Purpose. Anterior column screw fixation has been a useful tool in the management of acetabular fractures, either alone or in combination with other fixation techniques. Percutaneous insertion may be advantageous by limiting surgical dissection but little has been reported on its safety. The purpose of this study is to report on the efficacy and safety of percutaneous anterior column stabilization. Method. In a consecutive series of 122 operatively treated acetabular fractures, 56 patients were treated with antegrade percutaneous anterior column stabilization either alone or in combination with other fixation techniques by a single surgeon (JY). The technique was selected when the anterior column portion of the fracture was undisplaced or could be reduced via indirect methods. Intraoperative fluoroscopy was used to guide the placement of either a 6.5 mm or 7.3 mm cannulated antegrade anterior column lag screw. Postoperative radiographs (anteroposterior and Judet views) were obtained in the recovery room, prior to discharge and at clinic follow up. Results. The mean age of patients in the series was 52 years (range 17 91). Mean follow up was 13 months. There was one death from associated injuries. Based on the classification system described by Letournel, there were 22 anterior column, 8 transverse, 11 transverse / posterior wall, 9 anterior column / posterior hemitransverse, 1 associated both column and 5 T-type fractures. There were no vascular, neurologic, or urologic complications in the series. There were no cases of intraarticular screw placement. In two cases, the screw did not completely cross the entire fracture line on postoperative radiographs. There were no cases of hardware failure or loss of reduction. There were two cases of hardware removal for hardware prominence. There was one case of chronic proximal femur osteomyelitis, and two cases requiring subsequent total hip arthroplasty for associated injuries. All fractures healed. Conclusion. This study supports percutaneous anterior column stabilization as a safe and effective technique in the treatment of selected acetabular fractures

We wanted to verify the validity of the treatment of vertebroplasty and kyphoplasty to failure of the anterior column of the thoracic and lumbar spine. Since 2002, 39 procedures of vertebroplasties and kypholasties were performed to 36 patients. Most of the procedures were done because of painful ostoporotic fractures. 4 were because of metastasis, 2 hemangiomas of the vertebral body. 2 multiple myeloma. One Paget disease of bone. In cases of multiple osteoporotic fractures, decision was made based on clinical Findings and bone scan. Results were encouraging: 31 patients reported of improvement of pain. Analyzing Visual Analogue Score, alleviation was recorded immediately after surgery. Few complications were registered: 2 patients underwent further surgery because of radiating pain. In two patients malpositioning of the Vertebral Body Reconstraction was seen. One patient had osteomyelitis of the vertebral body. 2 cement leakage were seen. Vertebroplasty and kyphoplasty are good solutions for the treatment of failure of the anterior column in the thoracic and lumbar spine. Accurate patients election should be done in order to detect patients with spinal stenosis that will respond negatively to this treatment

To evaluate the incidence of complications and the radiographic and clinical outcomes from 2-stage reconstruction including 3-column osteotomy for revision adult spinal deformity. A prospective cohort study performed over 2 years at a major tertiary referral centre for adult spinal deformity surgery. All consecutive patients requiring 2-stage corrective surgery for revision adult spinal deformity were included. Radiographic parameters and clinical outcome measures were collected preoperatively and at 6 weeks, 6 months, 1 year and 2 years postoperatively. Radiographic parameters analysed included pelvic incidence, pelvic tilt, sacral slope, lumbar lordosis, thoracic kyphosis and sagittal vertical axis. Clinical outcome measures collected included EQ-5D, ODI, SRS 22 and VAS Pain Scores. Performing anterior column reconstruction followed by 3-column osteotomy and extension of instrumentation for revision spinal deformity resulted an excellent correction of sagittal alignment, minimal surgical complications and significant improvements in HRQOL. Restoration of lumbar lordosis, pelvic tilt and sagittal vertical axis were observed in addition to postoperative improvements in EQ-5D, ODI, SRS 22 and VAS Pain Scores at follow-up. Performing anterior column reconstruction prior to a 3-column osteotomy minimises complications associated with 3-column osteotomy and extension of posterior instrumentation. We propose a treatment algorithm for safe and effective treatment in revision adult deformity surgery

Introduction: Anterior wall and/or column acetabular fractures (AW/C) have a low incidence rate. Paucity of information exists regarding the clinical results of these fractures. We present our experience in treating AW/C at a tertiary referral centre. Methods: Between Jan-2002 and Dec-2007, 200 consecutive patients were treated in our institution with displaced acetabular fractures. All AW/C fractures according to the Letournel classification were included in the study. All patients underwent plain radiography and CT investigations. Retrospective analysis of the medical notes and radiographs was performed for type of associated injuries, operative technique, peri-operative complications. Radiological assessment of fracture healing was determined by Matta’s criteria and functional hip scores were assessed using Merle-d’-Aubigne scoring. The mean follow up was 44.5 months (28–64). Results: 15 patients (10 males) met the inclusion criteria (mean age 55.5years). Four had associated anterior dislocation. Associated injuries included pneumothorax, splenic rupture, tibial and distal radius fractures. Five were treated by percutaneous methods, 8 with plate-screw fixation, and 2 with circlage wire, (10 ilioinguinal approaches). Mean time-to-surgery was 14days(10–21days). The average operative time for the percutaneous group was 75min vs. 190min in the orif group. Mean postoperative-in-patient-stay was 4 days(3–7days), and 21days(14–37days). One patient developed chest infection post-operatively, two loss of sensation over the distribution of lateral cutaneous nerve. None of them developed incisional hernia, deep venous thrombosis and pulmonary embolism. At the last follow-up radiological outcome was excellent in 11 and good in 4 patients; clinical outcome was excellent in 12 and good in 3 patients, and none of the patients has developed heterotopic calcification or early osteoarthritis. Conclusion: Our results on management of these fractures are comparable to the early results reported by Letournel. Operative treatment for the rare anterior wall and anterior column fractures yields a favorable outcome resulting in early mobilization with limited patient morbidity

Aim of Study: (A) To study what causes Anterior Column Deficiency in Burst Fracture of Dorso Lumbar Spine in the acute and later phase. (B) To analyse radiologically, the significance of adjacent disc injuries in burst fracture of dorso lumbar spine. (C) To look into the effectiveness of posterior short segment stabilisation by pedicle screw fixation and fusion in these injuries, in relation to deformity and anterior column deficiency. Methods and Materials: Twenty consecutive cases of Superior Burst-split fracture of Dorsolumbar spine were studied prospectively. All cases underwent reduction, posterior short segment stabilisation by Steffee type pedicle screw fixation and two level posterolateral fusion. The average follow-up duration was 30.2 months. Standardised AP and lateral radiograph were taken pre-operatively and post-operatively at regular intervals (every three months). Radiological assessment using seven parameters (Vertebral body angle, Upper disc angle, Lower disc angle, Kyphotic angle, etc) were done from these radiographs. Result and Significance: The total average correction of kyphosis (in degree) at surgery was 21.5°, and the proportion of correction during surgery was – Upper disc 29% (6.3°), Vertebral body 68% (14.6°) and Lower disc 3% (0.6°). So 68% of the correction was at the vertebral body level and 32% at the adjacent discs levels. At follow-up, the total average loss of correction was 16.5°, and the proportion of loss at follow-up was – Upper disc 44% (7.2°), Vertebral body 14% (2.3°) and Lower disc 42% (7.0°). There was loss of 14.2° at the disc levels compared to 2.3° only at the vertebral body level. So 86% of the loss was at the adjacent disc levels. Conclusion: Distraction at the adjacent disc levels occurred at surgery while contouring the vertebral body using dorsal instrumentation. The distraction at the upper disc level was significant. Distraction at adjacent disc levels resulted in more anterior column deficiency. At follow-up, the loss in the vertebral body was minimal and most of the loss occurred at the adjacent disc levels. The anterior column deficiency caused by the injury to the adjacent disc is very major cause for failure of dorsal instrumentation than the deficiency caused by the vertebral body. The upper disc is more severely injured than the lower disc in the superior burst split fracture and so the degeneration is rapid in the upper disc and gradual in the lower disc. The CT cuts at the end plate levels of the vertebral body can help to judge roughly the extent of injury to the adjacent disc. Posterolateral fusion and late disc degeneration after consolidation of fusion result in collapse of the disc in kyphotic angulation, as it prevents collapse of posterior disc height

Introduction: Diaphyseal femoral allograft is well suited to anterior column reconstruction of the thoracolumbar spine due to its inherent structural properties and bio-compatibility. The Bridwell system of interbody fusion assessment. 1. is based on plain x-rays and therefore lacks sensitivity. A new classification system of bony union is proposed using high-speed spiral CT imaging. Methods: Twenty-six patients who underwent anterior thoracolumbar reconstruction for burst fracture using femoral allograft were followed for a minimum of 2 years. Each subject underwent high speed spiral CT scanning through the reconstructed region of the thoracolumbar spine and a classification system of graft to endplate union and central cancellous autograft incorporation was established. The classification system reflects gradually increasing biological stability of the construct. Grade I (complete fusion) implies cortical union of the allograft and central trabecular continuity. Grade II (partial fusion) implies cortical union of the structural allograft with partial trabecular incorporation. Grade III (unipolar pseudarthrosis) denotes superior or inferior cortical non-union of the central allograft with partial trabecular discontinuity centrally and Grade IV (bipolar pseudarthrosis) suggests both superior and inferior cortical non-union with a complete lack of central trabecular continuity. Intra- and inter-observer error studies were carried out involving spinal surgeons, radiologists and trainees to examine reliability of the classification. Results: In this series 84% of cases demonstrated Grade I or Grade II characteristics. 1 case (4%) was identified as Grade IV. The classification showed good reliability with a kappa score of over 0.7. Discussion: Plain radiographs have always proved unsatisfactory for the accurate assessment of incorporation of grafts in the thoracolumbar spine. The use of CT imaging in the assessment of graft union has allowed a more accurate assessment of union. The classifi cation system presented allows a reproducible and relevant categorisation of allograft incorporation

Anterior wall and/or column acetabular fractures (AW/ C) have a low incidence rate. Paucity of information exists regarding the clinical results of these fractures. We present our experience in treating AW/C at a tertiary referral centre. Between Jan-2002 and Dec-2007, 200 consecutive patients were treated in our institution with displaced acetabular fractures. All AW/C fractures according to the Letournel classification were included in the study. All patients underwent plain radiography and CT investigations. Retrospective analysis of the medical notes and radiographs was performed for type of associated injuries, operative technique, peri-operative complications. Radiological assessment of fracture healing was determined by Matta’s criteria and functional hip scores were assessed using Merle-d’-Aubigne scoring. The mean follow up was 44.5 months (28–64). 15 patients (10 males) met the inclusion criteria (mean age 55.5 years). Four had associated anterior dislocation. Associated injuries included pneumothorax, splenic rupture, tibial and distal radius fractures. Five were treated by percutaneous methods, 8 with plate-screw fixation, and 2 with circlage wire, (10 ilioinguinal approaches). Mean time-to-surgery was 14 days(10–21 days). The average operative time for the percutaneous group was 75min vs. 190min in the orif group. Mean postoperative-in-patient-stay was 4 days(3–7 days), and 21 days(14–37 days). One patient developed chest infection post-operatively, two loss of sensation over the distribution of lateral cutaneous nerve. None of them developed incisional hernia, deep venous thrombosis and pulmonary embolism. At the last follow-up radiological outcome was excellent in 11 and good in 4 patients; clinical outcome was excellent in 12 and good in 3 patients, and none of the patients has developed heterotopic calcification or early osteoarthritis. Our results on management of these fractures are comparable to the early results reported by Letournel. Operative treatment for the rare anterior wall and anterior column fractures yields a favourable outcome resulting in early mobilization with limited patient morbidity

Introduction and Aims: Socioeconomic deprivation and the HIV epidemic have accounted for the global increase in tuberculosis. Tuberculous spondylitis constitutes 60% of osteoarticular tuberculosis. Progressive kyphosis has been reported with rib grafts in spinal TB. We prospectively evaluated 45 patients treated with fresh frozen anterior cortical allografts for spinal TB.

Method: The mean age was 28.6 years and all patients were HIV negative. The neurological status (Frankel grade) was (A)10, (B)18, (C)17 and the dorsal spine was affected in 37 patients. The kyphosis measured 540 (range 270–740). Following pre-operative nutritional support all patients underwent a radical anterior decompression and the granulation tissue tethering the cord to the apex of the deformity was released. An appropriate length of fresh frozen cortical allograft was positioned by interference fit and stabilised with an anterior rod screw construct. Anti-tuberculosis treatment was prescribed for one year.

Results: Post-operatively, four patients developed pulmonary atelectasis and three patients had superficial wound infections, which resolved with physical therapy and antibiotics respectively. Four patients were excluded due to inadequate follow-up. At 12 months complete neurological recovery occurred in 32 patients, partial in five and no recovery in four patients. There was no radiological evidence of infection or fracture of the allografts. The criteria of Bridwell et al was used to classify the incorporation of allografts. The earliest radiological evidence of fusion and remodelling occurred between 12 and 18 months post-operatively. At the last follow-up (mean 7.8 years, range 6.5–9.2 years) the allografts had incorporated in 33 cases and in eight cases the remodelling was incomplete. Although the incorporation is slow, there were no cases of non-union. The kyphosis measured 220 (range 14–460) at the most recent follow-up.

Conclusion: The weakness of rib grafts is attributed to the unfavourable length, width ratio and the small surface area of contact. Allografts are biological and the stability is enhanced by a large surface area of contact and instrumentation.

Background. Surgical site infection following spine surgery is associated with increased morbidity, mortality and increased cost for the health care system. The reported pooled incidence is 3%. Perioperative antibiotic prophylaxis is a key factor in lowering the risk of acquiring an infection. Previous studies have assessed perioperative cefuroxime concentrations in the anterior column of the cervical spine with an anterior surgical approach. However, the majority of surgeries are performed in the posterior column and often involve the lumbar spine. Accordingly, the objective was to compare the perioperative tissue concentrations of cefuroxime in the anterior and posterior column of the same lumbar vertebra using microdialysis in an experimental porcine model. Method. The lumbar vertebral column was exposed in 8 female pigs. Microdialysis catheters were placed for sampling in the anterior column (vertebral body) and posterior column (posterior arch) within the same vertebra (L5). Cefuroxime (1.5 g) was administered intravenously over 10 min. Microdialysates and plasma samples were continuously obtained over 8 hours. Cefuroxime concentrations were quantified by Ultra High Performance Liquid Chromatography Tandem Mass Spectrometry. Microdialysis is a catheter-based pharmacokinetic tool, that allows dynamic sampling of unbound and pharmacologic active fraction of drugs e.g., cefuroxime. The primary endpoint was the time with cefuroxime above the clinical breakpoint minimal inhibitory concentration (T>MIC) for Staphylococcus aureus of 4 µg/mL as this has been suggested as the best predictor of efficacy for cefuroxime. The secondary endpoint was tissue penetration (AUC. tissue. /AUC. plasma. ). Results. Mean T>MIC 4 µg/mL (95% confidence interval) was 123 min (105–141) in plasma, 97 min (79–115) in the anterior column and 93 min (75–111) in the posterior column. Tissue penetration (95% confidence interval) was incomplete for both the anterior column 0.48 (0.40–0.56) and posterior column 0.40 (0.33–0.48). Conclusions. Open lumbar spine surgery often involves extensive soft tissue dissection, stripping and retraction of the paraspinal muscles which may impair the local blood flow exposing the lumbar vertebra to postoperative infections. A single intravenous administration of 1.5 g cefuroxime resulted in comparable T>MIC between the anterior and posterior column of the lumbar spine. Mean cefuroxime concentrations decreased below the clinical breakpoint MIC for S. aureus of 4 µg/mL after 123 min (plasma), 97 min (anterior column) and 93 min (posterior column). This is shorter than the duration of most lumbar spine surgeries, and therefore alternative dosing regimens should be considered in posterior open lumbar spine surgeries lasting more than 1.5 hours

Purpose of the study. Percutanous acetabular surgery is a new and developing technique in fixation of acetabulum fractures. The most common screw used is the anterior column screw that traverses anterograde or retrograde through the anterior column of the acetabulum. Standard height and width calculations derived from CT scans do not take the trajectory of the screw into consideration. They have been shown to exaggerate the available safe bone corridor for screw passage. Posterior column screws can be placed in a retrograde fashion via the ischial tuberosity to fixate posterior column. Limited international data is available and no studies to date have been conducted on the South African population. This study assesses the anterior and posterior acetabular columns of South African individuals and ascertains the safe bone corridor sizes. Methods. Pelvic CT-scans of 100 randomly selected patients were reviewed. Specific computer software was used to virtually place anterior screws through the anterior acetabular column, in its clinical trajectory. Specific entry points inferior to the pubic tubercles significantly changed the relation of the screw trajectory to the mid- column isthmus and were incorporated in the measurement of the anterior column. All the available lengths and diameters were measured and averages were calculated for males and females. Results. On average, males have longer and larger diameter anterior columns. The entry point on the pubic tubercle has a significant impact on the relative diameter at the mid- column. Not all commercially available cannulated screw diameters are safe to place into the anterior column. Conclusion. Although the international literature shows that percutaneous anterior column fixation is of value for early mobilisation after fractures, intimate knowledge of the local data regarding the available safe corridors for screw passage is limited. This study shows the safe bone corridors that can be used to avoid breaching the cortex during screw insertion. It also recommends safe screw diameters. NO DISCLOSURES

Purpose: The surgical approach is an essential element for precise reduction and rigid fixation of fractures of the acetabulum. In cases where the anterior column is mainly involved and total hip arthroplasty (THA) is indicated, classical approaches do not allow double assess to the anterior column necessary for reduction and fixation and to the femoral canal for insertion of the prosthesis. Combining Heuter’s anterior approach and Letournel’s ilio-femoral approach provides access to the anterior column and to the often associated posterior hemi-transverse fracture, while allowing insertion of the total hip prosthesis. Material and method: This combined approach was used for ten among 60 THA performed for fracture of the acetabulum. Seven were primary procedures and three were differed reconstruction procedures. Mean patient age was 60.6 years (range 50 – 85 years). Fracture types were: acetabular wall and anterior column (n=8), anterior column and posterior hemi-transverse (n=2). All fresh fractures exhibited major acetabular damage associated with fracture of the femoral neck. A hybrid THA was used for all cases after fixation of the fracture. The femoral heads were used as graft material for deficient anterior columns in two patients and as “piecemeal” grafts for the others. Results: Mean follow-up was 36 months (range 24–35 months). At last follow-up all fractures had healed and all acetabular components exhibited solid fixation with no sign of migration. The mean outer diameter of the ace-tabular components inserted was 56 mm (52–64) using a 2 mm press-fit and one screw. The only complication was one postoperative anterior dislocation. Pain relief and function were satisfactory in all patients at last follow-up with a Postel Merle d’Aubigné score of 16 (13–18). Discussion: This anterior surgical approach enables good access to the acetabular walls and anterior columns, allowing solid fixation and relatively easy THA. The Kocher-Langenbech approach is still better in case of posterior deficiency or when posterior fixation requires space for inserting an acetabular component. We reserve it for THA used to treat fresh fractures of the acetabulum with major damage to the acetabulum and/or the femoral head, with or without neck fracture in patients aged 55 years or more. For differed reconstruction, we also use this approach if the acetabular damage involves the anterior column

Introduction. Mode of non-operative management of thoracolumbar spine fracture continues to remain controversial with the most common modality hinging on bracing. TLSO is the device with a relative extension locked position, and many authors suggest they may have a role in the healing process, diminishing the load transferred via the anterior column, limiting segmental motion, and helping in pain control. However, several studies have shown prolonged use of brace may lead to skin breakdown, diminished pulmonary capacity, weakness of paraspinal musculature with no difference in pain and functional outcomes between patients treated with or without brace. Aims. To identify number of spinal braces used for spinal injury and cost implications (in a DGH), to identify the impact on length of stay, to ascertain patient compliance and quality of patient information provided for brace usage, reflect whether we need to change our practice on TLSO brace use. Methods. Data collected over 18-month period (from Jan.2020 to July 2021). Patients were identified from the TLSO brace issue list of the orthotic department, imaging (X-rays, CT, MRI scans) reviewed to confirm fracture and records reviewed to confirm neurology and non-operative management. Patient feedback was obtained via post or telephone consultation. Inclusion criteria- patients with single or multi -level thoracolumbar osteoporotic or traumatic fractures with no neurological involvement treated in a TLSO brace. Exclusion criteria- neurological involvement, cervical spine injuries, decision to treat surgically, concomitant bony injuries. Results. 72 braces were issued in the time frame with 42 patients remaining in the study based on the inclusion/exclusion criteria. Patient feedback reflected that 62% patients did not receive adequate advice for brace usage, 73% came off the brace earlier than advised, and 60% would prefer to be treated without a brace if given a choice. The average increase in length of stay was 3 days awaiting brace fitting and delivery. The average total cost burden on the NHS was £127,500 (lower estimate) due to brace usage. Conclusion. If there is equivalence between treatment with/without a brace, there is a need to rethink the practice of prescribing brace for all non-operatively treated fractures and a case-by-case approach may prove more beneficial

Introduction:. The anterior column of the spine is often destroyed by trauma or disease. It is reconstructed by using autograft, allograft, or synthetic cages. The fibula strut graft provides good strength, incorporates quickly and has less risk of disease transmission, which is a big advantage in communities with high incidence of HIV. Various authors cite that its major drawback is the size of its foot print. We could not find any literature that measures its size. We undertook a study to measure the size of the footprint of the fibular in relation to the surface area of the endplate. The clinical relevance is that it may guide the surgeon in deciding how many struts of fibular are required in reconstructing the anterior column, and also quantifies the statement that the fibular strut has a small footprint. Material and Method:. CT angiograms are done frequently for peripheral vascular diseases. These angiograms also show CT scans of the lumbar and thoracic vertebrae, and fibulae of the same patient. We retrospectively examined the first 35 scans done during the year 2012 at Steve Biko Academic Hospital. From the CT we measured the surface area of the endplate of the vertebral bodies T6, 8, 12, L2, and the surface area of the cut surface of the proximal, middle and distal thirds of the fibular, all in square millimetres. We then compared the areas of the vertebral measurements to the area of the fibular measurements. Results:. The middle third of the fibular had the biggest cross sectional surface area. This fact, together with anatomical features of the fibula, explains why the middle part of the fibular is the preferred graft donor site. The ratio of the fibular surface area to that of the vertebral endplate is 1:3–6. It is difficult to advise in a biological system how many struts are required, as compared to a mechanical system. However these ratios suggest that more than one fibular strut graft is required to reconstruct the anterior column. Conclusion:. This is the first time to our knowledge that the surface area of the fibular graft is quantified against the vertebral end plate surface area. The study shows that at least 2 fibula struts are required to reconstruct the thoracic and lumbar anterior columns

This report reviews the long-term results of treating acetabula with unusually severe problems, such as pelvic discontinuity or major column loss after failed total hip arthroplasty (THA) and reconstruction problems. Loss of acetabular bone stock results from removal of bone during the original procedure, prosthetic failure, and osteolysis. In massive structural failure, the acetabular rim, quadrilateral plate, and associated columns become deficient. At worst, this may be combined with pelvic discontinuity and disruption of the ilium and ischium. Prosthetic protrusio may result from fixation loss and be associated with scarring of the femoral vessels, femoral nerve, ureter and bowel. A variety of implants has been used to in ace-tabular reconstruction. The results are often poor because of insufficient bone stock to support the implant. In a consecutive series of 251 THA revisions done between 1988 and 1996, 17 patients were treated for major pelvic column loss, pelvic discontinuity or both. In five patients, a posterolateral approach without trochanteric osteotomy was used. The extensile triradiate approach with ilioinguinal extension was used in 12 patients in whom severe prosthetic protrusio increased the risk of intrapelvic iatrogenic injury. A long anterior column pelvic plate was applied. A posteriorly placed AO 4.5-mm pelvic reconstruction plate with 10 to 12 holes was used in nine cases of pelvic discontinuity and in five cases of posterior column bone loss. This plate extended from the most inferior extent of the ischium across the wall of the posterior column to a point high on the ilium. Anterior column fixation was done in eight of nine cases of pelvic discontinuity and all three cases of anterior column deficiency. This called for an 8 to 12-hole 3.5-mm AO pelvic reconstruction plate that extended from the pubic symphysis across the pelvic rim. This spanned the anterior column defect, ranging from 4 cm to 8 cm, to the medial wall of the ilium. Bulk allograft was used in 16 of the 17 patients. The patient in whom allograft was not used had pelvic discontinuity following pelvic irradiation. Whole pelvic acetabular transplants were used in seven with severe bone loss or following resection for chondrosarcoma and the other for pigmented or villonodular synovitis. Posterior segmental acetabular allograft was used in two cases of posterior column absence. Femoral heads were used in two posterior column defects, three pelvic discontinuities with anterior column defect, and two anterior column defects. Acetabular components were cemented in six of seven whole bulk ace-tabular transplants, six of nine pelvic discontinuities and two anterior column defects. Cemented implants were classified as loose if there was a complete radiolucent line at the bone cement interface, measurable component migration or measurable change in position. Uncemented acetabular components were considered loose if component migration had occurred or screws had broken. Pelvic plates were considered loose if there was measurable migration or change in plate position or if fixation screws had backed out or broken. Radiographic union was considered present when bridging callus or trabecular bone was visible across the discontinuity site. Junctional healing was considered probable when radiographs did not show obvious signs of failure. Grafts were considered unhealed if there was obvious displacement, bone gaps or hardware breakage. Seven of the nine patients with pelvic discontinuity had late evidence of healing of the fracture and allograft consolidation. One underwent removal of the graft at three weeks after developing acute postoperative infection: early junctional healing of a whole bulk acetabular allograft required an osteotomy to break up the interface. Another patient, who underwent removal of the graft and implant at three months for chronic infection, had consolidation of a whole bulk ace-tabular allograft. One patient underwent revision of a pressfitted acetabular component at 60 months, and the pelvic discontinuity was solidly united. In a fourth patient, explored at 124 months for loosening of a cemented cup, there was near complete dissolution of the graft posterior acetabular wall and a loose posterior pelvic plate. In a patient with pelvic discontinuity after radiation therapy for uterine carcinoma, satisfactory healing of the pelvic discontinuity was confirmed at 32 months, when excisional arthroplasty for late chronic infection followed urinary sepsis. Seven patients had major column loss with severe cavitary defects. Consolidation of the allograft was noted in all seven within the first 12 months of follow-up. Revision (47%) was required for infection in three patients, implant loosening in four, and recurrent implant dislocation in one. The four loose cups were revised to a cemented all-polyethylene component. All four implants had been placed on less than 50% host bone. None of the four has required subsequent revision. Dislocation postoperatively occurred in eight patients. In six, the extensile triradiate approach had been used. This approach led to dislocation in 50%. The main reasons for using the extensile triradiate approach were to avoid catastrophic injuries by direct exposure of vital structures and to allow stable anterior column plate fixation. In that no neurovascular injuries occurred and stable durable allograft consolidation and healing of pelvic discontinuity took place, these goals were largely met. Three patients developed late sciatic palsy. In one, plaster immobilisation had possibly caused direct pressure over the fibular head and led to chronic peroneal palsy. The other two underwent additional exploration of the sciatic nerve for late entrapment caused by migration of screws from the posterior column plate. Two patients developed bladder infections postoperatively. Another developed superficial phlebitis of the lower leg. Acetabular revision for loosening was necessary in three of seven cementless implants, while only two of 10 cemented implants failed. The acetabular component should be cemented into the allograft when more than 50% of the prosthetic interface is non-viable. Virtually all graft material, including dense cortical grafts, may ultimately fail if used for implant fixation. Patients should be told about the inevitable risks. However, techniques used led to stable healing of the pelvic discontinuity in most cases. Long pelvic plates that securely stabilise the pelvis and allografts carefully opposed to host bone may explain the relative success in this series

We performed a retrospective follow-up study investigating the safety and efficacy of an independently constructed non-linked double rod system for anterior column reconstruction. Our objective was to demonstrate safe and cost effective adaptation of a standard deformity system for use in anterior column reconstruction. Anterior only surgery in patients requiring corporectomy spares the posterior soft tissue envelope. Corporectomy and neural decompression is followed by insertion of a titanium mesh cage and bone graft. Several non-adaptable implant systems (locking plates and linked-rod constructs) have been validated both in clinical and in-vitro studies and are available to the surgeon. These devices can only be used to address the anterior column and can only span a limited number of spinal segments. Twenty-two patients have undergone anterior column reconstruction for tumour (8), trauma (11) and infection (3) in our unit are included. Mean follow up was 30.5 months. All had anterior corporectomy and decompression, insertion of a titanium mesh cage and stabilisation with an anterior non-linked dual rod construct (Synthes USS II). Follow-up records and radiographs have been analysed. Ninety-five percent of patients fused clinically and radiologically on plain radiograph examination. There was no failure of metalwork or deterioration in neurological function following surgery. There were 5 deaths in the study group, 4 from progression of metastatic malignant tumour and one within 30 days of surgery. Three patients have had local malignant disease recurrence, two requiring posterior decompression and one requiring further anterior surgery. This system is effective and safe. It allows fewer implants to be carried by individual hospitals and thus reduces hospital costs

Purpose of the study: Kyphoplasty was introduced to reinforce the anterior column in osteoporotic vertebral fractures. It can be used for non-osteoporotic fractures. The purpose of this work was to report the clinical and radiographic results of kyphoplasty for non-ostoporotic vertebral fractures. Material and methods: From December 2005 to August 2008, we followed prospectively 21 patients (12 M, 9 F) mean age 45 years (16–58) treated for thoracolumbar fractures by kyphoplasty in order to reinforce the anterior column. There were 23 fractures (T11 = 2, T12 = 5, L1 = 8, L2 = 4, L3 = 4) Magerl: A1 = 6, A3.1 = 7, A3.2 = 1, B1 = 2, B2 = 7. All patients were assessed preoperatively, postoperatively, and at last follow-up with a visual analogue scale (VAS) and the EIFEL function score. The sagittal CT scans passing through the pedicles and the midline were used to measure: the height of the anterior and posterior walls of the fractured vertebra and the supra and infra vertebrae as well as the kyphosis angle. Results: Thirteen fractures were treated by kyphoplasty alone; seven by kyphoplasty combined with percutaneous osteosynthesis; three by kyphoplasty combined with open osteosynthesis with decompression because of preoperative neurological deficits. Mean follow-up was 13 months (6–28). There were no postoperative neurological or infectious complications. At last follow-up, the mean VAS was 1.25 (05) and the mean EIFEL 4 (0–12). Preoperatively, mean compression was 40.9% (6.2–81.4) for the anterior column and 16.7% (0–60.2) for the posterior column. Postoperatively the respective values were 22.8% (5.1–69.3) and 12.3% (−12 to 72.6) for a mean correction of 46.2% for the anterior column and 14.3% for the posterior column. At last follow-up, compression was respectively 26.1% and 7.9%. The vertebral kyphosis was 16.3 (6–16.3) preoperatively and 9.1 (3–4) postoperatively (mean correction 8.7). At last follow-up, vertebral kyphosis was 9.1 (1.7–28.3). Discussion: Kyphoplasty allows satisfactory restoration of vertebral height without loosing short-term correction. For us, kyphoplasty should be associated with posterior fixation in patients with posterior injury. For neurological lesions, kyphoplasty associated with decompression and posterior fixation avoid the need for complementary anterior procedures

Abstract. Objectives. To evaluate the safety and efficacy of vertebroplasty with short segmented cement augmented pedicle screws fixation for severe osteoporotic vertebral compression fractures (OVCF) with posterior/anterior wall fractured patients. Methods. A retrospective study of 24 patients of DGOU type-4 (vertebra plana) OVCF with posterior/anterior wall fracture, were treated by vertebroplasty and short segment PMMA cement augmented pedicle screws fixation. Radiological parameters (kyphosis angle and compression ratio) and clinical parameters Visual analogue scale (VAS) and Oswestry disability index (ODI) were analysed. Results. A significant improvement was noted in VAS (preoperative, 7.90 ± 0.60; final follow-up 2.90 ± 0.54) and ODI (77.10 ± 6.96 to 21.30 ± 6.70), (P < 0.05). Neurological improvement was noted in all patients. Kyphosis corrected significantly from preoperative 23.20 ± 5.90 to 5.30 ± 1.40 postoperative with 5% (3.30 ± 2.95) loss of correction at final follow-up. Anterior vertebral height restored significantly from 55.80 ± 11.9% to 87.6 ± 13.1% postoperative with 4.5 ± 4.0% loss at final follow-up. One case had cement leakage was found, but the patient is asymptomatic. No implant-related complication was seen. No iatrogenic dural or nerve injury. Conclusions. Treatment with vertebroplasty with cement augmented screw fixation and direct decompression is a great option in treating such a complex situation in fragile age with fragile bones because. Vertebroplasty is viable option for restoring vertebral anterior column in patients who are considered as contraindications for vertebroplasty, like DGOU-4. It provides anterior support avoiding corpectomy, minimise blood loss and also duration of surgery. Addition of short segment fixation gives adequate support with less stress risers at the junctional area

Introduction. Severely comminuted, displaced acetabular fractures with articular impaction in the elderly population present significant treatment challenges. To allow early post-operative rehabilitation and limit the sequelae of immobility, treatment with acute total hip replacement (THA) has been advocated in selected patients. Achieving primary stability of the acetabular cup without early migration is challenging and there is no current consensus on the optimum method of acetabular reconstruction. We present clinical results and radiostereometric analysis of trabecular metal (TM) cup cage construct reconstruction in immediate THA without acetabular fracture fixation. Methods. Between 2011 and 2016, twenty-one acetabular fractures underwent acute THA with a TM cup cage construct. Patient, fracture and surgical demographics were collected. They were followed up for a mean of 24months (range 12–42months). Clinical and patient reported outcome measures were collected at regular post-operative intervals. Radiosterometric analysis (RSA) was used to measure superior migration and sagittal rotation of the acetabular component. Results. Thirteen fractures were classified as anterior column posterior hemi-transverse, two anterior column, two transverse and four associated both column acetabular fractures. There was one case of trochanteric fracture and transient foot drop. Mean Harris Hip Scores at 12months was 79 (range 33–98). The mean proximal migration of the acetabular components at 12months was 0.91mm (range 0.09–5.12 and mean sagittal rotation was 0.52mm (range 0.03–7.35). Conclusion. The TM cup-cage technique requires a single approach and provides immediate cup stability allowing full weight bearing day one post-op. To our knowledge this is the first study to accurately measure cup stability following THA for an acetabular fracture. Our promising early clinical and radiological outcomes suggest this technique may be an alternative to a fix and replace construct for immediate THA for acute acetabular fractures in the elderly

Displaced acetabular fractures in the older patient present significant treatment challenges. There is evidence the morbidity and mortality associated is similar to the fractured neck of femur cohort. Despite growing literature, there remains significant controversy regarding treatment algorithms; varying between conservative management, to fracture fixation and finally surgical fixation and simultaneous THA to allow immediate full weight bearing. £250k NIHR, Research for Patient Benefit (Ref: PB-PG-0815-20054). Trial ethical approval (17/EE/0271). After national consultation, 3 arms included; conservative management, fracture fixation and simultaneous fracture fixation with THA. Statistical analysis required minimum 12 patients/3 arms to show feasibility, with an optimum 20/arm. Inclusion criteria; patients >60 years & displaced acetabular fracture. Exclusion criteria: open fracture, THA in situ, pre-injury immobility, polytrauma. Primary outcome measure - ability recruit & EQ-5D-5L at 6 months. Secondary outcome measures (9 months); OHS, Disability Rating Index, radiographs, perioperative physiological variables including surgery duration, blood loss, complications and health economics. 11 UK level 1 major trauma centres enrolled into the trial, commenced December 2017. Failure surgical equipoise was identified as an issue regarding recruitment. Full trial recruitment (60 patients) achieved; 333 patients screened. 66% male, median age 76 (range 63–93), median BMI 25 (range 18–37), 87% full mental capacity, 77% admitted from own home. 75% fall from standing height. 60% fractures; anterior column posterior hemi-transverse. Trial feasibility confirmed December 2020. Presented data- secondary outcomes that are statistically significant in improvement from baseline for only the fix and replace arm, with acceptable trial complications. Issues are highlighted with conservative management in this patient cohort. Our unique RCT informs design and sample size calculation for a future RCT. It represents the first opportunity to understand the intricacies of these treatment modalities. This RCT provides clinicians with information on how best to provide management for this medically complex patient cohort

Spinal infections can result in devastating consequences for the patient. Surgery is indicated in certain circumstances. Our institution’s surgical intervention for the treatment of spinal infection was studied. The aim was to identify characteristics helpful for future management. Areas of particular interest were the causative agent, organism identification methods, indications for surgery, materials used for anterior column reconstruction and the ultimate outcome. A retrospective investigation of all patients receiving surgery for spinal infections between the years of 2004 to 2009 was conducted. All surgical postoperative infections were excluded. Twenty patients were identified in the nominated study period. Twelve males and eight females aged in between 15 to 83 with an average age of 59.4 years. The offending organism was a gram positive in half (50%) of the study group. Staphylococcus aureus was overwhelmingly the representative bacterium (90%). Five cases (25%) were attributed to gram negative organisms while tuberculosis was present in four (20%). No organism was identified in one. Blood cultures identified the causative agent in just over half (55%) of the cases while seven (35%) relied on surgically obtained tissue. Computer tomography guided biopsy was positive in only one case. The most common reason for surgical intervention was a combination of neurological deficit and failing medical management. The second most common reason was in cases with an unidentified organism along with neurological issues. Anterior column reconstruction using cortical strut allograft was performed in four patients while another four received a synthetic spacer device. Two patients had both allograft bone and a spacer device. Only single case of autograft anterior column reconstruction was identified. Two deaths occurred following surgery while all surviving patients with preoperative neurological deficits improved. All surviving patients are currently infection free. The surgical management of spinal infections can result in advantageous outcomes for the patient, especially in the setting of neurological deterioration or failing medical management. The use of allograft bone and synthetic spacer devices in the midst of infection does not appear to prevent successful organism eradication. The possibility of tuberculosis being the offending bacterium cannot be overlooked