Background: Type II odontoid fractures are the commonest upper cervical spine injury in the elderly, following minor falls. Structural heterogeneity within the axis with deficiency of bone mass in the base of the odontoid process has been attributed for these fractures.

Aims: To analyse whether osteoporosis at the dens-body junction is directly related to the occurrence of odontoid fractures in the elderly.

Material and Methods: We studied the reformatted CT scan images of 36 patients over the age of 70 years who had cervical spine injuries following minor trauma. In all these patients the severity of osteoporosis at the dens-body junction, and in the peg and body of axis were evaluated. The osteoporosis was graded into none, mild, moderate and severe. Statistical analysis was performed using Pearson’s Chi-square test to find the significance of osteoporosis at the dens-body junction in producing Type II odontoid fractures in the elderly.

Results: Type II odontoid fractures was seen in 21 patients. Eleven of the 21 patients with Type II fractures and eight of the 15 patients with no Type II odontoid fractures had significant osteoporosis at the dens-body junction. Five patients with Type II fracture and eight patients with no Type II fractures had significant osteoporosis at the dens and body of axis. Statistical analysis showed that the osteoporosis at the dens-body junction was not significant in patients with Type II odontoid fracture compared to those with no Type II odontoid fracture (χ² = 1.1; df = 3, p = 0.78).

Conclusions: Eventhough osteoporosis is one of the factors that increase the incidence of Type II fractures of the odontoid process in the elderly, it is not a direct aetiological factor.

Introduction Local steroid injection is commonly performed as a treatment for facet joint arthritis in the lumbosacral spine. The injection is performed under image guidance for which some surgeons utilise antero-posterior (A-P) imaging only while others prefer oblique imaging. The entry point and the direction of the needle entering into the facet joint are different in these techniques. Further the difficulties encountered in both the techniques are different.

Purpose To find out the difference in the functional outcome in patients who received the facet joint steroid injection by A-P imaging and those who had the injection by oblique imaging.

Material and Methods A prospective randomised controlled trial was performed by randomly allocating the 20 patients who was diagnosed to have facet joint arthritis clinically and by magnetic reasonance image scans, and who were then placed in the list for facet joint injections. Ten patients in Group I received the facet joint injections with A-P imaging while 10 patients in Group II received the facet joint injections with oblique imaging using image intensifier. All the patients received 40mg of methylprednisolone acetate with 1mL of 1% lignocaine and 1mL of 0.5% bupivacaine to each joint. The duration of the entire procedure was noted. Short Form-36 (SF-36) questionnaire was used before the procedure and at six weeks after the procedure to assess the functional outcome.

Results All the patients were followed up for a period of six weeks. The mean age was 51.3 yrs in Group I and 48.3 yrs in Group II. The male to female ratio was 3:7 in Group I and 2:5 in Group II. One patient in Group I had the facet injections at only one level (L4/5 or L5/S1) while it was in two patients in Group II. Further one patient in Group I and one in Group two had unilateral facet joint injections at two levels. All the other patients had bilateral facet joint injections at two levels (L4/5 and L5/S1). One patient was excluded from the study as the A-P image obtained was very poor and that an oblique image had to be performed to visualise the facet joint because of obesity. The mean duration of the procedure was 18.33 min (10–25 min) in Group I and 22 min (10–35 min) in Group II (p=0.14, 95%CI −8.5 to +1.4). The patient function score improved from a mean of 20.0% to 32.5% after the injection in Group I, and from 30.0% to 41.0% in Group II. The pain score improved from a mean of 33.3% to 47.2% in Group I, and from 35.6% to 44.4% in Group II. The difference in physical function score (p=0.85, 95% C.I. −15.29 to +18.29), and pain score (p=0.71, 95% C.I. −24.21 to +34.22) between the two groups were not statistically significant.

Conclusions There is no difference in the functional outcome of patients treated by facet joint injections using A-P or oblique imaging. However, with experience we found that it may be difficult to visualise the facet joint clearly by A-P imaging alone in obese individuals.

Background: Autologous blood from reinfusion drains are commonly used after major joint arthroplasties with a view to decrease the heterologous blood transfusion requirement. The aim of this study is to find the effect of reinfusion drains on the difference in haemoglobin (Hb) level before and after total knee arthroplasties.

Material and Methods: Between January 2001 and October 2003, 158 patients had total knee arthroplasty on one side. The type of thromboprophylaxis used was the same in all the patients. 74 patients had autologous blood transfusion through reinfusion drains (Group I) while 84 patients had no autologous blood transfusion and ordinary suction drains were used to drain the wound in the immediate postoperative period (Group II). The mean age was 72.1 +/− 8.5 in group I and 69.3 +/− 9.1 in group II. In each patient the preoperative Hb level, the amount of autologous blood transfusion, the postoperative Hb level and the amount of heterologous bleed transfusion requirement were noted.

Results: The mean preoperative Hb level was 13.6 +/− 1.4 g/dL (10.4–18.1) in group I and 13.7 +/− 1.3 g/dL (7.9–16.5) in group II. The mean postoperative Hb level was 10.7 +/− 1.5 g/dL (10.4–18.1) in group I and 10.7 + 1.6 g/dL (5.4 +/− 13.6) in group II. The difference in Hb level between the two groups was analysed using t-test and found to be not significant (p = 0.76), with the mean difference between the groups being 0.05 and the 95% CI to the mean difference includes zero (range −0.3 to +0.4). The difference in Hb level before and after surgery was plotted against the amount of autologous blood transfused and it was observed that there was no significant improvement with increased amount of autologous blood transfusion. The cost of reinfusion drain is 36.43 (~ 53.37 Euros) more than the suction drain.

Conclusion: Autologous blood from reinfusion drains did not significantly improve the postoperative Hb level. Further usage of reinfusion drain is not cost-beneficial.

Background: Type II odontoid fractures are the commonest upper cervical spine injury in the elderly, following minor falls. Structural heterogeneity within the axis with deficiency of bone mass in the base of the odontoid process has been attributed for these fractures.

Aims: To analyse whether osteoporosis at the dens-body junction is directly related to the occurrence of odontoid fractures in the elderly.

Material and Methods: We studied the reformatted CT scan images of 36 patients over the age of 70 years who had cervical spine injuries following minor trauma. In all these patients the severity of osteoporosis at the dens-body junction, and in the peg and body of axis were evaluated. The severity was graded into none, mild, moderate and severe, depending on the cortical thickness, trabecular pattern, and the size of holes (absence of trabeculae) using sagittal, coronal and transverse sections of CT scan pictures. The osteoporosis was graded into none, mild, moderate and severe. Statistical analysis was performed using Pearsons Chi-square test to find the significance of osteoporosis at the dens-body junction in producing Type II odontoid fractures in the elderly.

Results: Type II odontoid fractures was seen in 21 patients. Eleven of the 21 patients with Type II fractures and eight of the 15 patients with no Type II odontoid fractures had significant osteoporosis at the dens-body junction. Five patients with Type II fracture and eight patients with no Type II fractures had significant osteoporosis at the dens and body of axis. Statistical analysis showed that the osteoporosis at the dens-body junction was not significant in patients with Type II odontoid fracture compared to those with no Type II odontoid fracture (Chi-square value = 1.1; df = 3, p = 0.78).

Conclusions: Eventhough osteoporosis is one of the factors that increase the incidence of Type II fractures of the odontoid process in the elderly, it is not a direct aetiological factor.

Background Non-weight bearing hip is a common problem in the elderly population after a minor fall. Magnetic reasonance imaging (MRI) is used to diagnose occult fractures in the hip and the pelvic ring in these individuals. The aim of this study is to find the relationship between the incidence of occult fractures in the hip and that in the pelvic ring following low velocity trauma in the elderly.

Material and Methods Between January 2000 and February 2004, 106 elderly patients (mean age = 81.4 years; range = 67–101 years), underwent an MRI scan of the pelvis and hip to rule out fracture neck of femur. All of them presented with a non-weight bearing hip after a history of low velocity injury. All had standard radiographs of the pelvis and the hip which did not reveal a fracture of the femoral neck. However, eight patients had fracture of the pubic rami visible on plain radiographs. MRI scans were subsequently performed in all of them to rule out an occult fracture of the femoral neck.

Results Out of the 106 patients, 17 (16%) had intracapsular neck of femur fracture, 26 (24.5%) had extracapsular neck of femur fracture, 26 (24.5%) had pubic rami fracture, 17 (16%) had sacral fractures, and 37 (34.9%) had no fractures. All the sacral fractures occurred in patients with pubic rami fractures. Further except in one patient where the pubic rami fracture and the sacral fracture were contralateral, the remaining 16 patients had ipsilateral pubic rami and sacral fractures. None of the patients with pelvic ring fracture had associated femoral neck fracture.

Conclusion Inability to weight bear after a fall is a common presentation in the elderly population. Falls can lead to fracture neck of femur or a fracture of the pelvic ring but seldom both. We can also conclude that in an elderly patient with low velocity injury, if a pelvic ring fracture is detected in the plain radiograph there is no indication for further MRI to rule out femoral neck fracture. Further, the fracture in the anterior and posterior pelvic ring commonly involves the same side than the contralateral side, in the elderly after trivial trauma.

Study Design: Retrospective Series.

Objectives: To analyse loss of correction of the anterior wedge angle and the components responsible for the recurrence of kyphosis after surgical stabilisation of dorsolumbar fractures, and to assess the return of functional capacity in these patients.

Materials and Methods: Between January 1998 and March 2003, 34 patients had posterior stabilisation performed with the Universal Spine System (Synthes) for dorsolumbar fracture at a single level with no neurological deficit. There were 26 AO Type A fractures, 5 Type B fractures, and 3 Type C fractures. Serial standing lateral radiographs were taken from the immediate postoperative period to the most recent follow-up. The anterior wedge angle, the heights of the discs above and below the fractured vertebra, and the heights of the vertebral bodies above, at, and below the fractured level were measured. The height at each level was measured in three segments (anterior, middle and posterior). The values were normalised to avoid discrepancies while comparing radiographs. The difference in the height of each segment measured between the immediate postoperative period and the most recent follow-up were computed. Short Form 36 (SF-36) was used to assess the functional outcome in each.

Results: The mean follow-up period was 23.6 months (9 to 48 months). The mean anterior wedge angle was 10.1 ± 7.2 degrees in the immediate postoperative period and 17.1 ± 10.9 degrees at latest follow-up (p< 0.001). The mean loss of correction was 7.0 ± 8.5 degrees (−11 to 24) and this showed a linear relationship to the preoperative anterior wedge angle. Furthermore there was a linear increase in the loss of correction of the angle as the follow-up period increased. The correlation between the corresponding difference in the height of each segment and the degree of loss of correction of the anterior wedge angle showed significant correlation to the decrease in the anterior segment height at the fractured vertebral body level (Pearson’s coefficient r=0.53 significant at 0.01 level, p=0.001). The mean physical function score from SF-36 was 56.3 and the mean bodily pain score was 49.7. There was no relationship to the angle of kyphosis at follow-up to the physical function score (r=0.12, p=0.50) and the bodily pain score (r=0.14, p=0.44).

Conclusions: There is a progressive loss of correction (increasing kyphosis) after posterior stabilisation with instrumentation that roughly approximates the initial decrease in anterior height of the fractured vertebral body. The degree of loss of correction does not depend on the type of fracture. The loss of correction is related to the preoperative angle of kyphosis.

Introduction and Aims: Odontoid fractures are quite common in the elderly following minor falls. As there are a few articulations in the upper cervical spine, degeneration in any one particular joint may affect the biomechanics of loading of the upper cervical spine. We aimed to analyse the pattern and relationship of odontoid fractures to the upper cervical spine osteoarthritis in the elderly.

Method: Between July 1999 and March 2003, 185 patients had CT scan of the cervical spine for cervical spine injuries. Twenty-three out of 47 patients over the age of 70 years had odontoid fractures. The CT scan pictures of these patients were studied to analyse the type of fracture and its displacement, the severity of osteoarthritis in each articulation in the upper cervical spine, namely lateral atlantoaxial, atlantooccipital, atlantoodontoid and subaxial facetal joints, evaluation of osteopenia in the dens-body junction and in the body and odontoid process of the axis, and calcification of the ligaments.

Results: Twenty-one of the 23 patients had Type II odontoid fracture with posterior displacement in seven (33.3%) and posterior angulation in nine (42.8%) patients. In these patients with Type II dens fracture, the atlantodens interval was obliterated in 19 (90.48%) patients, with only two of them (9.52%) having lateral atlantoaxial osteoarthritis.

Conclusion: Type II fracture is the commonest odontoid fracture in the elderly. Posterior displacement of the fracture is common in elderly, unlike the younger population. There is a significant relationship between the upper cervical spine osteoarthritis, apart from osteopenia, to the incidence of Type II odontoid fractures. Significant atlantoodontoid osteoarthritis in the presence of normal lateral atlantoaxial joints increases the risk of sustaining Type II odontoid fracture.