Neurological complications in oncological and degenerative spine surgery represent one of the most feared risks of these procedures. Multimodal intraoperative neurophysiological monitoring (IONM) mainly uses methods to detect changes in the patient's neurological status in a timely manner, thus allowing actions that can reverse neurological deficits before they become irreversible. The utopian goal of spinal surgery is the absence of neurological complications while the realistic goal is to optimize the responses to changes in neuromonitoring such that permanent deficits occur less frequently as possible. In 2014, an algorithm was proposed in response to changes in neuromonitoring for deformity corrections in spinal surgery. There are several studies that confirm the positive impact that a checklist has on care. The proposed checklist has been specifically designed for interventions on stable columns which is significantly different from oncological and degenerative surgery. The goal of this project is to provide a checklist for oncological and degenerative spine surgery to improve the quality of care and minimize the risk of neurological deficit through the optimization of clinical decision-making during periods of intraoperative stress or uncertainty. After a literature review on risk factors and recommendations for responding to IONM changes, 3 surveys were administered to 8 surgeons with experience in oncological and degenerative spine surgery from 5 hospitals in Italy. In addition, anesthesiologists, intraoperative neuro-monitoring teams, operating room nurses participated. The members participated in the optimization and final drafting of the checklist. The authors reassessed and modified the checklist during 3 meetings over 9 months, including a clinical validation period using a modified Delphi process. A checklist containing 28 items to be considered in responding to the changes of the IONM was created. The checklist was submitted for inclusion in the new recommendations of the Italian Society of Clinical Neurophysiology (SINC) for intraoperative neurophysiological monitoring. The final checklist represents the consensus of a group of experienced spine surgeons. The checklist includes the most important and high-performance items to consider when responding to IONM changes in patients with an unstable spine. The implementation of this checklist has the potential to improve surgical outcomes and patient safety in the field of spinal surgery

Objectives. To employ a simple and fast method to evaluate those patients with neurological deficits and misplaced screws in relatively safe lumbosacral spine, and to determine if it is necessary to undertake revision surgery. Methods. A total of 316 patients were treated by fixation of lumbar and lumbosacral transpedicle screws at our institution from January 2011 to December 2012. We designed the criteria for post-operative revision scores of pedicle screw malpositioning (PRSPSM) in the lumbosacral canal. We recommend the revision of the misplaced pedicle screw in patients with PRSPSM = 5′ as early as possible. However, patients with PRSPSM < 5′ need to follow the next consecutive assessment procedures. A total of 15 patients were included according to at least three-stage follow-up. Results. Five patients with neurological complications (PRSPSM = 5′) underwent revision surgery at an early stage. The other ten patients with PRSPSM < 5′ were treated by conservative methods for seven days. At three-month follow-up, only one patient showed delayed onset of neurological complications (PRSPSM 7′) while refusing revision. Seven months later, PRSPSM decreased to 3′ with complete rehabilitation. Conclusions. This study highlights the significance of consecutively dynamic assessments of PRSPSMs, which are unlike previous implementations based on purely anatomical assessment or early onset of neurological deficits.and also confirms our hypothesis that patients with early neurological complications may not need revision procedures in the relatively broad margin of the lumbosacral canal. Cite this article: X-J. Lin. Treatment strategies for early neurological deficits related to malpositioned pedicle screws in the lumbosacral canal: A pilot study. Bone Joint Res 2016;5:46–51

The aim of this study was to compare the treatment ouctomes of severe idiopathic scoliosis (IS) (>90 degrees) using the staged surgery with initial limited internal distraction and typical IS treated using segmental pedicle screw instrumentation. We hypothesized that staged surgical treatment of severe scoliosis would improve more HRQoL and pulmonary function (PF) as compared with posterior spinal fusion (PSF) for typical IS curves. It was a retrospective review of a consecutive series of 60 IS, severe group (SG) vs. moderate group (MG) with min. 2 years of follow up (FU). The mean preoperative major curve (MC) was 120° and thoracic kyphosis (TK) was 80° for the SG and 54° and 17° for the MG, respectively (p<0.001). The MC was corrected to 58° and TK to 32° for the SG; the MC to 26° and TK to 14°, for the MG, respectively (p<0.001). The mean preoperative AVT was 8.9 cm and improved to 2.8 cm at the final FU for the SG and from 6.5 cm to 2.2 cm at the final FU for the MG (p<0.001). At baseline, the FVC% & FEV1% values were significant different between the two groups (41.5% vs. 83%, p <0.001) & (41.6% vs. 77%, p <0.001). Compared the baseline for SG vs. the values at 2-year FU the FVC % values were (41.5% vs. 66.5%, p <0.001), and the baseline for MG vs. the values at 2-year FU, the FEV1 values were (77% vs. 81%, NS). At last FU, no complications were reported. Gradual traction with complicity of multilevel Ponte's osteotomies and neuromonitoring followed by staged pedicle screws instrumentation in severe IS proved to be a safe and effective method improving spinal deformity (52% correction), PF (improved percentage of predicted forced vital capacity by 49%), and health-related quality and allows to achieve progressive curve correction with no neurologic complications associated to more aggressive one-stage surgeries

Femoral nerve block is a reliable and effective method of providing anaesthesia and analgesia in the peri-operative period but there remains a small but serious risk of neurological complication. We aimed to determine incidence and outcome of neurological complications following femoral nerve block in patients who had major knee surgery. During the period January 2003 to August 2008, medical records of all patients undergoing knee surgery by Dr Myles Coolican and Dr David Parker, who had been administered femoral block for peri-operative analgesia, were evaluated. Patients with a neurological complication were invited take part in the study. A detailed physical examination including sensory responses, motor response and reflexes in both limbs was performed by an independent orthopaedic surgeon. Subjective outcome and pain specific questionnaires as well as clinical measurements were also collected. Out of 1393 patients administered with femoral nerve block anaesthesia during this period, 28 subjects (M:F= 5:23) were identified on the basis of persistent symptoms (more than three months) of femoral nerve dysfunction. All the patients had sensory dysfunction in the autonomous zone of femoral nerve sensory distribution. The incidence of neurological complications was 2.01%. One patient was deceased of unrelated causes and five patients declined to participate in the study. 14 patients out of the 22 have been examined so far. Nine cases had a one shot nerve block and five had continuous peripheral nerve block catheter. Areas of hypoesthesia/anaesthesia involving femoral nerve distribution occurred in 7 subjects and hyperaesthesia/paresthesia occurred in four. One subject had a combination of hypoesthesia and hyperesthesia in different areas of the femoral nerve distribution. Three subjects had bilateral symptoms following bilateral simultaneous nerve blocks. Dysesthesias in the affected dermatomes were found in seven cases and paresthesias were found in eight cases. Douleur Neuropathique en 4 questions (DN4) score of ï. 3. 4 was found in all the patients (average value: 5.55). The average scores for tingling, pins and needles and burning sensation (in a scale from 0 to 10) are 3.8, 3.1 and 2.9 respectively. The incidence of persistent neurological complication after femoral nerve block in our series is much higher compared to the reported incidence in the contemporary literature (Auroy Y. et al. Major complications of regional anesthesia in France: Anesthesiology 2002; 97:1274 80). The symptoms significantly influence the quality of life in the affected cases and question the value of the femoral nerve block in knee surgery

Purpose: The supracondylar fractures of the distal humerus are the second most frequent fractures of the developing skeleton. Also their immediate and late complications are very often. The aim of this study is to describe their neurological complications. Material – methods: In our department 178 children were admitted with supracondylar fracture of the distal humerus during the period 1998–2002. Their age ranged from 2 to 16 years of age (the average was 7 years old, 63 girls and 115 boys). Forty-six patients were treated conservatively and 132 surgically. Neurological complications were appeared in 18 patients that had, according to Gartland classification, II and III type fractures. Manipulations for closed reduction had been made to 6 of them. Neurological deficit of the median nerve appeared to 10 patients, of the radial nerve to 6 patients and of ulnar nerve to 2 patients. The treatment of the fractures was surgical (open reduction, internal fixation with Kirschner wires and immobilization with a long arm cast for 4 weeks). The treatment of the neurological complications was conservative (free mobilization of the elbow was followed after the removal of the arm cast and Kirschner’s wires). Results: The results of the conservative treatment of the neurological complications of the supracondylar fractures of the distal humerus were excellent and the surgical exploration on the injured nerve was not necessary on any patient. The function of the nerves recovered completely in 2–3 months after the elbow’s fracture. Conclusion: The prognosis on the neurological complications of the upper limbs due to supracondylar fracture of the distal humerus is very good. They are successfully treated conservatively and the surgical exploration on the injured nerve is rarely necessary

Evaluate the complications and outcomes of off-hours spinal metastasis surgery. Retrospective analysis of a prospective collected data. Preoperative, operative and post-operative data were collected as well as the complications and Frankel score at all time checkpoints. Off-hours surgery was defined as surgery starting between 17:00 and 8:00 the following day or surgery during the weekend. p < 0 .05 was defined as statistical significance threshold. 376 patients were included with an incidence of off-hours surgery of 32%. There was an increase of neurologic complication in the off hours group. This was associated with a higher ASA score and older population group. Oddly, there was decreased operative time with off-hours surgery with no difference in bleeding and number of fusion levels. Nonetheless, there was a higher percentage of neurologic improvement with off hours surgery compared to in-hours surgery. Finally, there were no effect on patients' survival in this patient population. To our knowledge, this is the first report of the effect of off-hours surgery on complications and outcomes of spinal metastasis. Greater neurological compromise and higher age and ASA scores were associated with higher incidence of off-hours surgery. It is associated with decreased surgical time with higher percentage of neurological improvement. Finally, there is no effect of surgical timing on survival rates

To identify the presence of the Adamkiewica artery before operating spine tumor patients and avoid neurological complications as well as evaluate the impact on surgical strategy. All tumor patients requiring spinal fixation from Feb 2002 to March 2006 were prospectively enrolled in the study. Included patients either had a primary spine tumor or a spine metastasis. Patients underwent a selective arteriography of the level above, the level below and the level involved by the tumor in order to document any Adamkiewicz artery (AKA). Eighteen patients were enrolled. Six had a primary tumor and twelve had a metastasis between levels T1 to L3. There were no complications related to the radiological procedure. For ten (55%) of patients, the AKA was identified during the selective arteriogram. In seven of the twelve (58%) metastatic cases the AKA was found adjacent to the involved level. In 60% of cases the AKA was found on the left side. In all cases where the AKA was found, the surgical strategy was modified in order to preserve the AKA. No patients had permanent neurological complications. The location of the AKA is extremely variable. in more than half our cases, the AKA was found immediately adjacent to the involved level. This could suggest a vascular explanation for the location of tumors in the spine. The vicinity of the AKA to the tumor site may explain why neurological complications are frequent when operating such spine cases

Previous studies report the neurological complication rate for shoulder arthroplasty to be 4.3% to 5.0%, However, these studies were limited to total shoulder arthroplasty (TSA) and did not include hemiarthroplasty (HA) or reverse prosthesis arthroplasty (RPA). Our hypotheses were that the neurological complication incidence after shoulder arthroplasty would vary by type of procedure performed and that the overall incidence would be higher than previously reported in the literature. We retrospectively reviewed the charts of 307 consecutive patients who had a total of 349 SA by the same surgeon between June 1995 and August 2007. Only patients with over six months follow up were included. The charts were reviewed for any sensory or motor disturbance postoperatively. Those who had EMG confirmation of nerve injury (NI) were placed into the surgical complication group, with a second group composed of patients with neurological symptoms (NS) who did not require electromyography (Dr Ji or Matt---how many in the NI group did not have EMG?). These two groups were statistically compared to those patients without neurological injury using standard statistics software. There were 113 HA, 191 TSA and 45 RPA with over 6 month follow up, and there were 10 (10/349; 2.9%)neurological injuries (NI) There was no significant difference in the incidence between the groups (HA: N=3/113, 2.7%; TSA: N=5/191, 2.6%; RPA:N=2/45, 4.4%). There were an additional 34 neurological symptoms (NS) after shoulder arthroplasy, and if included with the NI then the total rate of neurological complaints after shoulder arthroplasty was 12.6% (44/349). If the NI and NS are combined, multivariate analysis showed that there was a statistically significant association between the development of neurological symptoms and revision surgery. The rate of neurological complications after shoulder arthroplasty was independent of the type of procedure. The incidence of neurological complaints after shoulder arthroplasty is higher than previously reported

Introduction: It is the accepted dogma that should paralysis complicate spinal deformity surgery, then the internal fixation should be removed within three hours. This dogma is based on MacEwen’s paper in 1975 which related to the Harrington system and which did not contain statistical analysis (MacEwen G.D. et al, JBJS 557A, 1975,404-8). Since that time spinal cord monitoring systems have been developed and internal fixation systems have become considerably more complex. Does the accepted dogma need to be reviewed?. Methods and results: The author has reviewed the literature which contains statistical analysis of risk factors and results in relation to major neurological complications of spinal deformity surgery (Dove J. Résonance Européenes du Rachis 1999, 7[23]961–66). The risk factors are adult scoliosis, congenital and neuromuscular curves, kyphosis, combined anterior and posterior surgery, intra-operative hypertension, distraction and certain types of segmental fixation. Furthermore these risks are additive. MacEwen’s 1975 paper did not include statistical analysis and its conclusions are not borne out by the information within the paper. The only statistical analysis of the management of neurological complications has shown that surgical removal of the internal fixation was not related to neurological recovery (Paonessa K.G., Hutching F. Scoliosis Research Society Meeting. New York. Sept 1998). Conclusion: Based on an analysis of the relevant literature and current clinical practice, the author suggests an algorithm to be followed by the surgeon faced with a major neurological complication of spinal deformity surgery. The author also raises the question as to whether the British Scoliosis Society should make a statement regarding “best practice” in such cases

Purpose of the study: Pott’s disease of the cervical spine is exceptional. We collected 27 cases over a period of 30 years. Material and methods: Mean patient age was 21 years. Male gender predominated. Most patients consulted because of cervical pain and 50% presented neurological disorders. Mean duration of symptoms was 14 months. A peri-spinal abscess was found in ten patients. The posterior cervical spine was affected in most patients and four presented suboccipital involvement. There was associated lung disease in two-thirds of the patients. Standard anti-tuberculosis chemotherapy was given associated with traction alignment in twelve patients to correct for kyphosis or associated spinal dislocation. Surgery was reserved for major bone destruction leading to instability or neurological disorders resistant to medical treatment. Results: Mean follow-up was five years. The anatomic result after medical or surgical treatment was characterized by vertebral fusion in all patients. There were three serious neurological complications after surgery. Improvement was achieved in eleven of the twelve patients with inaugural neurological complications

Background: The incidence of nerve injury following ankle arthroscopy has a documented rate of 1% to 24%1-15. The intermediate branch of the superficial peroneal nerve is at most risk with an antero-lateral portal incision 6, 9–12. The superficial peroneal nerve (SPN) is often marked as part of pre-operative planning,1 despite there being little evidence of the effectiveness of this simple measure in reducing nerve injury in ankle arthroscopies. Methods: We reviewed 100 consecutive cases who had an anterior ankle arthroscopy between February 2005 and April 2009. All arthroscopies were performed by a single surgeon (PFR) with pre-operative marking of the SPN. All patients were interviewed by telephone to find out if there had been any temporary or long-term neurological problems following the surgery. Any patients with neurological complications were reviewed in clinic. Patients’ notes were reviewed for any documented complications. Their level of satisfaction and improvement of symptoms were also assessed. Results: We were able to trace 98% of patients. The average follow up was 15.3 months (1 to 39 months). The only neurological deficit in this series was in one case (1%) who developed sensory loss in the distribution of the medial branch of the SPN. 61% of the cases were highly-satisfied/satisfied, 23% were moderately satisfied and 16% were not satisfied with the outcome of their surgery. The reason quoted by the 16% unsatisfied patients was failure to improve their symptoms to their expected level or their need for another operation (41% of the unsatisfied group). Conclusion: The incidence of nerve injury in our series was 1%. This is a dramatic improvement on the majority of published studies 1–15. We believe that marking the SPN prior to surgery is a simple and essential measure in reducing the neurological complications of ankle arthroscopy

Aims

A variety of surgical methods and strategies have been demonstrated for Andersson lesion (AL) therapy. In 2011, we proposed and identified the feasibility of stabilizing the spine without curettaging the vertebral or discovertebral lesion to cure non-kyphotic AL. Additionally, due to the excellent reunion ability of ankylosing spondylitis, we further came up with minimally invasive spinal surgery (MIS) to avoid the need for both bone graft and lesion curettage in AL surgery. However, there is a paucity of research into the comparison between open spinal fusion (OSF) and early MIS in the treatment of AL. The purpose of this study was to investigate and compare the clinical outcomes and radiological evaluation of our early MIS approach and OSF for AL.

Summary Statement. Incorrect pedicle screw placement can lead to neurological complications. Practice outside the operating room on realistic bone models, with force feedback, could improve safety. Pedicle forces in cadaveric specimens are reported, to support development of a training tool for residents. Introduction. Inserting screws into the vertebral pedicles is a challenging step in spinal fusion and scoliosis surgeries. Errors in placement can lead to neurological complications and poor mechanical fixation. The more experienced the surgeon, the better the accuracy of the screw placement. A physical training system would provide orthopaedic residents with the feel of performing pedicle cannulation before operating on a patient. The proposed system consists of realistic bone models mimicking the geometry and material properties of typical patients, coupled with a force feedback probe. The purpose of the present study was to determine the forces encountered during pedicle probing to aid in the development of this training system. Methods. We performed two separate investigations. In the first study, 15 participants (9 expert surgeons, 3 fellows, 3 residents) were asked to press a standard pedicle awl three times onto a mechanical scale, blinded to the force, demonstrating what force they would apply during safe pedicle cannulation and during unsafe cortical breach. In the second study, three experienced surgeons used a standard pedicle awl fitted with a one-degree of freedom load cell to probe selected thoracolumbar vertebrae of eight cadaveric specimens to measure the forces required during pedicle cannulation and deliberate breaching, in randomised order. A total of 42 pedicles were tested. Results. Both studies had wide variations in the results, but were in general agreement. Cannulation (safe) forces averaged approximately 90 N (20 lb) whereas breach (unsafe) forces averaged approximately 135–155 N (30–35 lb). The lowest average forces in the cadaveric study were for pedicle cannulation, averaging 86 N (range, 23–125 N), which was significantly lower (p<0.001) than for anterior breach (135 N; range, 80–195 N); medial breach (149 N; range, 98–186 N) and lateral breach (157 N; range, 114–228 N). There were no significant differences among the breach forces (p>0.1). Cannulation forces were on average 59% of the breach forces (range, 19–84%) or conversely, breach forces were 70% higher than cannulation forces. Discussion. To our knowledge, axial force data have not previously been reported for pedicle cannulation and breaching. A large range of forces was measured, as is experienced clinically. Additional testing is planned with a six-degree-of-freedom load cell to determine all of the forces and moments involved in cannulation and breaching throughout the thoracolumbar spine. These results will inform the development of a realistic bone model as well as a breach prediction algorithm for a physical training system for spine surgery. The opportunity to learn and practice outside of the operating room, including learning from deliberate mistakes, should increase the confidence and comprehension of residents performing the procedure, enhance patient safety, reduce surgical time, and allow faster progression of learning inside the operating room

Minimally invasive placement of iliosacral screws (SI-screw) is becoming the standard surgical procedure for sacrum fractures. Computer navigation seems to increase screw accuracy and reduce intraoperative radiation compared to conventional radiographic placement. In 2012 an interdisciplinary hybrid operating theatre was installed at the University of Ulm. A floor-based robotic flat panel 3D c-arm (Artis zeego, Siemens, Germany) is linked to a navigation system (BrainLab Curve, BrainLab, Germany). With a single intraoperative 3D scan the whole pelvis can be visualised in CT-like quality. The aim of this study was to analyse the accuracy of SI-screws using this hybrid operating theater. 32 SI-screws (30 patients) were included in this study. Indications ranged from bone tumour resection with consecutive stabilisation to pelvic ring fractures. All screws were implanted using the hybrid operating theatre at the University of Ulm. We analysed the intraoperative 3D scan or postoperative computed tomography and classified the grade of perforation of the screws in the neural foramina and the grade of deviation of the screws to the cranial S1 endplate according to Smith et al. Grade 0 stands for no perforation and a deviation of less than 5 °. Grade 1 implies a perforation of less than 2 mm and a deviation of 5–10°, grade 2 a perforation of 2–4 mm and a deviation of 10–15° and grade 3 a perforation of more than 4 mm and a deviation of more than 15°. All patients were tested for intra- and postoperative neurologic complications and infections. The statistical analysis was executed using Microsoft Excel 2010. 32 SI-screws were implanted in the first 20 months after the hybrid operating theatre had been established in 2012. All 30 patients were included in this study (15 men, 15 women). The mean age was 59 years ±23 (13–95 years). 20 patients received a single screw in S1 (66.7%), 1 patient 2 unilateral screws in S1 and S2 (3.3%), one patient 2 bilateral screws in S1 (3.3%) and 8 patients a single screw stabilising both SI-joints (26.7%). 27 screws showed no perforation (84.4%), 1 screw a grade 1 perforation (3.1%) and 4 screws a grade 2 perforation (12.5%). There was no grade 3 perforation. Furthermore there was no perforation of the neural foramina or the ventral cortex in the axial plane of the SI-screws stabilising one SI-joint (24 screws). Only single SI-screws bridging both SI joints showed a perforation of the neural foramina (37% grade 0, 12.5% grade 1, 50% grade 2, 0% grade 3). In the frontal plane 23 screws (71.9%) showed a deviation of less than 5°. In 5 screws a grade 1 deviation (15.6%) and in 4 screws a grade 2 deviation (12.5%) could be found. There was no grade 3 deviation. There were no infections or neurological complications. The high image quality and large field of view in combination with an advanced navigation system is a great benefit for the surgeon. All SI-screws stabilising only one joint showed completely intraosseous placement. Single SI-screws bridging 2 SI-joints intentionally perforated the neural foramina ventrally in 5 cases because of dysmorphic sacral anatomy. This makes image-guided implantation of SI-screws in a hybrid operating theatre a very safe procedure

Background: Treatment of high-grade spondylolisthesis remains controversial. In-situ fusion does not address the sagital balance, reduction and fusion on the other hand is associated with unacceptably high rate of neurological complications. Aim: To describe the results of a novel technique using Magerl External Fixateur for gradual reduction followed by circumferential fusion. Methods: From 1988 to 2006, thirteen patients were treated with this technique at our institution. They all had high grade spondylolisthesis. Retrospective case note review and radiographic analysis were carried out. 10 point Visual Analogue Sore (VAS) for pain, Oswestry Disability Index (ODI), Low Back Outcome Score (LBOS), SF-36 Health Survey, and Patient Satisfaction Questionnaire were collected. Complete set of data was available for 9 patients, 7 Female and 2 Male. Mean age at operation was 16 years (range 12–22), and average length of follow-up was 11 years (range 5–19). Results: Post operatively, Percentage of Slip was improved by an average of 70%(range 32–96%)(p=0.001), Slip Angle by 72%(p=0.0001) and sacral Inclination by 59%(p=0.0016). Radiological fusion was achieved in all but one. VAS for leg and back pain improved from 8.4 (range 8–9) and 8.2 (range 6–10) to 0.8(range 0–2) and 1.2 (range 0–2) respectively. These improvements were statistically significant (p< 0.001). ODI at the latest follow-up averaged 8% (range 0–16%) and LBOS 56.6 (range 44–70). The mean SF-36 for physical domains was 87.5 (range 80–93) and that for the psychological domains was 91.25 (range 81–100). All patients were fully satisfied. 3 cases had culture negative excessive discharge from one pin site. 2 patients developed transient parasthesia and one patient developed asymptomatic pseudoarthrosis. Conclusion: Our technique albeit in a small cohort of patients, achieved significant correction of the commonly used and widely accepted radiological measurements without any neurological complications. The radiological improvement was also reflected in statistically significant improvement in validated outcome measures

Purpose: This work revealed the advantages of percutaneous suture of the Achilles tendon using an improved technique with entirely resorbable material. Material and methods: Thirty cases of subcutaneous tears were operated on two to ten days after the accident (range 24 hr – 7 weeks). We used a 4-thread resorbable V-suture anchored in the calcaneum and, after blocking the ankle in the equine position, on the proximal fragment using two bioresorbable buttons. Postoperatively, immediate weight bearing was progressive using an adjustable and removable orthesis. Active-passive rehabilitation was initiated immediately. The material was left in place indefinitely and was resorbed after three months. Results: We followed these patients for 24 – 8 months. Wound healing was excellent and material tolerance was exceptional (only one complaint of transient calcaneal pain). Objective outcome was comparable with that obtained with conventional suture, with a significant reduction in the risk of skin and neurological complications. There were no cases of recurrent tears. CT and MRI controls confirmed the early healing, the quality of the tendon repair, and material resorption within the expected delay. Subjective outcome was excellent. Discussion: While the results obtained in this series are comparable to those with prior percutaneous techniques, the important improvement was the very significant reduction in skin and neurological complications often reported in other series. It is also noteworthy that there were no recurrent tears. The advantages are even more remarkable compared with surgery. The greater solidity authorises very rapid rehabilitation, similar to protocols advocated for nonoperative care. The limitations on indications appear to be tears seen after three weeks and true calcaneal de-insertions. Conclusion: This technique improves patient comfort and follow-up while allowing safer rehabilitation

Aims

The aim of the present study was to analyze the oncological and neurological outcome of patients undergoing interdisciplinary treatment for primary malignant bone and soft-tissue tumours of the spine within the last seven decades, and changes over time.

Aims

The management of mid-shaft clavicle fractures (MSCFs) has evolved over the last three decades. Controversy exists over which specific fracture patterns to treat and when. This review aims to synthesize the literature in order to formulate an appropriate management algorithm for these injuries in both adolescents and adults.

Purpose of the study: Surgical strategies for high-grade spondylolisthesis are controversial. The main subject of debate concerns the indications for reduction or in situ fusion. We present mid-term results obtained in a series of patients with high-grade spondylolisthesis treated by posterior reduction and fusion. Material and methods: Sixteen patient who had undergone surgery for spondylolisthesis of the superior isthmus > 50% were reviewed. Mean age was 12 years (range 9–16 years). Preoperatively, all patients were symptomatic with lumbalgia, truncated radicular pain, and gait anomalies. Surgical treatment consisted in a single posterior approach, L5 laminectomy, curettage of the L5-S1 disc combined with excision of the S1 dome, L4-S1 instrumented reduction, anterior L5-S1 and posterolateral L4S1 arthrodesis. Postoperative immobilization was achieved with a resin lumbar cast with crural stabilization for three months then a lumbar orthesis for three months. Clinical and radiographic outcome was assessed at 44 months on average (range 10–260 months). Results: Clinically, 14 patients were pain free and had resumed their former activities. One patient complained of intermittent pain. No improvement was observed in one patient. Radiographic results were: displacement 78% (range 52–100%) preoperatively and 30% (8–95%) at last follow-up. The L5S1 displacement angle was 14° kyphosis (range 8–30°) preoperatively and 9° lordosis (range 3–12°) at last follow-up excepting one case with complications. The pelvic incidence was 85° (range 65–100°) preoperatively and 74° (range 50–90°) at last follow-up. Complications: There was one early infection treated by wash-out debridement and antibiotics without removing implants. Disassembly of the implanted material in one patient with a poor clinical result led to complete recurrence and lumbosacral kyphosis. Sacral screw fracture was diagnosed in six patients on average one year after surgery but without any progression or recurrence of the displacement. There were no neurological complications. Discussion and conclusion: Posterior reduction enables restoration of a good sagittal balance. More than the reduction, it is particularly important to restore the lumbosacral junction in a lordosis position to guarantee long-term stability. This technique is a difficult surgical challenge and raises the risk of recurrence and potential neurological complications

Purpose of the study: Appropriate treatment of displaced supracondylar fractures of the distal humerus in children remains a controversial topic. Blount reduction followed by percutaneous or open pin fixation have been widely used. The purpose of this study was to analyze outcome after open surgical treatment of these fractures in pediatric trauma victims. Material and methods: The study included all pediatric patients who underwent surgical treatment for displaced supracondylar fractures of the distal humerus over a ten year period. Fractures were classified III or IV according to Lagrange and Rigault. Cross pinning was used in all cases, via a posterior approach or a double lateral and medial approach. The mechanism of the fracture and pre- and postoperative vascular and neurological complications were noted. The long-term assessment included standard x-rays of the elbow joint (ap and lateral views) and a physical examination to search for misalignment and residual neurological disorders. Results: We identified 110 patients, 61 boys and 49 girls, mean age 7.61 years (range 2–15 years). There were 96 grade IV fractures and 24 grade III. Mechanisms were: sports accident (n=44), fall from height (n=36), fall from own height (n=30). A neurological complication was observed in 29 children, skin opening in three and regressive vascular damage in six. A posterior approach was used for 95 patients and a double approach for 15. There was one revision for secondary displacement. Five patients developed transient paresthesia of the ulnar nerve which resolved without sequela. Three patients presented a moderately hypertrophic or deformed callus which had little functional impact. One patient with an open fracture required surgerical arthrolysis for stiffness six months after fracture. Discussion and conclusion: Open surgery is a very reliable treatment for supracondylar elbow fractures with a low rate of short- and long-term complications. Ulnar nerve palsy, the classical complication of percutaneous cross pinning, can be attributed to the medial pin (7–16% of cases in the literature). The Blount method and Judet or Métaizeau fixations can sometimes be complicated by secondary displacement or a deformed callus, complications which were almost never observed in our series. The results obtained in this series favor our approach for open surgery for the treatment of displaced supracondylar fractures of the distal humerus in children