Introduction

Controversy exists as to whether the short external rotator tendons and capsule of the hip should be repaired after posterior approach primary total hip arthroplasty (THA). Recent studies using radiopaque markers have demonstrated that reimplantation of these muscle tendons fail early and may not prevent post operative dislocation.

Historically the management of distal radial fracture has been often inadequate. It can be difficult to internally fix complex distal radial fractures with conventional plates. The fracture often collapses with metalwork failure. Literature suggests that malunion may lead to painful wrist with loss of function. In recent years fixed angle locking plate has been advocated for treatment of complex distal radius fracture. Our aim was to assess to assess the effectiveness of the volar locking plate (DePuy) in maintaining fracture reduction in distal radial fractures.

Radiographs of 170 distal radius fractures treated by the DVR plate were analysed. Fractures were classified according to the Melone and AO classifications. The post injury, intra-operative, 6 weeks postoperative and final postoperative radiographs were reviewed to obtain measurements for radial height, radial slope and volar inclination. The measurements were correlated with fracture pattern, locking screw length, presence or absence of radial styloid screw and plate placement in relation to the wrist joint. The results were analysed statistically using Wilcoxon signed rank test.

Radiologically there was minor loss of radial height, slope and volar inclination but this was not statistically significant. There was a statistically significant correlation between complexity of fracture and loss of radiological parameters. There was no statistically significant correlation between loss of radiological parameters and screw length, plate placement or presence or absence of radial styloid screw.

The DVR volar locking plate appears to maintain a satisfactory reduction of the fracture except for some complex fractures with dorsal comminution in which case dorsoradial plates may be preferable.

Retrospective review of eighteen patients with sacral fracture dislocations and cauda equina deficits treated with posterior sacral decompression and lumbopelvic fixation. At mean nineteen-month follow-up, all fractures healed without loss of alignment despite immediate full weight-bearing. Fifteen patients (83%) improved neurologically, and ten patients (56%) had full bowel/ bladder recovery. Complications consisted mainly of infection (17%) and asymptomatic rod breakage (33%). This series demonstrates the clinical effectiveness of lumbopelvic fixation, allowing the application to sacral injuries of decompression and fixation principles commonly used in fractures with neurologic deficits that occur in more rostral areas of the spine.

To evaluate the results of sacral decompression and lumbopelvic fixation for sacral fracture-dislocations with neurologic deficits.

Lumbopelvic fixation provided the stability necessary for full weight-bearing without loss of fracture reduction despite extensive sacral decompression. The functional neurologic improvement in most patients and complete neurologic recovery in all but one patient with intact lumbosacral roots are encouraging. The effectiveness of lumbopelvic fixation facilitates the application of principles of early decompression and stabilization to sacral fracture-dislocations.

Sacral fractures healed in all eighteen patients without loss of reduction. Average sacral kyphosis improved from forty-one to twenty-four degrees. Fifteen patients (83%) had normalization or improvement of bowel and bladder deficits, although only ten patients (56%) had improved Gibbons scores. Average Gibbons type improved from four to 2.8 at nineteen-month average follow-up. Rod breakage (33%) and infection (17%) were the most common complications. Recovery of bowel and bladder function was less likely in patients with disruption of any lumbosacral root (36% vs. 86%, p=.066) and complete deficits (47% vs. 100%, p=.241) although the small cohort size precluded statistical significance.

Retrospective review of medical records, radiographs, and prospectively collected data of eighteen consecutive patients with sacral fracture-dislocations and cauda equina deficits identified between 1997 and 2002 through institutional databases. Treatment consisted of open reduction, sacral decompression and lumbopelvic fixation. Radiographic and clinical results of treatment were evaluated. Neurologic outcome was measured by Gibbons’ criteria.

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Retrospective review of seventeen consecutive survivors of craniocervical dissociation (CCD). Thirteen patients had delay in diagnosis, with associated neurologic deterioration in five. Diagnosis of CCD was entertained after lateral C-spine x-ray in only two patients, and after screening C-spine CT in two others. At fifteen-month average follow-up, mean ASIA motor score improved from fifty preoperatively to seventy-nine postoperatively. One patient had temporary postoperative neurologic decline. There were no pseudarthroses. The diagnosis of CCD is often missed, with potentially severe neurologic consequences. Early diagnosis and stabilization are neuroprotective. A classification that identifies minimally displaced yet unstable injuries may improve diagnostic accuracy.

To identify the timing and method of diagnosis, diagnostic reliability of screening lateral radiographs, effect of delayed diagnosis, complications of treatment, and neurologic outcome of this life-threatening condition.

Diagnosis of craniocervical dissociation (CCD) was frequently delayed, increasing the risk of neurologic decline. Early diagnosis and stabilization protected against worsening spinal cord injury.

This study highlights the importance of disciplined evaluation of the lateral cervical spine radiograph of poly-traumatized patients. Head-injured patients with cranio-facial trauma and asymmetric high cervical spinal cord injuries should heighten clinicians’ suspicion of CCD.

CCD was identified or suspected on two of seventeen (12%) initial lateral cervical spine radiographs, and on screening CT scan in only two additional patients (12%), despite an abnormal dens-basion relationship in 16/17 (94%) patients. Of the thirteen patients with (two-day average) delay in diagnosis, 5/13 (38%) had profound neurologic deterioration. One patient worsened temporarily after fixation. There were no pseudarthroses at fifteen-month average follow-up. Mean ASIA motor score of fifty improved to seventy-nine, and the number of patients with useful motor function (ASIA D or E) increased from seven (41%) preoperatively to thirteen (76%) postoperatively.

Four patients with severe craniocervical instability had < 3 mm displacement. We therefore adopted a classification based on provocative traction testing of minimally displaced injuries.(Table).

Retrospective review of seventeen consecutive CCD survivors identified between 1994–2002 through institutional databases. Radiographic and clinical results were evaluated, emphasizing timing of diagnosis, effect of delayed diagnosis, clinical or radiographic warning signs, and response to treatment.

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The purpose of this study was to determine the effect of the use of a system to retransfuse salvaged drainage blood in patients undergoing primary THR with the aim of avoiding the significant risks that allogeneic blood transfusion poses to the patient. This was a retrospective cohort study where records of 109 patients undergoing elective THR following the introduction of an autologous retransfusion system at the institution were compared with a cohort of similar patients who underwent the same procedure prior to the introduction of the autologous system. The two groups were matched for age, surgeon, approach and technique and the results were subjected to statistical analysis. The use of a system to retransfuse postoperative salvage drainage blood, without concomitant use of predonation or intraoperative blood salvage, significantly reduced the need for allogeneic blood transfusion from 30% to 9%(p< 0.001). Patients who received salvaged blood also had a significantly smaller haemoglobin drop (Difference 0.56g/dL p=0.001) in the perioperative period, even though the preoperative haemoglobin level was not significantly different in the two cohorts. The overall cost of using the retransfusion system was similar to that of routine vacuum drainage when the savings of reduced allogeneic blood transfusion were considered. In conclusion the retransfusion of postoperative salvage drainage blood is a simple, effective and economical way of providing autologous blood for patients undergoing primary THR

Introduciton Diagnosis of cranio-cervical dissociaton is frequently delayed, and neurological consequences may be severe. Our purpose was to identify problems with the diagnosis and treatment of craniocervical dissociation, while reporting the results of early craniocervical fusion with posterior segmental fixation.

Methods We present a retrospective review of 17 survivors of cranio-cervical dissociation identified through institutional spine and trauma registries. Medical records, radiographs, and prospectively collected data were used to identify the timing and method of diagnosis, and the effect of delayed diagnosis. Radiographic and clinical results of treatment were evaluated. Emphasis was placed on identifying missed or delayed diagnoses, decline in neurologic function, potential clinical or radiographic warning signs, and response to treatment.

Results Despite an abnormal Basion-Dens relationship in all but one patient, cranio-cervical dissociation was identified or suspected on the initial lateral cervical spine radiograph in only two patients (12%), and was diagnosed in only four patients (24%) following initial trauma evaluation (lateral radiograph and CT of cervical spine). The two day average delay in diagnosis was associated with profound neurologic deterioration in five patients. One patient had post-operative neurologic worsening. No patients developed craniocervical pseudarthrosis or hardware failure after a 15-month average follow-up period. The mean ASIA motor score of 50 improved to seven, and the number of patients with useful motor function (ASIA D or E) increased from seven patients (41%) pre-operatively to 13 (76%) post-operatively. The typical patient profile was of a polytraumatized patient with associated head injuriy, cranio-facial trauma, and asymmetric motor deficits extending above the C5 level.

Conclusions Better clinician awareness and disciplined review of screening C-spine radiographs are important for prompt diagnosis and stabilization of craniocervical instability. Of 17 patients with CCD necessitating internal fixation (stage two and three), 13 had a delay in diagnosis either at our institution or the transferring hospital, with severe neurological consequences in five patients. Significant recovery of neurologic function was a consistent post-operative finding, confirming the importance of prompt diagnosis and operative stabilization of these devastating injuries.

Introduction A promising new approach in the treatment of osteoporosis is the reinforcement of fractured vertebrae with percutaneous injection of bone cement: percutaneous vertebroplasty. This paper reviews the current state of medical literature on this topic and raises concerns about the rapid acceptance of this procedure despite the poor quality of the evidence relating to its safety and efficacy.

Methods We performed a search and critical formal review of the available literature on percutaneous vertebroplasty listed in the MEDLINE database.

Results We found it difficult to summarize the distinct cases reported in the literature because of duplication of case reports and questionable citation in summary reports. Pain relief within 48 hours of treatment was almost universally reported, although clearly defined outcome measures and long-term follow-up were often not reported. The most common complication was leakage of the cement, with 90 instances reported out of 226 patients treated. The leaks were associated with clinical symptoms in three percent of the instances.

Conclusions New high-tech solutions to difficult medical problems are enticing. We must force new treatments through rigorous assessments before proclaiming them safe and successful. The percutaneous vertebroplasty literature fails in this responsibility.