 2015 and December 2020. We evaluated the records of patients with acetabular or pelvic fractures who underwent open reduction and internal fixation with infra-acetabular screw placement. We collected demographic data and described infra-acetabular screw placement as follows: ideal placement, articular penetration, and out of the bone. Articular penetration was assessed independently on each pelvic radiograph and compared statistically with the CT scans. Sensitivity, specificity, correct interpretation rate, and prevalence-adjusted bias-adjusted kappa (PABAK) were calculated for each radiograph. Thirty-nine patients underwent infra-acetabular screw placement. The mean age of patients was 55 years (range, 27–90 years); there were 29 men and 10 women. One patient underwent bilateral infra-acetabular screw placement; therefore, 40 infra-acetabular screws were included in total. Six (6/40, 15%) infra-acetabular screws showed articular penetration on CT and two (2/40, 5%) showed infra-acetabular screws extending out of the bone. Hip joint penetration was correctly identified at a rate of 92.5% (95% confidence interval [CI], 79.6–98.4%) on the outlet view and 87.5% (95% CI, 73.2–95.8%) on the anteroposterior (AP) view. The PABAK for the agreement between pelvic radiographs and CT scans was 0.85 in the outlet view and 0.75 in the AP view. The outlet view is an accurate method for detecting articular penetration of infra-acetabular screws. We recommend the insertion of an infra-acetabular screw under fluoroscopic outlet view to avoid articular penetration intraoperatively.

Case A traumatic sciatic nerve entrapment and transection because of a combined pelvic ring injury and acetabular fracture has never previously been described. We report such a case of a 32-year-old man who was found intraoperatively to have entrapment and transection of the sciatic nerve within the acetabular fracture. Conclusion Consideration for urgent intervention should be given to patients who present with a sciatic nerve palsy in the setting of certain acetabular fracture patterns with residual posterior column displacement. Early recognition and intervention with neurolysis may help provide the best environment for recovery.

BACKGROUND No clear guidelines exist for appropriate surgical treatment of congenital scoliosis. The spectrum varies from isolated posterior instrumentation and fusion (PIF-only) to vertebral column resections. Multiple posterior column osteotomies (PCOs) with and without concave rib osteotomies have previously been suggested as an alternative to invasive 3-column osteotomies. The aim of the study is to analyze outcomes of spinal surgery in congenital scoliosis patients for a new treatment algorithm based on a traction radiograph under general anesthesia (TruGA). METHODS Surgical intervention was determined according to flexibility with TruGA: patients with >40% correction underwent PIF-only; patients with

Objective : The stability is an important factor to decide the treatment plan in thoracolumbar burst fracture patients. Patients with an unstable burst fracture generally need operative management. Decrease in vertebral body height, local kyphosis, involvement of posterior column, and/or canal compromise are considered important factors to determine the treatment plan. On the other hand, in thoracolumbar injury classification system (TLICS), surgery is recommended in patients with TLICS of more than 5 points. The purpose of this study was to apply the TLICS score in patients with thoracolumbar burst fractures and to distinguish the differences of treatment plan on burst fracture.Methods : All patients, diagnosed as a thoracolumbar burst fracture between January 2006 and February 2019 were included in this study. Unstable thoracolumbar burst fracture was defined as burst fracture with neurologic deficit, three-column injury, kyphosis over 30 degrees, decrease of anterior body height over 40 percent and canal comprise more than 50%. TLICS score was measured with morphology, neurological involvement and posterior ligamentous complex integrity. The existence of instability was compared with TLICS score.Results : Total 233 patients (131 men, 102 women) were included in this study. In Denis classification, 51 patients (21.9%) diagnosed as stable burst fracture while 182 patients (78.1%) had unstable burst fracture. According to TLICS, 72 patients (30.9%) scored less than 4, while 161 patients (69.1%) scored 4 or more. All the patients with stable burst fracture scored 2 in TLICS. Twenty-one patients (9.0) scored 2 in TLICS but diagnosed as unstable burst fracture. Thirteen patients had over 40% of vertebra body compression, four patients had more than 50% of canal compromise, three patients had both body compression over 40% and kyphosis over 30 degrees, one patients had both body compression and canal compromise. Fifteen patients presented kyphosis over 30 degrees, and three (20%) of them scored 2 in TLICS. Seventy-three patients presented vertebral body compression over 40% and 17 (23.3%) of them scored 2 in TLICS. Fifty-three patients presented spinal canal compromise more than 50%, and five (9.4%) of them scored 2 in TLICS.Conclusion : Although the instability of thoracolumbar burst fracture was regarded as a critical factor for operability, therapeutic strategies by TLICS do not exactly match with the concept of instability. According to the concept of TLICS, it should be reconsidered whether the unstable burst fracture truly unstable to do operation.

Limited unilateral instrumentation has been used in the past in the treatment of adolescent idiopathic scoliosis; however, to our knowledge, there are no reported cases with ultra-long follow up regarding this. Our objective is to report on the 43-year follow-up of limited Harrington rod instrumentation for the treatment of a double major adolescent idiopathic scoliosis curve. We describe the patient’s initial presentation, including history, physical exam, radiographic findings and clinical decision-making. Initial coronal cobb angle measurements before surgery were: 14° T1-T5, 42° T5-T12, 44° T12-L4. At 43 years of follow up, there was progression (14°>24°, 42°>70°, 44°>50°) of the patient’s double major scoliosis curve despite unilateral, limited Harrington rod instrumentation from L4-S1. The patient was treated with a T3-pelvis instrumentation and fusion and posterior column osteotomies. To our knowledge, this is the longest follow-up and subsequent revision of a patient undergoing limited, unilateral Harrington rod instrumented fusion for the treatment of a double major adolescent idiopathic scoliosis curve.

BACKGROUND: Modern treatment principles for posterior wall fractures have become widespread in the last decade in many countries by means of international or local courses. The purpose of this study was to compare the clinical and radiologic outcomes of acetabulum posterior wall fractures using unconventional methods of fixation, including plates placed in unusual directions, or, in the case of reoperation, only interfragmentary screws. In addition, we examined acetabulum posterior wall fractures treated by open reduction and internal fixation with standard undercountered plates from ischion to iliac bone in latter cases. METHODS: Twenty-one patients who had open reduction and internal fixation of an unstable unilateral fracture of the posterior wall of the acetabulum between 2009 and 2013 were included. Group 1 was composed of 10 former patients who were treated with unconventional methods that included a compression technique with a direct plate or solely screw fixation. Group 2 was composed of latter 11 patients who were treated with standard surgery that included undercountered plates oriented from the ischial tuberosity to the iliac bone proximally and reconstruction of marginal impaction if necessary. The functional outcome was evaluated with the use of the clinical grading system adopted by Merle d'Aubigné and Postel. The Kellgren–Lawrence radiologic criteria were used for the radiologic assessments. The reduction of the fracture, posterior dislocation, marginal impaction, mean fracture particle amount, trochanteric osteotomy and avascular necrosis were compared between the two groups and examined with the Mann–Whitney U test. RESULTS: In Groups 1 and 2, the median score of the modified Merle d'Aubigné and Postel clinical scoring system was 16 (8–18) and 18 (14–18), respectively. The clinical scores between the two groups were statistically significant (p

We report two cases of subacute combined degeneration (SCD) caused by nitrous oxide (N2O) gas intoxication, which is rarely reported in Korea. Two patients recreationally inhaled N2O gas daily for several months. They presented with paresthesia of limbs, voiding difficulty, and gait disturbance. The initial vitamin B12 levels were normal or decreased, but homocysteine levels of the two patients were increased. Magnetic resonance imaging of the cervical spine showed T2-weighted hyperintensity in the bilateral dorsal columns of the cervical spinal cord. Electromyography and somatosensory evoked potential tests for both patients suggested posterior column lesion of the spinal cord combined with sensorimotor polyneuropathy. According to these findings, we concluded that the two patients had SCD. The patient’s symptoms partially improved after cessation of N2O gas inhalation and the receiving of vitamin B12 supplementation therapy. As the incidence of recreational N2O gas inhalation is increasing in Korea, physicians must be alert to the N2O induced SCD in patients presenting with progressive myelopathy.

Introduction: Since acetabular fractures are intra-articular, accurate anatomic reduction is essential to achieve a good functional outcome. Among the various surgical approaches, ilioinguinal and modified Stoppa approaches are the only available intra-pelvic approaches. Even though ilioinguinal approach is more commonly used, modified Stoppa approach is becoming more popular due to the possibility of visualising and reducing quadrilateral plate fragments as well as fixation of posterior column through anterior approach. The aim of our study was to assess the efficacy of various reduction tools/ techniques for reduction and fixation of fractures operated using modified Stoppa approach. Materials and Methods: We have operated on 16 patients with acetabular fractures through modified Stoppa approach in the age group of 19 years to 70 years (mean 42 years) with male female ratio of 13:3. In patients requiring combined approach, the anterior approach was done first. In all the patients, modified Stoppa was combined with a lateral window. We have used various reduction techniques including transtrochanteric Schanz pin, intra-focal elevators, ball spike, bone hook, iliac crest Schanz pin, Farabeuf forceps, undercontoured plate, etc. Results: Matta’s radiographic reduction criteria showed anatomic reduction in 10 cases. Clinical assessment using Merle d’ Aubigne scoring showed excellent results in 9 cases and good results in 6 cases. Follow up was done for a maximum period of six months. Conclusion: Modified Stoppa approach provides better visualisation of quadrilateral surface and sciatic buttress when compared to the ilioinguinal approach. The use of appropriate reduction techniques helps in achieving good reduction of anterior column, at the same time provides opportunity to fix the posterior column from the anterior aspect using anterior to posterior column screws, obviating the need for a separate posterior approach. Keywords: Modified Stoppa, Acetabulum

Sagittal imbalance is most commonly seen in patients with multilevel degenerative disc disease, inflammatory arthropathies, severe osteoporosis, and untreated idiopathic scoliosis. The degree of imbalance is closely correlated with clinical symptoms. Sagittal deformity can occur from a variety of causes in both young and elderly patients, however it has been found to most likely be multifactorial. Other causes include Scheuermann's Kyphosis, iatrogenic flat-back, post-traumatic, neuromuscular, and congenital disorders such Klippel–Feil and infantile scoliosis. Clinical evaluation includes a thorough health history and physical examination, as well as more advanced methods such as surface topography and 3D postural analysis. The determination to utilize an osteotomy during deformity surgery is based on many factors including the patient's global sagittal alignment and radiographic assessment, the amount of correction needed to restore proper alignment, the relative rigidity of the deformity, and any focal areas of severe angulation. The three most commonly utilized osteotomies are discussed below including the posterior column Smith–Peterson/Ponte osteotomy, as well as the three-column pedicle subtraction osteotomy and vertebral column resection. The goal of a corrective osteotomy is to normalize the local segment's curve in order to correct the overall global spinal alignment and improve patient function. Complication rates as high as 25–40 percent have been reported in literature.

Study design Retrospective case series. Purpose Describe the technique and evaluate the outcome of apical vertebral column resection (VCR) with sagittal rotation and anterior opening and posterior closing (AOPC) maneuver for correction of severe post-tubercular kyphosis (PTK). Overview of literature The surgical procedures described for the correction of PTK are VCR, pedicle subtraction osteotomy, transpedicular decancellation osteotomy, and closing-opening osteotomy. Methods We retrospectively evaluated 21 patients who had been operated on with single stage apical VCR with AOPC maneuver. Radiographs were obtained before surgery and at regular follow-up intervals. These were used to calculate the angle of kyphosis. Back pain was rated using the Visual Analog Scale (VAS) and neurological status was graded using Frankel grading. Radiological outcome was assessed by the improvement in the angle of kyphosis and fusion following surgery. Neurological status was assessed using Frankel grading. Results The study included eight males and 13 females with a mean age of 21.9 and average follow-up time of 30.4 months. The average number of vertebral bodies destroyed was 2.57. Kyphosis was improved from a mean of 68.42°±13.23° preoperative to 8.71°±4.58° postoperative. The average correction achieved was 87.10%. Preoperative VAS score improved from a mean of 6.38±0.92 preoperative to 1.38±0.49 postoperative. No patients had any sign of neurological deterioration. Seven out of eight patients with a preoperative neurological deficit improved following surgery. Two patients developed superficial wound maceration, one had persistent postoperative hypotension, and the other developed hemothorax. All patients recovered fully without a need for additional surgery. Conclusions Single stage simultaneous anterior column lengthening and posterior column shortening is an effective method for surgical correction of severe PTK.

Background and purpose Low-energy acetabulum fractures are uncommon, and mostly occur in elderly patients. Determining the optimal operative treatment for such fractures is challenging. Here we investigated whether acutely performed total hip arthroplasty plus posterior column plating (THA) reduced complications and reoperations compared with open reduction and internal fixation (ORIF) in elderly patients with acetabular fractures.Patients and methods We retrospectively reviewed the records of 59 patients, > 55 years of age, with complex acetabular fractures, caused by low-energy trauma, treated between January 2008 and September 2017. Of these patients, 34 underwent acute THA, and 25 ORIF alone. Patient and implant survival were compared between groups using Kaplan-Meier survival analysis and Cox multiple regression. Functional outcomes assessed by Oxford Hip Score (OHS) were compared between the THA patients and those 9 ORIF patients who underwent secondary THA due to posttraumatic hip osteoarthritis (OA) during follow-up.Results Overall patient survival was 90% (95% CI 82-98) at 12 months, and 64% (CI 47-81) at 5 years. Of 25 ORIF patients, 9 required secondary THA due to posttraumatic OA. Large fragments on the weight-bearing acetabular dome upon imaging predicted ORIF failure and secondary THA. The acute THA group and secondary THA group had similar 12-month OHS.Interpretation Acute THA including a reinforcement ring resulted in fewer reoperations than ORIF alone in elderly patients with acetabular fractures. These findings support acute THA as first-line treatment for complex acetabular fractures in elderly patients.

Cervical spine finite element models reported in biomechanical literature usually represent a static morphology. Not considering morphology as a model parameter limits the predictive capabilities for applications in personalized medicine, a growing trend in modern clinical practice. The objective of the study was to investigate the influence of variations in spinal morphology on the flexion-extension responses, utilizing mesh-morphing-based parametrization and metamodel-based sensitivity analysis. A C5-C6 segment was used as the baseline model. Variations of intervertebral disc height, facet joint slope, facet joint articular processes height, vertebral body anterior-posterior depth, and segment size were parametrized. In addition, material property variations of ligaments were considered for sensitivity analysis. The influence of these variations on vertebral rotation and forces in the ligaments were analyzed. The disc height, segmental size, and body depth were found to be the most influential (in the cited order) morphology variations; while among the ligament material property variations, capsular ligament and ligamentum flavum influenced vertebral rotation the most. Changes in disc height influenced forces in the posterior ligaments, indicating that changes in the anterior load-bearing column of the spine could have consequences on the posterior column. A method to identify influential morphology variations is presented in this work, which will help automation efforts in modeling to focus on variations that matter. This study underscores the importance of incorporating influential morphology parameters, easily obtained through computed tomography/magnetic resonance images, to better predict subject-specific biomechanical responses for applications in personalized medicine.

Introduction: Acute osteomyelitis usually occurs in the metaphysis of the long bones, the lower limb being more commonly affected than the upper limb. Pelvic localization is rare. Observation: An 11-year-old boy with no remarkable history of illness visited our emergency room complaining from high fever and atromatic right hip pain. The orthopedic examination objectified a limitation of the right hip joint motions especially in extension, the palpation of the groin’s crease was slightly painful without local inflammatory signs nor lymphadenopathies. Blood laboratory tests found an inflammatory syndrome. Hip X-rays did not show any abnormality, the ultrasound of the right hip showed a joint effusion of low abundance measuring 1 mm. Magnetic resonance imaging detected anhypointense signal on T1-weighted sequences and a high intensity signal on T2-weighted on the right acetabulum with contrast enhacement after gadolinium administration. It combines a fat infiltration and a collection of 13x6 mm in the internal obturator muscle. The diagnosis of acute osteomyelitis of the posterior column with soft tissue invasion and reactive arthritis was confirmed. The blood cultures did not isolate a germ and the urinalysis was negative. The child was given antibiotic therapy: amoxicillin clavulanic acid and fusidic acid intravenously for a period of 21 days and then orally for a total duration of 12 weeks. The evolution was marked by a clinical improvement and a negation of the CRP. A 3-month control MRI showed total regression of the soft tissue collections. Discussion: Pelvic osteomyelitis is rare, patients with pelvic osteomyelitis can present various clinical signs, which gives place to late or erroneous diagnosis. The prognosis of pelvic osteomyelitis is very favorable. The rate of recovery without sequelae is greater than 95%, but decreases with late diagnosis and treatment failure. Conclusion: Osteomyelitis remains an endemic pathology in Tunisia despite the development of diagnostic’ means and antibiotic therapy. Pelvic osteomyelitis is rare; it poses a diagnostic problem especially with Ewing's sarcoma. Its prognosis is favorable but decreases with a delay of antibiotic administration.

Anterior column release is a powerful surgical technique for achieving spinopelvic balance in adult patients with sagittal plane deformities. We present an alternative strategy for focal deformity correction from a posterior-only approach. The purpose of this study was to evaluate the feasibility and efficacy of a novel surgical technique called posterior open-wedge diskectomy and anterior longitudinal ligament (ALL) release (POWAR). A cadaveric torso underwent POWARs at the L1-L4 intervertebral disc spaces. Baseline measurements of end-plate angle (EPA), anterior intervertebral disc height (ADH), and posterior intervertebral disc height (PDH) were obtained. These measurements were repeated after three stages of correction: posterior column compression alone, posterior column compression following Schwab grade 2 osteotomies, and posterior column compression following POWAR. A second cadaver underwent posterolateral spinal dissection to demonstrate the pertinent anatomical features relevant to this novel procedure. With each stage of correction, a sequential increase in EPA and ADH and a decrease in PDH were demonstrated. The large increase in ADH seen following POWAR confirmed successful release of the ALL. In situ investigation of the aorta and inferior vena cava following anterior exposure revealed no injury to the great vessels or surrounding structures. Ex vivo testing of the aorta and inferior vena cava took place at the L3-4 level. This testing demonstrated no injury or tears to either vessel. POWAR is a new surgical technique that can provide an alternative to three-column osteotomy for surgeons performing spinal reconstructions in adults through an open, posterior-only approach. Clin. Anat. 32:348-353, 2019. © 2018 Wiley Periodicals, Inc.

Background Context: One of the characteristics of reported observations in adolescent idiopathic scoliosis (AIS) is that the thoracic spine is longer anteriorly than posteriorly, more pronounced around the apex than the transitional zones. This reversal of the normal kyphotic anatomy of the thoracic spine is related to questions of etiopathogenesis of AIS. The changes in the anatomy of the anterior column have been described rather in detail; however, the role of the posterior spinal column and the laminae has so far not been elucidated. If the posterior column exhibits a longitudinal growth disturbance, it could act as a tether, leading to a more or less normal anterior column with a deformed and shorter posterior aspect of the spine. So far, it has remained unclear whether this anterior-posterior length discrepancy is the result of relative anterior lengthening or relative posterior shortening, and which tissues (bone, disc, intervertebral soft tissue) are involved. Purpose: The present study aimed to compare the discrepancy of the anterior-posterior length of the spinal column in the “true” midsagittal plane of each vertebra in patients with idiopathic scoliosis versus controls, using three-dimensional computed tomography (CT) scans. Study Design/Setting: This is a cross-sectional study. Patient Sample: The sample consisted of computed tomography scans of 80 patients with moderate to severe AIS (Cobb angle: 46°–109°) before scoliosis navigation surgery and 30 non-scoliotic age-matched controls. Outcome Measures: The height of the osseous and non-osseous structures from anterior to posterior in the “true” midsagittal plane has been determined: the anterior side of the vertebral body and disc, the posterior side of the vertebral body and disc, the lamina and interlaminar space and the spinous process and interspinous space, as well as the height ratios between the anterior column and posterior structures of the primary thoracic and lumbar AIS curves and corresponding levels in non-scoliotic controls. Methods: Semiautomatic software was used to reconstruct and measure the parameters in the true midsagittal plane of each vertebra and intervertebral structure that are rotated and tilted in a different way. Results: In AIS, the anterior height of the thoracic curve was 3.6±2.8% longer than the posterior height, 2.0±6.1% longer than the length along the laminae, and 8.7±7.1% longer than the length along the spinous processes, and this differed significantly from controls (−2.7±2.4%, −7.4±5.2%, and +0.7±7.8%; p

Study design Controlled cadaveric study of surgical technique in transforaminal and posterior lumbar interbody fusion (TLIF and PLIF) OBJECTIVE.: To evaluate the contribution of surgical techniques and cage variables in lordosis recreation in posterior interbody fusion (TLIF/PLIF). Summary of background data The major contributors to lumbar lordosis are the lordotic lower lumbar discs. The pathologies requiring treatment with segmental fusion are frequently hypolordotic or kyphotic. Current posterior based interbody techniques have a poor track record for recreating lordosis, although recreation of lordosis with optimum anatomical alignment is associated with better outcomes and reduced adjacent segment change needing revision. It is unclear whether surgical techniques or cage parameters contribute significantly to lordosis recreation. Methods Eight instrumented cadaveric motion segments were evaluated with pre and post experimental radiological assessment of lordosis. Each motion segment was instrumented with pedicle screw fixation to allow segmental stabilization. The surgical procedures were unilateral TLIF with an 18° lordotic and 27 mm length cage, unilateral TLIF (18°, 27 mm) with bilateral facetectomy, unilateral TLIF (18°, 27 mm) with posterior column osteotomy (PCO), PLIF with bilateral cages (18°, 22 mm), and PLIF with bilateral cages (24°, 22 mm). Cage insertion used and "insert and rotate" technique. Results Pooled results demonstrated a mean increase in lordosis of 2.2° with each procedural step (lordosis increase was serially 1.8°, 3.5°, 1.6°, 2.5°, and 1.6° through the procedures). TLIF and PLIF with PCO increased lordosis significantly compared with unilateral TLIF and TLIF with bilateral facetectomy. The major contributors to lordosis recreation were PCO, and PLIF with paired shorter cages rather than TLIF. Conclusion This study demonstrates that the surgical approach to posterior interbody surgery influences lordosis gain and PCO optimizes lordosis gain in TLIF. The bilateral cages used in PLIF are shorter and associated with further gain in lordosis. This information has the potential to aid surgical planning when attempting to recreate lordosis to optimize outcomes. Level of evidence N/A.

OBJECTIVESpinal osteotomies and anterior column realignment (ACR) are procedures that allow preservation or restoration of spine lordosis. Variations of these techniques enable different degrees of segmental, regional, and global sagittal realignment. The authors propose a comprehensive anatomical classification system for ACR and its variants based on the level of technical complexity and invasiveness. This serves as a common language and platform to standardize clinical and radiographic outcomes for the utilization of ACR.METHODSThe proposed classification is based on 6 anatomical grades of ACR, including anterior longitudinal ligament (ALL) release, with varying degrees of posterior column release or osteotomies. Additionally, a surgical approach (anterior, lateral, or posterior) was added. Reliability of the classification was evaluated by an analysis of 16 clinical cases, rated twice by 14 different spine surgeons, and calculation of Fleiss kappa coefficients.RESULTSThe 6 grades of ACR are as follows: grade A, ALL release with hyperlordotic cage, intact posterior elements; grade 1 (ACR + Schwab grade 1), additional resection of the inferior facet and joint capsule; grade 2 (ACR + Schwab grade 2), additional resection of both superior and inferior facets, interspinous ligament, ligamentum flavum, lamina, and spinous process; grade 3 (ACR + Schwab grade 3), additional adjacent-level 3-column osteotomy including pedicle subtraction osteotomy; grade 4 (ACR + Schwab grade 4), 2-level distal 3-column osteotomy including pedicle subtraction osteotomy and disc space resection; and grade 5 (ACR + Schwab grade 5), complete or partial removal of a vertebral body and both adjacent discs with or without posterior element resection. Intraobserver and interobserver reliability were 97% and 98%, respectively, across the 14-reviewer cohort.CONCLUSIONSThe proposed anatomical realignment classification provides a consistent description of the various posterior and anterior column release/osteotomies. This reliability study confirmed that the classification is consistent and reproducible across a diverse group of spine surgeons.

We aimed to determine the changes in cervical canal diameters and spinal cord compression at each level from C2-3 to C7-T1 in flexion and extension positions and to study the use of flexion-extension magnetic resonance imaging (MRI). We also aimed to assess the changes in the length of the spinal cord in flexion and extension positions of the cervical spine.Flexion-extension MRI scans were performed consecutively on sixty-six patients with neck pain with/without neurogenic symptoms of the cervical spine. All patients were treated conservatively. We investigated the length of the cervical spinal cord (LSC), length of the cervical spinal anterior column (LAC), length of the cervical spinal posterior column (LPC), spinal canal diameter, and severity of cord compression in flexion, neutral, and extension positions.At each intervertebral level (from C2-3 to C7-T1), the average spinal canal diameter showed significant decrease from flexion to extension positions (P 0.05). The average LSC, LAC, and LPC were decreased on extension of the neck compared with flexion (P 0.05). Higher stages were found in extension position than in flexion position with statistically significant differences (P 0.05).The use of flexion-extension MRI may demonstrate true pathology that contributes in the pathogenesis of cervical degenerative disease (CDD). Higher stages in spinal cord compression were found in extension position than in flexion position. However, higher stages in spinal cord compression in extension position did not necessarily cause severe myelopathy. This finding is an important evidence for conservative therapy on patient neck position education.

Introduction: Operative treatments of T-type acetabular fractures are challenging surgical procedures. Open reduction and internal fixation is the standard method for the operative management of these fractures, however this is associated with high blood loss, long hospital stay and longer rehabilitation. Anterior subcutaneous pelvic fixation (internal fixation = INFIX) and retrograde pubic screw fixation have shown promising results in minimally invasive treatment of pelvic ring fractures. For T-type acetabular fractures, however, minimally invasive treatment concepts are still rare. Therefore we performed a mechanical in vitro study to: - investigate the potential favorability of minimally invasive treatment options over the already established open anterior locking plate osteosynthesis of acetabular T-fractures regarding biomechanical stability and post-surgical stiffness;- explore the biomechanical feasibility of the INFIX;- assess its potential ability to reduce the anterior acetabular column. Hypothesis: A minimally invasive treatment of acetabular T-type fractures is biomechanically equivalent to an open anterior plate osteosynthesis. Methods: Twenty-four synthetic hemipelvis specimens with a T-type acetabular fracture were divided in four groups. A posterior column screw was placed in every pelvis of every group. The anterior column was fixed with: - anterior column screw;- anterior column screw incl. INFIX;- INFIX alone;- 14-hole angular stable locking plate (standard fixation method). Displacement of the anterior column was reduced in group 2 +3 using the INFIX. All specimens were cyclically loaded with 200 N until a maximum of 600 N. Movement/displacement of the fracture fragments were detected with a 3D-ultrasound measuring system. Displacement (mm) and Stiffness (N/mm) of the construction were analyzed. Results: Statistical assessment showed no significant differences between the four fixation types (p > 0.05). The 14-whole locking plate (group 4) displayed the overall highest stability with a displacement of 1.3 +/- 0.04 mm and stiffness of 76.3 +/- 2.4 N/mm. Anterior screw fixation (group 1) proved to be the minimally invasive fixation method with the least displacement and highest stiffness (1.5 +/- 0.2 mm, 68.3 +/- 6.8 N/mm). The combination of an INFIX and an anterior column screw (group 2), showed a mean stiffness of 62.1 +/- 6.0 N/mm and a mean displacement of 1.7 +/- 0.2 mm. INFIX only (group 3) presented a displacement of 1.6 +/- 0.1 mm and a stiffness of 64.5 +/- 4.5 N/mm. Discussion: Minimally invasive fixation techniques for T-type acetabular fractures show promising biomechanical stability in non- or slightly displaced fractures. Furthermore, INFIX could be a feasible tool for the reduction of the anterior acetabular column.

Background Tibial plateau fractures are the most common intra-articular fractures, which require careful evaluation and preoperative planning. The treatment of tibial plateau fractures in elderly patients is challenging, and the comprehension of epidemiology and morphology can be helpful. This study described the characteristics of geriatric tibial plateau fractures. Methods A total of 327 (23.24%) patients aged ≥60 years were reviewed in our level one trauma center over a 4-year period (from January 2013 to November 2016). The following parameters were collected and evaluated: (1) demographic data, (2) injury mechanisms and (3) fracture classifications. Results Females accounted for 60.86% in all included elderly patients. Electric-bike accidents were the cause of 32.42% of all these injuries, and 39.62% of these led to high-energy injuries. The most common type of fracture was Schatzker II (54.74%). According to the three-column classification, single lateral column fracture (28.75%) and four-quadrant fracture (involving lateral, medial, posterolateral and posteromedial fractures) (23.24%) were the two most frequent patterns. In all cases, 67.58% involved the posterior column, and the prevalence of posterolateral and posteromedial fractures were 62.69% and 37.92% respectively. Isolated posterior column fractures accounted for 12.54% of patients in total, which mostly consisted of posterolateral fracture in older females (85.37%). Conclusions The majority of elderly patients with tibial plateau fractures are females, and Electric-bike accidents are an important cause of injury. Geriatric tibial plateau fractures have unique distribution in classification.

In spinal deformity surgery, posterior column osteotomies (PCOs) are used to increase spinal flexibility and permit greater deformity correction, while avoiding the morbidity of anterior column surgery. Complications related to use of PCOs have been well characterized in adults; however, there is a paucity of information in the pediatric population. A single-surgeon retrospective analysis was completed of 484 PCOs in 142 patients (average age: 14.5 years) undergoing spinal deformity surgery. All surgeries were completed by a standard posterior approach using a midline incision and dual-rod, pedicle screw constructs. PCO-related complications were recorded (intraoperative monitoring alerts, postoperative neurologic deficit, dural tear/violations, cerebrospinal fluid [CSF] leak, pseudarthrosis, etc.) and analyzed by diagnosis (idiopathic, congenital, neuromuscular, syndromic). The diagnoses for the 142 patients were idiopathic (103 patients), neuromuscular (23 patients), syndromic (14 patients), and congenital (2 patients). In a subset of 87 patients with 2-year radiographic follow-up, the preoperative major coronal Cobb measurement was 75.5° ± 17.6°, which corrected to 34.9° ± 17.5° postoperatively and 37.8° ± 17.9° at last follow-up (p < .0001, p < .0001). Complications evaluated were postoperative neurologic deficit (0% of patients, 0/142), dural tears/violations at site of PCO (0.4% of PCOs, 2/484), CSF leak (0% of patients, 0/142), and pseudoarthrosis at site of PCO (0% of PCOs, 0/290). The overall frequency of complications related to PCOs was 0.4% (0.4% dural tears/violations) with 0% postoperative neurologic deficit, CSF leak, or pseudarthrosis. Based on these data, PCOs appear to be a safe technique in pediatric spine deformity surgery, with a low rate of technique-related complications. Retrospective case series. To report the frequency of posterior column osteotomy complications (neurologic deficit, dural tear, cerebrospinal fluid leak, and pseudarthrosis) in pediatric patients undergoing spinal deformity surgery. Level IV.

To evaluate the results of short-term follow-up of patients of both column acetabular fractures managed through anterior and posterior column plating. Both column acetabular fractures are challenging articular injuries. Majority of them are treated operatively. The concept of “secondary congruence” was introduced by Letournel. Despite this, biomechanical data on secondary congruence indicate that nonoperative treatment leads to an increase in peak pressures in the supraacetabular region with the potential risk of developing posttraumatic degenerative osteoarthritis. Operative management is therefore justified. A cohort of 10 patients having both column (anterior and posterior) acetabular fractures managed using bicolumnar plating between January 2016 and December 2017 were enrolled in the study and were analyzed during follow-up period. In total, 80% of the patients had excellent to good result. Average postoperative score was 85.7. Assessment was done using modified Harris Hip score.

BACKGROUND This study aimed to evaluate outcome following a single lateral rectus abdominis surgical approach for complicated acetabular fractures, involving anterior and posterior columns. MATERIAL AND METHODS From January 2012 to March 2016, 59 patients, including 36 anterior column hemitransverse fractures, 18 two-column fractures, and five T-type complicated acetabular fractures, were treated with a single lateral rectus abdominis approach and fixed by plates and cannulated lag screws. Anterior column fractures were fixed with 3.5 mm reconstruction plates; posterior column fractures were fixed with 6.5 mm cannulated lag screws. The quality of surgical reduction (using the Matta criteria), functional outcome (using the modified Merle d'Aubigné and Postel scoring system), and postoperative complications were assessed with 24-month follow-up. RESULTS Fifty-nine patients (mean age, 45 years; range, 18-64 years) including 39 men and 20 women underwent surgery. Mean intraoperative blood loss was 514.6 ml (range, 150-830 ml) and mean operating time was 86.3 min (range, 42-145 min). Anatomical reduction was good in 40 cases (67.8%), fair in 15 cases (25.4%), and poor in four cases (6.8%). The modified Merle d'Aubigné score was excellent in 39 cases (66.1%), good in 14 cases (23.7%), fair in five cases (8.5%), and poor in one case (1.7%). At follow-up, there were five cases of peritoneal damage, eight cases of obturator nerve dysfunction, and four cases of postoperative traumatic arthritis. CONCLUSIONS The single lateral rectus abdominis surgical approach for the treatment of complicated acetabular fractures was minimally invasive with good anatomical exposure and good outcomes.

Background It is often difficult to achieve stable fixation in Tile type C1 pelvic fractures and there is no standard fixation technique for these types of injuries. Hypothesis Iliac screw fixation can be used for treating Type C1 pelvic fractures. Patients and methods A retrospective review was performed on 47 patients who underwent iliac screw fixation in posterior column of ilium (PCI) for Tile type C1 pelvic fractures from July 2007 to December 2014. All patients were treated with fracture reduction, sacral nerve root decompression (if needed), internal fixation by iliac screw and connecting rod. The data on surgical time, intraoperative bleeding volume, postoperative neurologic functions and postoperative complications were analyzed. Patients were follow-up for at least 12 months. Results The mean surgical time was 148 minutes, and the mean intraoperative bleeding volume was 763 ml. Patients were encouraged in-bed activities immediately after surgery. The postoperative Majeed functional score was 48–100 points (mean 80.2), corresponding to an excellent and good recovery of 91.5%. Postoperative X-radiographs and CT scans indicated satisfactory fracture reduction. Discussion Iliac screw fixation combined with sacral nerve canal decompression could effectively restore pelvic alignment and improve neurological functions for complex pelvic trauma.

Introduction: Modified kocher-langenbeck technique aims at achieving osteosynthesis by creating two windows: between the gluteus medius and piriformis superiorly and between external rotators and ischial tuberosity inferiorly. The reconstruction plate can be slid under the piriformis and the short external rotators, we propose an easy way for the placement of the reconstruction plate Case report: We present a series of three cases with acetabular fractures posterior column fixed with reconstruction plates by modified kocher-langenbeck approach with a minimum follow up of 2 years. Case 1: 37yr male patient with right posterior column fracture left anterior and posterior column fracture, right posterior column and left anterior column are fixed with percutaneous screws, left posterior column fracture fixed with reconstruction plate and screws.Case 2: 45yr male patient with left posterior column fracture fixed with reconstruction plate and screws.Case 3: 41yr male patient with right posterior column fracture anterior column fracture fixed with reconstruction plate and screws. All the patients posterior column was fixed using modified kocher-langenbeck approach, all patients were followed for a period of 2 years, all patients had excellent outcome, there is no incidence of avascular necrosis of head in any case. Discussion: Modified kocher-langenbeck approach is tissue preserving and prevents damage to the vascularity of the head, in all the cases after reduction of fracture, an umbilical tape was tied to the end of the reconstruction plate using a long artery forceps the umbilical tape is pulled under the submuscular tunnel thus positioning the reconstruction plate under the intact short external rotators, the plate is fixed with appropriate screws. Use of this technique provides an easy positioning of reconstruction plate.

OBJECTIVES To determine risk factors for early conversion total hip arthroplasty (THA) after operative treatment of acetabular fractures. DESIGN Retrospective cohort. SETTING Level I trauma center. PATIENTS AND INTERVENTION We reviewed 685 operative acetabular fractures at our institution from 2011 to 2017, with a median follow-up of 12 months (range, 4-105 months). MAIN OUTCOME MEASURE Multivariable regression analysis was performed after univariate analysis to identify independent risk factors for conversion THA. Sensitivity analysis was performed with minimum follow-up set at 6 and 12 months. RESULTS One hundred eight patients (16%) underwent conversion THA, with 52% of conversions occurring within 1 year, an additional 27% within 2 years, and the remaining 21% within 6 years of the index acetabular open reduction internal fixation. The median time to conversion THA was 11.5 months (range, 0.5-72 months). The risk of conversion THA by fracture pattern was 53 of 196 (27%) for transverse posterior wall (TPW), 12 of 52 (23%) for T shaped, 10 of 68 (15%) for posterior column with posterior wall, and 25 of 207 (12%) for posterior wall. Independent risk factors for early conversion included the following: TPW fracture, protrusio, hip dislocation, increased body mass index, increased age, infection, and dislocation after open reduction internal fixation. Independent risk factors for early conversion THA specific to patients with TPW fractures include only increased age and body mass index. Sensitivity analysis showed no change in results using either 6 or 12-month minimum follow-up. CONCLUSION Transverse posterior wall fractures have a high risk of early conversion THA compared with other acetabular fracture patterns, especially when in combination with other significant risk factors. Consideration for different and novel management options warrants further study in this subset of acetabular fracture patients. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

SUMMARY Displaced transverse acetabular fractures are unstable injuries that frequently require repair. Although multiple approaches, techniques, and fixation constructs have been described to treat this pattern, achieving an anatomical reduction and applying fixation to maintain this until union remains the goal of treatment. We present a surgical technique for transverse or transverse/posterior wall acetabular fractures repaired using a clamp-assisted reduction through the sciatic notch, followed by anterior column screw fixation and subsequent posterior column plating through a Kocher-Langenbeck exposure. We review a case series of 55 patients treated with this technique and evaluate reduction quality using postoperative computed tomogram scans to assess for any residual step-off.

Purpose: Due to the growing percentage of degenerative spinal diseases among the population, it is extremely important to assess how the orientation of the articular facets affects the changes in the intervertebral disc. Therefore, the aim of this study was to assess the effect of the orientation of the articular facets on the changes occurring in individual layers of the annulus fibrosus of the intervertebral disc under the influence of the load causing extension. Methods: Numerical simulations were performed for five configurations of the functional spinal units: physiological, with moderate tropism, severe tropism, and segments in which non-physiological orientation was modelled of both processes with different ranges. Results: It can be concluded that severe tropism causes more significant changes in intervertebral disc bulging on the physiological side of the orientation of the articular facets. Furthermore, the value of stress on articular processes increases tenfold on the side of severe tropism compared to the physiological facet joint orientation. Conclusion: Facet joint orientation plays an important role in the transfer of loads by the spine and the posterior column provides important support for the spine during extension.

This is a case report of an 40 years female patient with Scheuermann Kyphosis with a rigid thoracic hyperkyphosis of 90o and compensatory lumbar hyperlordosis of 92o, treated with a single posterior approach, Ponte osteotomy and instrumented posterolateral fusion. There is some discussion about the best surgical approach. Combined approach was classically considered the gold-standard, but recent studies revealed that posterior-only approach allows comparable corrections with less complications rate. Posterior-only approach good results are related with advances in posterior instrumentation combined with posterior column shortening techniques, such Ponte osteotomies. Preoperative planning is essential. Spine instrumentation should extend from proximal end vertebra to sagittal stable vertebra.

First described by Ganz and Mast, the Bernese periacetabular osteotomy (PAO) was first developed for the treatment of hip dysplasia. The purpose of the surgical technique is to expose the innominate bone through a modified Smith-Petersen approach, thereby allowing osteotomies around the acetabulum to be performed while leaving the posterior column intact. Once the osteotomies have been completed, the acetabular fragment is freely mobile allowing reorientation based on the preoperative deformity. There are several anatomic structures at risk during the surgical procedure including the lateral femoral cutaneous nerve, femoral neurovascular structures, obturator neurovascular structures, sciatic nerve, and medial femoral circumflex vessels. The purpose of this chapter is to describe the modified technique we use to minimize the risk of injuries to these anatomic structures.

OBJECTIVE Three-column osteotomies (3COs) for surgical correction of lumbar kyphosis show a strong correction capacity, but this procedure carries high morbidity rates. The anterior column release (ACR) technique was developed as a less invasive procedure. In this study the authors aimed to evaluate sagittal alignment restoration using ACR and to determine factors that affect the degree of correction. METHODS This study included 36 patients (68 cases) who underwent ACR of more than one level for adult spinal deformity. Parameters for regional sagittal alignment included segmental lordosis (SL). The parameters for global sagittal alignment included pelvic incidence, lumbar lordosis, sacral slope, pelvic tilt, and sagittal vertical axis (SVA). In addition, the interdiscal height (IDH) and difference of interdiscal angle (DIDA) were measured to evaluate the stiffness of the vertebra segment. The changes in SL were evaluated after ACR and the change of global sagittal alignment was also determined. Factors such as the location of the ACR level, IDH, DIDA, cage height, and additional posterior column osteotomy (PCO) were analyzed for correlation with the degree of SL correction. RESULTS Thirty-six patients were included in this study. A total of 68 levels were operated with the ACR (8 levels at L2–3, 27 levels at L3–4, and 33 levels at L4–5). ACR was performed for 1 level in 10 patients, 2 levels in 20, and 3 levels in 6 patients (mean 1.9 ± 0.7 levels per patient). Mean follow-up duration was 27.1 ± 4.2 months. The mean SL of the total segment was 0.4° ± 7.2° preoperatively and increased by 15.3° ± 5.5° at the last follow-up (p < 0.001); thus, the mean increase of SL was 14.9° ± 8.1° per one ACR. Global sagittal alignment was also improved following SL restoration with SVA from 101.9 mm to 31.4 mm. The degree of SL correction was correlated with the location of ACR level (p = 0.041) and was not correlated with IDH, DIDA, cage height and additional PCO. CONCLUSIONS This study demonstrated that the mean correction angle of SL was 14.9 per one ACR. The degree of disc space collapse and stiffness of segment did not affect the degree of correction by ACR.

Most of them are caused by indirect trauma, such as falling from a height or violently flexing their torso; direct trauma can happen less often, with things such as impacts of traffic accidents or sharp contraction of muscles leading to avulsion fractures or transverse process fractures. The injury type according to the fracture position can be divided into anterior, middle, and posterior column fractures. The anterior column includes the anterior longitudinal ligament, the anterior 1/2 of the vertebral body, and the anterior portion of the disc; the middle column includes the posterior longitudinal ligament, the posterior 1/2 of the vertebral body, and the posterior portion of the disc; the posterior column includes the vertebral arch, the ligamentum flavum, and the intervertebral facet joints and interspinous ligaments. According to the injury mechanism, it can be divided into: (1) flexion compression fracture, (2) burst fracture, (3) flexion traction injury (chance fracture, also known as a seat belt fracture), (4) flexion and rotation fracture dislocation, and (5) shear-type dislocation.

Background The infra-acetabular screw which is placed from the pubis to the ischium can be used as a special positional screw of the posterior column of the acetabulum. This study was performed to simulate the surgical procedure and obtain the ideal insertion point, diameter, length and angle of the screw through the method of axial perspective in Chinese patients. Methods We randomly collected the pelvic computed tomography (CT) scans of 200 adults. DICOM-formatted CT-scan images were imported into Mimics software to establish the 3D digital model of the right semi-pelvic was established. A virtual cylinder representing the screw was placed from the pubis to the ischium to fix the posterior column. The largest secure diameter and length of the virtual screw were measured and the position of the insertion point and the directions of the screw were also researched. Results The screw insertion safe zone exhibits an irregular shape of “tear drop” in the reconstructed pelvic model. The mean maximum diameter of screws was 5.01 ± 1.28 mm, and the mean maximum length of screws was 93.99 ± 8.92 mm. The screw insertion corridor with the least diameter 3.5 mm was found in 94 of 100 males (94%) and 86 of 100 females (86%). We found gender-dependent differences for the mean maximum diameter and the maximum length of the screw. There was statistically significant difference between genders in the position of insertion point. Conclusions In this study, we suggest an individual preoperative 3D reconstruction simulation to develop better screw placement plans, which provides a valuable guideline for seeking the largest secure corridor of infra-acetabular screw. Further biomechanical studies are needed to verify the function of the screw.

Background Inadequate release of the posterior spinal bone elements may hinder the correction of the lumbosacral fractional curve in degenerative lumbar scoliosis, since the lumbosacral junction tends to be particularly rigid and may already be fused into an abnormal position. The purpose of this study was to evaluate the surgical outcome and complications of posterior column osteotomy plus unilateral cage strutting technique on lumbosacral concavity for correction of fractional curve in degenerative lumbar scoliosis patients. Methods Thirty-two degenerative lumbar scoliosis patients with lumbosacral fractional curve more than 15° that were surgically treated by posterior column osteotomy plus unilateral cage strutting technique were retrospectively reviewed. The patients’ medical records were reviewed to identify demographic and surgical data, including age, sex, body mass index, back pain, leg pain, Oswestry Disability Index, operation time, blood loss, and instrumentation levels. Radiological data including coronal balance distance, Cobb angle, lumbosacral coronal angle, sagittal vertical axis, lumbar lordosis, and lumbosacral lordotic angle were evaluated before and after surgery. Cage subsidence and bone fusion were evaluated at 2-year follow-up. Results All patients underwent the operation successfully; lumbosacral coronal angle changed from preoperative 20.1 ± 5.3° to postoperative 5.8 ± 5.7°, with mean correction of 14.3 ± 4.4°, and the correction was maintained at 2-year follow-up. Cobb’s angle and coronal balance distance decreased from preoperative to postoperative; the correction was maintained at 2-year follow-up. Sagittal vertical axis decreased, and lumbar lordosis increased from preoperative to postoperative; the correction was also maintained at 2-year follow-up. Lumbosacral lordotic angle presented no change from preoperative to postoperative and from postoperative to 2-year follow-up. Postoperatively, there were 8 patients with lumbosacral coronal angle more than 10°, they got the similar lumbosacral coronal angle correction, but presented larger preoperative Cobb and lumbosacral coronal angle than the other 24 patients. No cage subsidence was detected; all patients achieved intervertebral bone fusion and inter-transverse bone graft fusion at the lumbosacral region at 2-year follow-up. Conclusion Posterior column osteotomy plus unilateral cage strutting technique on the lumbosacral concavity facilitate effective correction of the fractional curve in degenerative lumbar scoliosis patients through complete release of dural sac as well as the asymmetrical intervertebral reconstruction by cage.

Background Spinal epidural lipomatosis (SEL) is the excessive accumulation of extradural adipose tissue. Severe cases could result in myelopathy, and very rarely, in syringomyelia formation. Surgery has been associated with high morbidity and mortality, and no proven long-term benefits. The objective was to provide a technical description of an efficient and cost-effective procedure for multilevel thoracic decompression without requiring spinal instrumentation. Methods A technique of multilevel hemilaminotomy windows is described in a patient with severe thoracic SEL causing syringomyelia. A 3-dimensional spine model was created to illustrate the technique and working angles. We performed a literature review by searching PubMed, Ovid Embase, and Scopus electronic databases with the predetermined inclusion criteria of cases with spinal lipomatosis and a fluid cavity within the spinal cord. Results The patient's deficit and syringomyelia resolved postoperatively. A review of the literature revealed only 3 cases of syringomyelia secondary to SEL. Syringomyelia expansion occurred in all cases leading to progressive neurologic decline, and surgery with removal of the excessive adipose tissue resolved the syringomyelia and improved the neurologic functioning in all cases. Conclusions This technique of multilevel alternating hemilaminotomy “windows” allows for safe and effective decompression and resection of the excessive adipose tissue with reduced operative time and without requiring spine instrumentation. The technique maintains the integrity of the posterior column, thus reducing the risk of postdecompression deformity. Careful bipolar electrocoagulation of internal vertebral veins and meticulous hemostasis is key for minimizing the intraoperative blood loss and avoiding postoperative hematoma formation.

First utilized in spine surgery in the late 1980s, the Ponte osteotomy is a method of surgically shortening the posterior column in order to obtain greater corrective power in the management of kyphosis or kyphoscoliosis. It is accomplished by removal of bone around the articulation of spinal facet joints, which alters the mechanical axis of rotation and enables greater deformity correction potential. This procedure is performed in the following steps: (1) a posterior midline incision is made in order to expose and clear soft tissues from the desired surgical site; (2) the spinous process and base of the lamina are removed to allow for better visualization and working space; (3) the inferior facet is excised, followed by (4) removal of the superior facet and the (5) ligamentum flavum. If performed correctly, this procedure should allow for appropriate deformity correction and the ability to place desired instrumentation without problems.

The aim of this study was to determine safe paths for screw placement on the posterior column of the acetabulum.A total of 25 male hemipelvises were utilized in this study. These hemipelvises were sectioned, and formed cross-sections A, B, C, D, and E. The length of the screw and screw posterior column angle of the entry points at cross-sections B, C, and D were measured.On the margin of the acetabulum, lateral middle 1/4 point, midpoint, medial middle 1/4 point, and medial margin of the posterior column of each cross-section, the safe entry angle of inclination is 39, 57, 74, 90, and 106°, respectively, and the length of the screw is 35.5 mm, 33 mm, 32 mm, 31 mm, and 74 mm, respectively.On the lateral 1/4 region, lateral middle 1/4 region, medial middle 1/4 region, and medial 1/4 region of the posterior column, the screw posterior column angle is 40 ~ 60°, 60 ~ 75°, 75 ~ 90°, and 90°~parallel to the quadrilateral plate, respectively, and the length of the screw is 30 mm.ZIEL: Ziel dieser Studie ist es, sichere Wege für die Platzierung von Schrauben an der hinteren Säule des Acetabulums zu bestimmen.In dieser Studie wurden insgesamt 25 männliche Hemipelvise verwendet. Diese Hemipelvise wurden geschnitten und bildeten Querschnitte A, B, C, D bzw. E. Die Länge der Schraube und der Winkel zwischen Schraube und hinterer Säule der Eintrittspunkte in den Querschnitten B, C und D wurden gemessen.Am Rand des Acetabulums, am lateralen mittleren 1/4 Punkt, am Mittelpunkt, am medialen mittleren 1/4 Punkt und am medialen Rand der hinteren Säule jedes Querschnitts beträgt der sichere Eintrittsneigungswinkel 39 °, 57 °, 74°90 ° bzw. 106 ° beträgt die Länge der Schraube 35,5 mm, 33 mm, 32 mm, 31 mm bzw. 74 mm.Im lateralen 1/4 Bereich, im lateralen mittleren 1/4 Bereich, im medialen mittleren 1/4 Bereich und im medialen 1/4 Bereich der hinteren Säule beträgt der Winkel der hinteren Säule der Schraube 40°~60°, 60°~75°, 75°~90° und 90°~parallel zur viereckigen Platte beträgt die Länge der Schraube 30 mm.

Tibial plateau fractures can involve fracture planes that require reduction and stabilization from a posterior approach. This includes posteromedial, posterolateral, and posterior column shear-type injuries. This video outlines the prone posteromedial approach to the tibial plateau for posterior column fracture exposure, reduction, and fixation.

Background: A posteromedial tibial plateau fracture is considered a challenging injury pattern of the tibial plateau. Fracture line lies in the coronal plane leading to separation of a posteromedial fragment of variable size. This type of fracture is not rare, but it has been underappreciated previously. Objectives: This study is aiming to spot light on posteromedial approach as new concept in treatment of tibial plateau fracture as regarding to clinical and radiological outcome and to assess its surgical efficacy and advantages in such cases and to show is it beneficial to the patients or not? Patients and Methods: This is a prospective study that included 15 consecutive patients (13 males & 2 females) with closed posteromedial tibial plateau fractures who had undergone open reduction and internal fixation through a posteromedial approach by plate and screws between May 2019and September 2019. Our protocol in follow up ranged from three to six months postoperative. Results: In our study, the total clinical score according to the Rasmussen system was excellent in 8 patients (53.3%) and good in 7 patients (46.7%). As for complications, one case presented at the 3rd day postoperative with signs of compartment syndrome followed by superficial infection. The patient improved with conservative treatment with no need for surgical intervention. Conclusion: The posteromedial approach in managing posteromedial tibial plateau fracture is considered a safe and efficient approach. It allows perfect visualization and reduction of the displaced fragments. This approach uses an intermuscular plane without exposure of the neurovascular bundle.

Background: The management of severe scoliosis may lead to significant complications, and adequate mobilization is a key step to achieve maximal correction, usually requiring extensive approaches. There is still no consensus on the management of these severe and rigid curves. In this study we evaluated the clinical and radiologic outcome of a posterior-only approach with multilevel asymmetric Ponte osteotomy with a minimum of 2 years9 follow-up. Methods: In this retrospective study, 23 patients with severe and rigid adolescent idiopathic scoliosis who underwent surgery with a single-staged posterior-only approach were included. The surgical procedures in these patients were excision of posterior ligaments and spinous process, partial laminectomy in caudal part of lamina, excision of the ligamentum flavum, facetectomies, and multilevel asymmetric posterior column osteotomies (Ponte) followed by instrumented fusion. Clinical records—including demographic data; operating time; hospitalization time; blood loss; number of segments instrumented, fused, and osteotomized; functional improvement; follow-up duration; and complications—were recorded. Results: The mean preoperative Cobb angle of major curve in coronal plan was 97.5° (range, 82°–131°) with the mean flexibility of 21.4° (range, 10°–25°) on bending radiography. The mean immediate postoperative Cobb angle of major curve was 34.8° (range, 17°–61°), showing a 64.2% correction. The mean preoperative coronal and sagittal imbalances of 3.8 and 4.2 cm were improved to 1.0 and 1.3 cm at postoperative measurements, respectively. A mean of 6.1 (range, 5–9) vertebral segments were osteotomized. We experienced no major complications. Conclusions: We found that a posterior-only procedure in patients with severe and rigid adolescent idiopathic scoliosis could provide correction rate, coronal and sagittal balance, and clinical outcomes comparable with other procedures. Using this technique can eliminate the need for the anterior release, with the associated complications related to anterior surgery, in the treatment of severe rigid scoliosis.

Cervical deformity, particularly kyphosis, is frequently encountered in surgical practice. While many cases are asymptomatic, some patients may have significant pain and disability. We provide a brief review of the pathophysiology of cervical deformity and the technical aspects of deformity correction in the cervical spine. Anterior techniques reviewed here include anterior cervical discectomy and fusion (ACDF), anterior corpectomy and fusion (ACCF) and anterior osteotomy (ATO). Posterior techniques include laminectomy and fusion, posterior column osteotomy (PCO) and pedicle subtraction osteotomy (PSO). This is a fast-evolving field as our understanding of cervical deformity matures and longer-term surgical outcomes are available.

Introduction Cervical disc arthroplasty (CDA), a motion-preserving alternative to anterior cervical discectomy and fusion (ACDF), is used in military patients for the treatment of disorders such as spondylosis. Since 2007, the FDA has approved eight artificial discs. The objective of this study is to compare the biomechanics after ACDF and CDA with two FDA-approved devices of differing designs under head and head supported mass loadings. Materials and Methods A previously validated osteoligamentous C2-T1 finite element model was used to simulate ACDF and two types of CDA (Bryan and Prodisc C) at the C5-C6 level. The hybrid loading protocol associated with in vivo head and head supported mass was used to apply flexion and extension loading. First, intact spine was subjected to 2 Nm of flexion extension and the range of motion (ROM) was measured. Next, for each surgical option, flexion-extension moments duplicating the same ROM as the intact spine were determined. Under these surgery-specific moments, ROM and facet force were obtained at the index level, and ROM, facet force, and intradiscal pressure at the rostral and caudal adjacent levels. Results ACDF led to increased motion, force and pressures at the adjacent levels. Prodisc C led to increased motion and facet force at the index level, and decreased motion, facet force, and intradiscal pressure at both adjacent levels. Bryan produced less dramatic biomechanical alterations compared with ACDF and Prodisc C. Numerical results are given in the article. Conclusions Recognizing that ROM is a clinical measure of spine stability/performance, CDA demonstrates a more physiological biomechanical response than ACDF, although the exact pattern depends on the implant design. Anterior and posterior column load-sharing patterns were different between the two implants and may affect implant selection based on the anatomical and pathological state at the index and adjacent levels.