Purpose of the study: Fixing the pedicles can be difficult to achieve during surgical treatment of scoliosis involving the thoracic spine because of the vertebral rotation raising the risk of neurological and vascular disorders. Use of extrapedicular thoracic screws has been proposed for more adapted and safe fixation. No clinical data has been published concerning the safety of these screws. Material and methods: This multicentric retrospective clinical and radiological study included 467 thoracic screws in 34 patients operated for scoliosis. Neurophysiological monitoring was used for all procedures. Screws were positioned free hand without radioscopic control. Pedicular screws were inserted in T10, T11, T12. Extra-pedicular screws were inserted for thoracic vertebrae above T10 to T4. Correction was achieved with rods bent in situ. The purpose of this study was to evaluate the position of the thoracic screws within the vertebral body and in relation to the great vessels and the cord. The position of the screws in the thoracic spine was studied by two independent observers reading multiple thin-slice CT images. The observers noted malposition as: 1) penetration into the canal more than 2 mm, 2) less than 1 cm hold in the vertebral body, 3) screw protrusion more than 2 mm beyond the vertebral cortical. Results: Screw malposition was observed for 9 of 161 pedicular screws (5.4%) and for 21 of 306 (6.8%) thoracic screws. None of the screw malpositions had a clinical expression. There was one episode of thoracic effusion associated with thoracoplasty. Two patients required revision (one for poor indication and one for disincarceration). There were no postoperative deep infections. Three cases of intercostals neuralgia subsided within three months. Conclusion: Insertion of thoracic screws for fixation and correction is a useful technique with few complications. It enables better 3D correction and better control of the deformation. Screw malposition in this series was similar to that observed with classical pedicular techniques. There was no major complication associated with thoracic screws

Aim: Volar locking plates are increasingly used in the management of distal radius fractures. As with any new implant, understanding the rate and type of potential metalwork related complications is important. The aim of the study was to determine the type and rate of implant related complications that require further surgery when using volar locking plates in the management of distal radius fractures. Methods: In this study, we reviewed 114 distal radius fractures treated with volar locking plating. Patient records were reviewed with regards to demographics, operative details and post-operative outcomes. Fractures were classified as intra-articular or extra-articular. They were further classified using the AO classification system. Results: In our series, 12 cases (10%) underwent further surgery for metal work related complications mainly for screw protrusion into the radiocarpal joint following fracture collapse. Intra-articular fractures had a significantly greater complication rate as compared to extra-articular ones (11 vs. 1, P=0.04). There was no significant difference between the three plating systems used in this series with regards to need of further surgery (P=0.43). There was no significant difference between the grade of the operating surgeon with regards to metal work complications (P=0.9). There was no difference in rate of complications between males and females (P=0.27). Similarly there was no difference in metal work complications between patients aged less than 60 as compared to those aged more than 60 years (P=0.58). Our study has shown that volar locking plates may be associated with up to 10% rate of metalwork complications requiring revision surgery. The most common (8 out of 12) cause of re-operation was to remove the screws protruding into the radio-carpal joint. Discussion: Our results suggest that volar locking plates are associated with a high rate of metal work related complications requiring further surgery. In conclusion our study suggests that volar locking plates are associated with high reoperation rates for implant related complications. Intraoperative screening to ensure that there is no intrarticular penetration is also essential. We favour obtaining intra-operatively a lateral view with the forearm elevated 15–20 degrees to the horizontal plane to allow for the medial-lateral radial inclination and taking the posterior-anterior view at about 20 degrees to the horizontal plane to allow for the normal volar distal radial tilt. We feel that for a common fracture such as distal radial fractures an ideal implant should be easily reproducible with a low complication rate

Femoral head osteonecrosis is a progressive disease that affects patients in the third to the fifth decades. It is probably a multifactorial disease since many patients that have the known risk factors never develop it and others develop the disease without any risk factors. There isn’t any totally effective treatment that can stop the disease and prevents bone collapse, but it is known that operative treatment gives better results than conservative treatment in Ficat stages I and II. The authors began in October of 2003 the surgical treatment of pre-collapse patients (Ficat stage I and II) with the tantalum hip screw hopping that it could prevent progression to collapse. The tantalum is an innovating new metal with an excellent bio-integration and with mechanic properties very close to normal bone. The tantalum hip screw gives structural support to the necrotic bone segment, permits immediate charging of the affected hip and pretends to be a substitute to peroneal graft. There isn’t any published clinical result of the use of the tantalum hip screw in the literature to date. Between the October of 2003 and November of 2004 we made 10 such procedures in 8 patients with mean age of 44 years. The patients were Ficat grade I and II and we could identify that most of the patients had been taking corticosteroid medication. There was one hip with less than 15% of extension and 9 with a severe extension (more than 30% of the femoral head from the University of Pennsylvania system of classification and staging). There was rapid radiographic progression of the disease in all patients but one with bilateral involvement. There was progression for femoral head collapse in 70% of the patients despite the femoral hip screw. In 3 patients the collapse led to screw protrusion on the acetabulum and needed hip arthroplasty, on average, 12 months after screw implantation. The harris hip score of the 5 patients (7 hips) than weren’t submitted to hip arthroplasty gave a good result in 1 patient and a fair result in 3 patients (4 hips). There was a poor result in the other patient. The tantalum hip screw made it more difficult to do a hip arthroplasty but it didn’t make it impossible. This study shows that the tantalum hip screw didn’t prevent the progression of the femoral neck osteonecrosis in all but one patient with an initial Ficat grade IIa. The fact that 9 in 10 patients had a severe extension of the disease (> 30% of the femoral head diameter) could have prevented the success of the tantalum hip screw because the area of sustention of the screw was limited and the disease continued to progress around the screw

Aim: To test the null hypothesis that plain X-rays can provide the same assessment of sacral screw placement as CT. Introduction: Engaging the anterior cortex of the sacrum provides additional strength to fixation and is a goal of surgery. The sacrum with its unique anatomy makes it a difficult bone to assess screw placement radiologically. This study examines the positioning of sacral screws as seen on X-rays and compares the result with spiral CT “gold standard”. Materials and methods: Inclusion criteria: Sacral fixation using Diapason (Stryker) Titanium pedicle screws by one surgeon. Spiral CT, plain AP and lateral X-rays of the sacrum. Exclusion criteria: X-rays with more than three level fixation. There were 66 patients (132 S1 screws). Surgical technique engaged the anterior cortex to enhance fixation. Two independent observers (a musculoskeletal radiologist and spinal fellow) who were blinded to outcome, reported findings in forms with constrained fields. Assessment of plain X-ray and CT was at separate times not less than three weeks apart. Variables noted: Screw position in pedicle, screw tip position, and angle of screw (sagittal on axial CT scans). AP X-ray was divided, for each screw, into nine zones based on the first sacral foramina. The position of the screw tip in the zones was noted. The lateral X-ray was divided into three zones to note the tip of the screw in relation to the cortex. The extent of screw protrusion was measured. X-ray technique: Supine AP centred on fusion and lateral X-ray standing, X-ray source 200 cm from the film. CT: Images acquired on Picker PQ 6000 spiral CT with collimated thickness of 3 mm, pitch 1.25 and reconstructive index of 1.Para-sagittal and coronal reconstructions. Spiral CT was used to note the position of the screw within the pedicle and the relation of the screw tip to the anterior cortex. For screws within the pelvis any structure in close proximity was noted. Results: On CT 10% of the screws had breached the pedicle compared with 2% on the plain X-rays. Anterior cortical perforation had been achieved in 48 out of 132 screws on CT. The sensitivity of the plain X-rays to perforation was 40% with a specificity of 92%. There was an average under estimation of the extent of screw perforation by 4.4 mm (95% confidence ±1 mm). There was a correlation between the position of the screw tip on the AP X-ray and the sensitivity of the lateral X-ray to detect a perforation. The sensitivity ranged from 52% for zone 1 to 15% in zone 8. 15/31 perforations were missed in zone 1, compared with 11/13 in zone 8. For screws penetrating 5 mm or more, in zone 8, 9 out of 10 were missed on lateral X-rays. Eighty-five screws were placed at an angle of less than or equal to 25° to the sagittal; this included 28 out of 34 screws placed in zone 8. The inter-observer variance of screw angle measurement was 1.1° and intra-observer difference 1.7°. Overall 95% confidence of a single measurement was ±3.3°. Conclusion: Plain X-rays and CT do not provide the same assessment of sacral screw placement. This is particularly true for sagitally placed screws with screw tips in zones 7–8