Role of Including the Index level in Short Segment Pedicular Fixation in Traumatic Thoraco-Lumbar Fractures

Background It is generally acknowledged that short-segment pedicle screw instrumentation is the preferred surgical method for thoracolumbar fractures. However, the use of short-segment instrumentation with or without intermediate screws at the fracture level remains controversial. This review will evaluate the evidence available to date regarding the efficacy of including the fracture level in trans-pedicular screw short segment fixation, to assess clinical and radiological outcome. Objectives Our primary objective is evaluating the efficacy and outcome of including the fractured level vertebra in short segment fixation. And concerns regarding the use of pedicle screws into the fractured vertebra as to whether it is safe to insert a screw through a broken bone. Our secondary objective analyzing the importance of posterior pedicle screw fixation in unstable thoracolumbar fractures. Methods The following electronic databases will be searched from 1992 to 2018: PubMed, Google scholar search engine. Cochrane database of systematic reviews, EMBASE and science Direct, using the keywords “TLICS”, "index screw", “short segment fixation”, "Thoracolumbar spine trauma", "traumatic spine injury", "spinal cord injury", "spine trauma", "role", “reliability”.Studies will be eligible if they contain the target keywords in title or abstract, addressing our age group. Afterwards the full text of the articles will be reviewed to exclude full texts not fulfilling the criteria or deviating from the initial impression taken from the title/abstract reviewing. References/bibliography of the selected articles will be examined to evaluate potential for further research and possible inclusion in the analysis. Any differences will be sorted by discussion between study team (student, director, and co-directors). Results A total of 3010 studies were screened for eligibility , 8 studies were included in our systematic review for comparing the short segment fixation “including” the fracture level with “conventional” methods whether short or long segment fixation. Overall study population reached 512 patients. Analysis showed comparable results regarding clinical picture and radiography, showing highly statistically significant difference in favor of “including” index level in fixation in post operative kyphosis angle correction, loss of correction of kyphosis angle through follow up until 2 years and loss of correction of AVH, also statistically significant difference in rate of implant failure in favor for “including” group, and with no significant difference in operative time , blood loss and VAS for post-operative pain. Conclusion We conclude that Short segment fixation including the fracture level is a promising surgical option when it comes to thoraco-lumbar unstable fractures. In conclusion, inclusion of the fracture level into the construct offers a better kyphosis correction, in addition to fewer instrument failures, without additional complications, and with a comparable-if not better-clinical outcome, the radiologic correction achieved is maintained even at the end of 2 years and reflected in good functional outcomes. We recommend insertion of screws into pedicles of the fractured thoracolumbar vertebra when considering a short segment posterior fixation, especially in Magerl type C fractures. Large population prospective randomized controlled studies and clinical trials are recommended for more high level evidence data.

Does Instrumentation of the Fractured Level in Thoracolumbar Fixation Affect the Functional and Radiological Outcome?

Study Design: Retrospective comparative study. Objectives: To compare radiological and functional outcomes of patients with fixation constructs utilizing pedicle screw stabilization at the fracture level (FL group) versus patients with non-fracture level (NFL group) fixation in single level fractures of the thoracolumbar junction (T11-L1). Methods: 53 patients of whom fracture level screw was used in 34 (FL group) were compared to 19 patients in NFL group. Radiological parameters analyzed were sagittal index, bi-segmental kyphosis (Cobb) angle and degree of vertebral height restoration. Prospectively collected patient reported functional outcomes and post-operative complications were also studied. Stepwise regression analysis adjusted by age, gender and functional scores was performed to account for the small numbers and unequal sizes of the groups. Results: Back pain score was significantly lower in the FL group ( P < 0.025). Core Outcome Measures Index scores and leg pain scores, though low in the FL group, were not statistically significant. The regression analysis showed that the inclusion of the fracture-level screw was independently associated with a greater change in sagittal index and vertebral height restoration post-operatively. Sagittal index was maintained through to final follow up as well. The bi-segmental Cobb’s angle correction was not associated with fracture-level screw construct. There was no significant difference between the groups for revision surgery, deep infection, implant failure or length of hospital stay. Conclusion: The inclusion of the fracture-level pedicle screws in the fixation construct significantly improves the immediate and final measured radiological parameters, with improved functional scores in single level unstable vertebral fractures of the thoracolumbar junction.

The Feature Ambiguity Mitigate Operator model helps improve bone fracture detection on X-ray radiograph

This study was performed to propose a method, the Feature Ambiguity Mitigate Operator (FAMO) model, to mitigate feature ambiguity in bone fracture detection on radiographs of various body parts. A total of 9040 radiographic studies were extracted. These images were classified into several body part types including 1651 hand, 1302 wrist, 406 elbow, 696 shoulder, 1580 pelvic, 948 knee, 1180 ankle, and 1277 foot images. Instance segmentation was annotated by radiologists. The ResNext-101+FPN was employed as the baseline network structure and the FAMO model for processing. The proposed FAMO model and other ablative models were tested on a test set of 20% total radiographs in a balanced body part distribution. To the per-fracture extent, an AP (average precision) analysis was performed. For per-image and per-case, the sensitivity, specificity, and AUC (area under the receiver operating characteristic curve) were analyzed. At the per-fracture level, the controlled experiment set the baseline AP to 76.8% (95% CI: 76.1%, 77.4%), and the major experiment using FAMO as a preprocessor improved the AP to 77.4% (95% CI: 76.6%, 78.2%). At the per-image level, the sensitivity, specificity, and AUC were 61.9% (95% CI: 58.7%, 65.0%), 91.5% (95% CI: 89.5%, 93.3%), and 74.9% (95% CI: 74.1%, 75.7%), respectively, for the controlled experiment, and 64.5% (95% CI: 61.3%, 67.5%), 92.9% (95% CI: 91.0%, 94.5%), and 77.5% (95% CI: 76.5%, 78.5%), respectively, for the experiment with FAMO. At the per-case level, the sensitivity, specificity, and AUC were 74.9% (95% CI: 70.6%, 78.7%), 91.7%% (95% CI: 88.8%, 93.9%), and 85.7% (95% CI: 84.8%, 86.5%), respectively, for the controlled experiment, and 77.5% (95% CI: 73.3%, 81.1%), 93.4% (95% CI: 90.7%, 95.4%), and 86.5% (95% CI: 85.6%, 87.4%), respectively, for the experiment with FAMO. In conclusion, in bone fracture detection, FAMO is an effective preprocessor to enhance model performance by mitigating feature ambiguity in the network.

Outcomes with fracture-level transpedicular screws used for thoracolumbar junction fractures

Background Short-segment transpedicular screw fixation (SSTSF) is the preferred treatment option for thoracolumbar burst fractures. Adding screws in the fractured body may be helpful in achieving and maintaining fracture reduction. However, the operative approach is disputed. Objective To compare clinical outcomes of transpedicular fixation with and without screws in the fractured vertebral body after isolated uncomplicated fractures at the thoracolumbar junction. Material and methods A retrospective cohort study enrolled 62 patients with Th11–L2 thoracolumbar burst fractures (AOSpine A3, A4) who underwent SSTSF with (n = 32) and without (n = 30) pedicle screws at the fracture level. Demographic data of the patients, operating time and blood loss were registered. Clinical evaluation using Visual analogue scale (VAS ) for pain, Oswestry Disability Index (ODI) to quantify disability and imaging parameters of segmental kyphosis, loss of correction, anterior vertebral body height (AVBH) at the fracture level, spinal canal stenosis (SCS) were measured preoperatively, at one week, 1 month, 6 and 12 months postoperatively. Results The patients of the two groups showed no statistically significant differences in the demographic data, VAS and ODI scores, measurements of kyphotic angle, AVBH, SCS preoperatively (p > 0.05). Screws at the fracture level did not affect the operating time and intraoperative blood loss relative to conventional no-screw group. Benefits with fracture screws were evident at 7 days (p < 0.01) measuring SCS, at 6 months (p < 0.01) and 12 (p < 0.01) months measuring kyphotic angle. There was better kyphosis correction (p < 0.01) and AVBH (p = 0.034) seen at 12 months after surgery. Conclusion Reinforcement of a broken vertebra with fracture-level screws has been shown to provide better stability of clinical and radiographic results as compared to those with conventional SSTSF.

Acute retrograde tibiotalocalcaneal nailing in osteoporotic periarticular ankle fractures

Objective: This study aimed to report the short-term results of retrograde tibiotalocalcaneal (TTC) nailing in a selected series of patients with fragility ankle fractures. Methods: This study included 17 patients who underwent primary retrograde TTC nailing from January 2016 to April 2019. The Olerud-Molander ankle score (OMAS) was recorded preoperatively and at the final follow-up. Results: Mean patient age was 81.5 years (range, 67-91 years), and mean follow-up duration was 20.9 months (range, 8-50 months). No patient was lost to follow-up. Eleven patients had diabetes. Thirteen patients were able to walk with an assistive device, and 4 with help from another person. Two patients died at 8 and 9 months after treatment. Radiographic healing was observed in 100% of the fractures. No deep infection or scarring problems were recorded. Two patients were wheelchair bound after treatment, whereas 15 recovered their previous autonomy. The mean OMAS score changed from 64.1 (range, 55-75) preoperatively to 55.3 (range, 45-65) postoperatively. Conclusion: Our results suggest that primary retrograde TTC nailing is a valid option in selected patients with fragility ankle fractures, multiple comorbidities, poor soft tissue condition, and difficulty in walking before the fracture. Level of Evidence IV; Therapeutic Studies, Case Series.

Limitations of Plain Film Radiography in Identification of Hyperextension Fractures in Patients With Ankylosing Spinal Disorders

Study Design: Efficacy study. Objectives: To elucidate the limitations of radiography in patients with spinal ankylosing disorders (SAD) with an emphasis on thoracolumbar injuries, which have been less focused upon. Methods: We searched our hospital’s emergency room database for patients who underwent a total spine computed tomography (CT) following a diagnosis of SAD on radiographs following a minor fall. A high-quality presentation containing 50 randomly situated anteroposterior + lateral radiographs was created. Of these, 24 contained a hyperextension type fracture diagnosed by CT. Twelve physicians—4 spine surgeons, 4 senior orthopedic residents and 4 junior orthopedic residents were requested to identify the pathologic radiographs and note the fracture level. Results: Fracture diagnosis stood at 65% for the best reader. When examining the different subgroups, the mean rate of diagnosis for spine surgeons was 55% and for orthopedic residents 32%. Mean diagnosis of thoracic fractures was 26%, of lumbar fractures was 55%, and for the entire thoracolumbar spine was 40%. The interobserver agreement (kappa coefficient) was found to be 0.37 for the entire group and 0.39 for spine surgeons. This finding was statistically significant. Conclusions: The simple radiograph is an inefficient modality for diagnosis of hyperextension type thoracolumbar fractures in patients with SAD. The poor interobserver agreement rate further amplifies this finding. Advanced imaging is recommended in these patients.

Comparison of the Therapeutic Effects of Short-Segment Posterior Fixation With Monoaxial Pedicle Screws or Polyaxial Pedicle Screws via Injured Vertebra on Thoracolumbar Fracture

Purpose: To evaluate the therapeutic effects of short-segment posterior fixation with monoaxial pedicle screw or polyaxial pedicle screw via injured vertebra on thoracolumbar fracture.Methods: All patients who underwent short-segment posterior fixation with monoaxial pedicle screws or polyaxial pedicle screws in the injured vertebra of a thoracolumbar fracture (T12-L2). The clinical and radiological data such as the correction of deformity, sagittal profle and record of the perioperative morbidity of the patients were analyzed.Results: There were 63 patients (21 males and 42 females) with an average age of 44.7 years and were categorised into two groups: monoaxial pedicle screws group (group A) and polyaxial pedicle screws group (group B). There were no significant differences in age, gender, fracture site, TLISS Score, ASIA Score, AO Classification, hospital stay, Injury-to-operation intereval, and associated injury between the two groups (P>0.05). Howere, compared with group B, the injury vertebral endplate centre ratio significantly increased postoperatively and at the final follow-up (P<0.05) in group A.Conclusion: Short-segment posterior fixation with monoaxial or polyaxial pedicle screws via the fracture level for thoracolumbar fracture can achieve kyphosis correction, reduce sagittal alignment correction failure, and maintain anterior vertebral height. The insertion of monoaxial pedicle screws at the fracture level after thoracolumbar vertebral fracture has a flick up ffect on the central vertebral body of the injured vertebrae, which is beneficial to the recovery of the vertebral endplate.

Retrieval of fractured Endodontic Instrument under dental operating microscope using ultrasonic tips : A Case Report

A Patient came with the complaint of pain in the lower right back region of the jaw. Root canal treatment was planned. While preparing for the bio-mechanical procedure, the Hand pro taper fractured in the apical third. Iatrogenic occurred as a result of the fracture of the endodontic instrument. Retrieval of the fractured instrument was planned to complete the cleaning and shaping of the canal. The removal of the fractured instrument was planned to be done under the Dental Operating Microscope. The use of an operating microscope enhanced the illumination and the magnification of the instrument. This illumination and magnification helped in the precision of removal. The ultrasonic tip enabled to reach of the fractured instrument in the canal and loosen the dentin around the fractured instrument. It allowed easy retrieval of the fractured instrument. During the retrieval procedure, the fractured instrument was bypassed before the use of the ultrasonic tip. After the removal of the fractured instrument, cleaning and shaping were completed, followed by obturation, definitive restoration, and prosthesis. As the removal of the fractured instrument enabled complete cleaning and shaping, it improved the prognosis of the case. When the endodontic instrument gets fractured, it should be analyzed over the radiograph to assess the fracture level, the anatomy of the root canal, size of the fractured instrument, check accessibility, stage of fracture, etc. If all the above criteria are met with the removal of the instrument only then, replacement should be tried. Otherwise, it may lead to a severe loss of root dentin, decreasing fracture resistance of the root.