Pedicle screw (PS) insertion has been critised for its risk of serious injury to neurovascular structures. Although computed tomography (CT)-based navigation has been developed to avoid such complications, perforation remains an issue, even with the aid of additional guidance. We clarify screw perforation rate and direction in 359 consecutive patients treated using CT-based PS insertion and present important considerations for more accurate screw placement.

The medical records of 359 consecutive patients who underwent PS insertion involving C2-L5 using a CT-based navigation system were reviewed. Postoperative CT images were analysed to evaluate the accuracy of screw placement. We investigated both rate and direction of screw perforation according to vertebral level.

Of the 3413 PS that were inserted, 3.0% (104/3413) were judged as Grade 3 (more than 4mm) perforations. Allover perforation rates by vertebral level were shown in Table 1. The rate of these perforations was 5.0% for C2, 7.8% for C3–5, 3.9% for C6–7, 3.4% for T1–4, 3.5% for T5–8, 1.4% for T9–12, and 1.7% for L1–5. We also analysed the odds ratio (OR) for screw perforation in vertebrae accounting for the effects of age and disease. Multivariate analysis identified that PS insertions at C3–5 (OR 4.9, 95% CI 2.2–10.9; p<0.001) were significantly associated with Grade 3 screw perforation as compared with that of L1–5.

Even with CT-based navigation, careful insertion of PS is needed in the middle cervical spine because of a significantly higher perforation rate as compared with the lumbar region.

For figures and tables, please contact authors directly.

Objectives

Our objective was to predict the knee extension strength and post-operative function in quadriceps resection for soft-tissue sarcoma of the thigh.

The ratio of the incidence of trochanteric to cervical fractures increased with age in the elderly female population, but the reason for this fact remain unclear.

The purposes of this study were to investigate whether or not there are specificities of the local distribution of mechanical properties at the trochanteric region of the elderly female using a scanning acoustic microscope (SAM). Human proximal femurs were harvested from seven female cadavers (67–88 years) and proximal femur was coronally sectioned into halves across the center of neck. The surface of the coronal section was polished in order to achieve flat surfaces of smoothness well below the surface resolution in scanning with SAM. Bone tissue density and elastic modulus were calculated from the acquired SAM data. Mechanical properties were measured at the lateral and medial trochanter. Cortical bone tissue of the lateral trochanter had significantly lower elastic modulus than that of the medial trochanter in the all specimen over 70s(p<0.05). Trabecular bone tissue of proximal region of the lateral trochanter had significantly lower elastic modulus than that of distal region in all 80s specimens (p<0.05). Decrease of the elastic modulus of cortical bone in the lateral trochanter and low value of the elastic modulus of trabecular bone in the proximal region of the lateral trochanter may be related to the increase of the ratio of trochanteric to cervical fractures with age in the elderly female population.

Total elbow arthroplasty (TEA) has been shown to be a treatment option for elderly patients with complex distal humeral fractures and osteoporotic bone. The published results have often included rheumatoid patients who traditionally would be expected to do well from elbow arthroplasty. Only short-term results have been published using this technique in non-rheumatoid patients.

The current study contains the largest number and longest follow-up of non-rheumatoid patients whose fractures have been treated with a non-custom TEA. In total there were 26 patients, mean age 72 years, 22 female and 4 male, 25% dominant arm. The mean follow-up was of 5 years. There was 1 case of loosening, 1 radial nerve palsy and 2 cases of heterotrophic ossification. At final review the mean range of flexion/extension was 97.5 degrees and the mean range of pronation/supination was 151.75 degrees. The mean Mayo Elbow Performance score was 92.

We would suggest that TEA provides a very satisfactory outcome in elderly patients with complex distal humeral fractures, the benefit of which can be observed at a mean of 5 years.

Intra-articular distal humeral fractures in the elderly are difficult to treat. There is evidence in the literature to support the use of both Open Reduction and Internal Fixation (ORIF) and Total Elbow Arthroplasty (TEA) as primary procedures, although we have been unable to find any direct comparisons of outcome.

This study reports the results of ORIF in 12 elderly patients with distal humeral fractures and compares the outcome with 12 matched patients who had undergone TEA.

All procedures were performed by two experienced Consultant Surgeons. The Coonrad-Morrey TEA was used in all cases of TEA and a double-plating technique was used in all ORIFs.

Both groups of patients were similar with respect to fracture configuration, age, sex, co-morbidity and hand dominance. The mean follow-up in both groups of patients was over 30 months.

At final review, patients who had had a TEA had a mean Mayo score of 91 and a range of flexion/extension of 90 degrees. There was 1 superficial wound infection that resolved with antibiotics, 1 temporary radial nerve palsy, and 1 case of heterotrophic ossification The ORIF group had a mean Mayo score of 89 (p> 0.05) and a range of flexion/extension of 112 degrees (P=0.03). There was 1 case of heterotrophic ossification, 2 cases of ulnar nerve compression that needed decompression and 1 superficial wound infection that resolved with antibiotics. All the fractures united.

This study indicates that both treatment modalities can lead to excellent results. ORIF has the advantage of preserving the joint and once union has occurred has a low risk of long term complications.