Introduction. Correction and arthrodesis for cervical kyphosis associated with atetoid cerebral palsy has been considered to be difficult because of their involuntary neck movements and severe deformity. The aim of this study is to evaluate the surgical outcome of midline T-saw laminoplasty and posterior arthrodesis using pedicle screws. Methods. 15 patients were retrospectively reviewed. There were 6 women and 9 men, with a mean age 52.9 years (range 31–71 years). Mean follow-up period was 43 months (range 24–84 months). For clinical evaluation, the Japanese Orthopaedic Association (JOA) score and Barthel index (BI) which shows independence in ADL were used. For radiographic evaluation, change of C2–C7 Cobb angle of sagittal alignment, adjacent segment instability after the surgery were evaluated. Results. The average JOA score improved significantly from 6.2 preoperatively to 10.5 postoperatively. The average BI improved from 44.2 before surgery to 72.5 after surgery. C2–C7 Cobb angle of sagittal alignment measured 12.3 degrees of kyphosis preoperatively and 1.2 degrees of lordosis postoperatively. Solid posterior bony fusion was achieved in all cases. There was two cases of adjacent segmental instability, which required additional surgery. Seven (5.6%) out of the 125 inserted screws showed more than 2mm deviation. However, there were no neurovascular complications during or after surgery in any cases, and all cases maintained strong internal fixation. Conclusion. Midline T-saw laminoplasty and posterior arthrodesis using pedicle screw is a favorable option for the patient with kyphotic deformity associated with atetoid cerebral palsy, as it preserves cervical alignment, and improve neurological status and ADL

Introduction. To introduce a new classification method and analyze related risk factor about lateral wall perforation associated with lower cervical pedicle screw and free-hand insertion technique. Methods. A Retrospective study was made to analyze 214 patients (1024 screws) with various cervical spine disorders, involved in pedicle screw instrumentation at C3-7 from July 2004 to July 2009. Researchers assessed the position of the screws in the pedicle by carefully probing intraoperatively and studying postoperative thin-slice computed tomography scan. Perforation of lateral wall was classified into two phases. Phase I refers to the burst of the pedicle by screw, which means that the length of screw threads penetrating the external cortex of pedicles on CT scan is 2 mm, whereas in Phase, the length is >2 mm. The Penetrated screws and related factors were analyzed though Backward Stepwise (Wald) Logistic regression. Results. During the follow-up, 2 screws were reported to be broken and 1 screw loosened. Of the screws inserted, total of 129 screws 12.60% have shown violated of lateral pedicle walls, included 101 screws (9.86%) causative of Phase I and 28 screws (2.73%) of Phase II. Two variance were deduced in the regression analysis, which concerned to ratio variance between inner and lateral walls, PRC 0.695, OR value = 2.003and angle difference variance between screws implanted and measurements preoperativePRC −1.542, OR value = 0.214). Conclusions. Free-hand lower cervical pedicle screw insertion in this series was comparatively safety. Phase I Penetration was believed to be safe of vertebral artery and Phase II faced to higher risk of artery damage. The main risk factor of lateral wall perforation was the ratio variance between inner and lateral wall, while the main protection factor was the angle difference variance between screws implanted and CT measurements

Improvised Explosive Device (IED) attacks on vehicles have been a significant feature of recent conflicts. The Dynamic Response Index (DRI), developed for predicting spinal injury in aircraft ejection, has been adopted for testing vehicles in underbelly blast. Recent papers suggest that DRI is not accurate in blast conditions. We suggest that the distribution of blast and ejection injuries is different. A literature review identified the distribution of spinal fractures in aircraft ejection incidents. A Joint Theatre Trauma Registry search identified victims of mounted IED blast with spinal fractures. The distribution of injuries in the two groups was compared using the Kruskall Wallis test. 329 fractures were identified in ejector seat incidents; 1% cervical, 84% thoracic and 16% lumbar. 245 fractures were identified in victims of mounted blast; 16% cervical, 34% thoracic and 50% lumbar. There was no significant similarity between the two (p=1). There was no statistically significant difference between the distribution of fractures in blast survivors versus fatalities. The difference between blast and ejection injury patterns suggests that injury prediction models for ejection should not be extrapolated to blast mechanisms and that new models need to be developed

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

The optimal method for the management of neglected traumatic bifacetal dislocation of the subaxial cervical spine has not been established. We treated four patients in whom the mean delay between injury and presentation was four months (1 to 5). There were two dislocations at the C5-6 level and one each at C4-5 and C3-4. The mean age of the patients was 48.2 years (27 to 60). Each patient presented with neck pain and restricted movement of the cervical spine. Three of the four had a myelopathy. We carried out a two-stage procedure under the same anaesthetic. First, a posterior soft-tissue release and partial facetectomy were undertaken. This allowed partial reduction of the dislocation which was then supplemented by interspinous wiring and corticocancellous graft. Next, through an anterior approach, discectomy, tricortical bone grafting and anterior cervical plating were carried out. All the patients achieved a nearly anatomical reduction and sagittal alignment. The mean follow-up was 2.6 years (1 to 4). The myelopathy settled completely in the three patients who had a pre-operative neurological deficit. There was no graft dislodgement or graft-related problems. Bony fusion occurred in all patients and a satisfactory reduction was maintained. The posteroanterior procedure for neglected traumatic bifacetal dislocation of the subaxial cervical spine is a good method of achieving sagittal alignment with less risk of iatrogenic neurological injury, a reduced operating time, decreased blood loss, and a shorter hospital stay compared with other procedures

Purpose. Clinicians need knowledge about early and valid predictors of short-term outcome of patients with hip fracture, to adjust and plan rehabilitation. The concept of multimodal rehabilitation has proven effective. Still, some patients do not regain basic mobility independency in the acute orthopaedic setting. The aim was to examine the predictive value of age, sex, prefracture functional level, mental and health status, and fracture type of in-hospital basic mobility outcome, and discharge destination after hip fracture surgery. Subjects. A total of 213 consecutive patients (157 women and 56 men) with a median age of 82 (25–75% quartile, 75–88) years, admitted from their own home, and following a multimodal rehabilitation concept, were included. Fifty percent of patients had a high prefracture functional level, evaluated by the New Mobility Score (NMS), 77 and 62% had respectively, a high mental and health status, and the distribution of cervical versus intertrochanteric fractures were equally divided. Methods. Outcome variables were the regain of independency in basic mobility during admittance and discharge destination. The Cumulated Ambulation Score was used to evaluate basic mobility defined as, independency in getting in and out of bed, sitting down and standing up from a chair, and walking. Discharge destination was classified as own home or further inpatient rehabilitation facilities in the community. Results. A total of 50 (24%) patients did not regain their basic mobility independence during admittance, and 51 patients (24%) were not discharged to their own home. Simple regression analysis showed that age, the prefracture NMS functional level, mental status and fracture type (P<0.01), significantly influenced basic mobility outcome, while sex (P=0.06) and health status (P=0.08), did not. Multiple logistic regression analysis, revealed the prefracture NMS level, age and fracture types as the only independent predictors, when adjusted for sex, mental and health status. Thus, a patient with a low prefracture NMS and/or an intertrochanteric fracture was respectively, 6 and 4 times more likely not to regain independency in basic mobility during admittance, and 4 and 3 times more likely not being discharged to own home, compared to a patient with a high prefracture NMS level and a cervical fracture, respectively. Further, odds of not being discharged directly to own home increased with 9% per each additional year the patient got older. Conclusion. The prefracture NMS functional level, age and fracture type were strong and independent predictors of in-hospital outcome in patients with hip fracture who followed a multimodal rehabilitation concept. Clinicians using these three easily available variables, have the possibility to identify patients who may benefit from special attention

Aims

The aim of this study was to assess whether it is possible to predict the mortality, and the extent and time of neurological recovery from the time of the onset of symptoms and MRI grade, in patients with the cerebral fat embolism syndrome (CFES). This has not previously been investigated.

A wide variety of intra- and extramedullary devices for the treatment of trochanteric fractures has been described. The Percutaneous Compression Plate is a minimally invasive and extramedullary device, which requires two 2–2.5 cm long incisions with minimal dissection oft soft tissue on the lateral aspect of the proximal femur. Earlier studies indicated that internal fixation using the PCCP is associated with a decreased perioperative blood loss, reduced transfusion requirements, with less postoperative pain, more rapid mobilisation, and with a reduced incidence of collapse of the fracture when compared with the standard device Dynamic Hip Screw. Aim of this study is to analyze the risk factors for the occurrence of local complications after internal fixation of intertrochanteric fractures of the femur using a Percutaneous Compression Plate. In a retrospective cohort study patients with trochanteric fractures who underwent internal fixation with a PCCP were included. We investigated the potential risk factors age, gender, experience of the surgeon as indicated by the numbers of surgical procedures with the PCCP device, stability of the fracture according to the AO/OTA classification, and co-morbidities of the patients according to the ASA classification. The operations were performed by ten different surgeons. All local complications which required re-operation were recorded. They included cutting out of the screw, loosening of the screw barrels, local haematoma, and infections. Logistic regression analysis was carried out to determine the risk factors for local complications. The mean age of the 122 patients included in this study was 78.5 years. 87 patients were female (70.7 %), 36 patients were male (29.3 %). With respect to the stability of the fracture 64 trochanteric fractures (52.5%) were classified as stable according to the AO/OTA classification, whereas 58 (47.5%) were considered to be unstable. Of the total of 122 patients with 122 trochanteric fractures eleven underwent re-operation due to local complications (9 %). The most frequent complication was complete or imminent cutting out of the upper cervical screw (N=5; 4 %). In the multivariate logistic regression model the only statistically significant risk factor was the experience of the surgeon (p=0.0316; odds ratio=4.7; CI 1.1–19.4). Our data indicate that the experience of the surgeon is a significant risk factor for the occurrence of local complications. The frequent use of this device seems to lower the re-operation rate

Introduction. Surgical treatment of spinal metastasis belongs to the standards of oncology. The risk of spinal cord compression represents an operative indication. Intraoperative bleeding may vary, depending on the extent of the surgical technique. Some primary tumors, such as the renal cell carcinoma, present a major risk for hemorrhage and preoperative embolisation is mandatory. The purpose of this study is to evaluate the possible benefit of embolisation in different types of primary tumors. Material and Methods. The charts of 93 patients (42 women, 51 men, mean age 60.5 years) who were operated for spinal metastasis, 30 cases with multiple levels, were reviewed. Surgical procedures were classified as: (1) thoracolumbar laminectomy and instrumentation, (2) thoracolumbar corpectomy or vertebrectomy, (3) cervical corpectomy. A preoperative microsphere embolisation was performed in 35 patients. The following parameters, describing blood loss, were evaluated: hemoglobin variation from beginning to end of surgery, blood volume in suction during the intervention, number transfused packed red blood cells units until day 5 after surgery. A Poisson model was used for statistical evaluation. Results. The origins of spinal metastasis were: 28 breast cancer (30.1%), 19 pulmonary carcinoma (20.4%), 16 renal cell carcinoma (17.2%), 30 other cancers (32.3%). An embolisation was always performed in metastasis of renal cell carcinoma. An embolisation was performed in 8 cases in breast, 3 in pulmonary and 9 in other cancers. In the breast cancer group, there was no difference between embolisation versus non-embolisation concerning intraoperative blood loss and transfusion (P=0.404). In the pulmonary group, no difference was found either, but the number of embolisation cases was limited. For other metastasis types, the embolisation had no significant influence (P=0.697). The type of surgical intervention (2) increased intraoperative bleeding significantly in all groups: breast (P=0.002), pulmonary (P=0007), others (P=0.001). The average intraoperative hemoglobin decrease was: 2.3 in renal, 2.5 in breast, 3.0 in pulmonary, 1.9 in other metastasis (P=0.692). Conclusion. Several studies have clearly shown that the preoperative embolisation of renal cell carcinoma is recommended because of their risk of hemorrhage. However, the benefits of this procedure have been less described for other metastatic vertebral lesions. For breast cancer and other carcinoma (mainly digestive and prostate), the results of this study do not indicate a clear benefit for patients who received an embolisation. The same tendency was observed for pulmonary metastasis. The extent of the operation (corpectomy or vertebrectomy) represents the main factor that influences intraoperative bleeding

We explored the role of iron overload, deficiency of vitamin C and alcohol abuse in the aetiology of cervical and intertrochanteric fractures of the neck of the femur as a result of minor trauma. We studied prospectively 72 patients (45 men, 27 women). Levels of serum iron markers, vitamin C and alcohol markers were measured. Consumption of alcohol was estimated using questionnaires. The findings were compared with those of an age- and gender-matched control group. The mean age of the men was 59.5 years and of the women 66.9 years, with a male predominance. In the men, iron overload, as shown by high levels of serum ferritin (p < 0.001) and deficiency of vitamin C (p < 0.03), as well as abuse of both Western and the traditional type of alcohol, appear to be important aetiological factors. In women, alcohol abuse was also common, but iron markers and levels of vitamin C did not differ significantly from the control group

Introduction. While there is a desperate need for effective treatments for acute spinal cord injury (SCI), the clinical validation of novel therapeutic interventions is severely hampered by the need to recruit relatively large numbers of patients into clinical trials for sufficient statistical power. While a centre might annually admit 100 acute SCI patients, only a fraction may satisfy the basic inclusion criteria for an acute clinical trial, which typically requires patients of a certain injury severity (eg ASIA A), within a specific time window (eg. 12 hours from injury), and without other major injuries or conditions that would cloud the baseline neurologic assessment. This study was conducted to define that “fraction” of SCI patients that would theoretically satisfy standard inclusion criteria of an acute clinical trial. Methods. Using a local database, we reviewed patients admitted to our Level 1 trauma center with a complete (ASIA A) or an incomplete (ASIA B, C and D) acute SCI involving bony spinal levels between C0 and sacrum. All patients admitted over the 4 year period from 2005 to 2009 were reviewed. Demographic information and data about the patients' SCI and other injuries were reviewed. We then determined how many of the total number of SCI patients would be eligible for enrolment into a hypothetical acute clinical trial that required a valid baseline assessment of neurologic impairment, and an enrolment window of either 12 hours, 24 hours, or 48 hours. Results. 408 acute traumatic SCI patients were admitted over the 4 year period. 253 of 408 (62%) patients presented within 12 hours of injury, 60 (15%) between 12–24 hours, and 28 (7%) between 24–48 hours. 42% of patients were ASIA A, 13% B, 18% C and 27% D. The number of patients who presented with injuries or other conditions that would exclude them from enrolment was relatively high: 4% had penetrating injuries, 12% had illicit drug use, and 20% had either alcohol intoxication or head injuries which precluded a valid baseline neurologic examination. Conclusions. Out of a total of 408 patients admitted over 4 years, the number who would have been optimistically eligible for an acute neuroprotective trial was disappointingly small. Given that acute clinical trials are increasingly interested in cervical ASIA A patients (in whom segmental motor recovery can be assessed), the number of such patients who would actually be eligible for an acute intervention was surprisingly low. Given that additional inclusion/exclusion criteria would also be applicable in a real clinical trial, the true number of “eligible” or “recruitable” patients is conservatively even lower. This study is the first to quantify this challenging aspects of conducting acute SCI clinical trials, and provides valuable information for those planning such initiative

We studied a consecutive series of 58 patients with penetrating missile injuries of the brachial plexus to establish the indications for exploration and review the results of operation. At a mean of 17 weeks after the initial injury, 51 patients were operated on for known or suspected vascular injury (16), severe persistent pain (35) or complete loss of function in the distribution of one or more elements of the brachial plexus (51). Repair of the nerve and vascular lesions abolished, or significantly relieved, severe pain in 33 patients (94%). Of the 36 patients who underwent nerve graft of one or more elements of the plexus, good or useful results were obtained in 26 (72%). Poor results were observed after repairs of the medial cord and ulnar nerve, and in patients with associated injury of the spinal cord. Neurolysis of lesions in continuity produced good or useful results in 21 of 23 patients (91%). We consider that a vigorous approach is justified in the treatment of penetrating missile injury of the brachial plexus. Primary intervention is mandatory when there is evidence of a vascular lesion. Worthwhile results can be achieved with early secondary intervention in patients with debilitating pain, failure to progress and progression of the lesion while under observation. There is cause for optimism in nerve repair, particularly of the roots C5, C6 and C7 and of the lateral and posterior cords, but the prognosis for complete lesions of the plexus associated with damage to the cervical spinal cord is particularly poor

Objectives

The aim of this systematic literature review was to assess the clinical level of evidence of commercially available demineralised bone matrix (DBM) products for their use in trauma and orthopaedic related surgery.

A total of 11 patients with combined traumatic injuries of the brachial plexus and spinal cord were reviewed retrospectively. Brachial plexus paralysis in such dual injuries tends to be diagnosed and treated late and the prognosis is usually poor. The associated injuries, which were all on the same side as the plexus lesion, were to the head (nine cases), shoulder girdle (five), thorax (nine) and upper limb (seven). These other injuries were responsible for the delayed diagnosis of brachial plexus paralysis and the poor prognosis was probably because of the delay in starting treatment and the severity of the associated injuries. When such injuries are detected in patients with spinal cord trauma, it is important to consider the possibility of involvement of the brachial plexus.

We carried out a retrospective review over ten months of patients who had presented with a low-energy subtrochanteric fracture. We identified 13 women of whom nine were on long-term alendronate therapy and four were not. The patients treated with alendronate were younger, with a mean age of 66.9 years (55 to 82) vs 80.3 years (64 to 92) and were more socially active. The fractures sustained by the patients in the alendronate group were mainly at the femoral metaphyseal-diaphyseal junction and many had occurred after minimal trauma. Five of these patients had prodromal pain in the affected hip in the months preceding the fall, and three demonstrated a stress reaction in the cortex in the contralateral femur.

Our study suggests that prolonged suppression of bone remodelling with alendronate may be associated with a new form of insufficiency fracture of the femur. We believe that this finding is important and indicates the need for caution in the long-term use of alendronate in the treatment of osteoporosis.

The purpose of this study was to identify changing trends in the pattern of distribution of the type and demographics of fractures of the hip in the elderly between 2001 and 2010. A retrospective cross-sectional comparison was conducted between 179 fractures of the hip treated in 2001, 357 treated in 2006 and 454 treated in 2010. Patients aged < 60 years and those with pathological and peri-prosthetic fractures were excluded. Fractures were classified as stable extracapsular, unstable extracapsular or intracapsular fractures.

The mean age of the 179 patients (132 women (73.7%)) treated in 2001 was 80.8 years (60 to 96), 81.8 years (61 to 101) in the 357 patients (251 women (70.3%)) treated in 2006 and 82.0 years (61 to 102) in the 454 patients (321 women (70.1%)) treated in 2010 (p = 0.17). There was no difference in the gender distribution between the three study years (p = 0.68).

The main finding was a steep rise in the proportion of unstable peritrochanteric fractures. The proportion of unstable extracapsular fractures was 32% (n = 57) in 2001, 35% (n = 125) in 2006 and 45% (n = 204) in 2010 (p < 0.001). This increase was not significant in patients aged between 60 and 69 years (p = 0.84), marginally significant in those aged between 70 and 79 years (p = 0.04) and very significant in those aged > 80 years (p < 0.001). The proportion of intracapsular fractures did not change (p = 0.94).

At present, we face not only an increasing number of fractures of the hip, but more demanding and complex fractures in older patients than a decade ago. This study does not provide an explanation for this change.

Cite this article: Bone Joint J 2013;95-B:1250–4.

Heterotopic ossification occurring after the use of commercially available bone morphogenetic proteins has not been widely reported. We describe four cases of heterotopic ossification in patients treated with either recombinant bone morphogenetic protein 2 or recombinant bone morphogenetic protein 7. We found that while some patients were asymptomatic, heterotopic ossification which had occurred around a joint often required operative excision with good results.

We have reviewed our experience in managing 11 patients who sustained an indirect sternal fracture in combination with an upper thoracic spinal injury between 2003 and 2006. These fractures have previously been described as ‘associated’ fractures, but since the upper thorax is an anatomical entity composed of the upper thoracic spine, ribs and sternum joined together, we feel that the term ‘fractures of the upper transthoracic cage’ is a better description. These injuries are a challenge because they are unusual and easily overlooked. They require a systematic clinical and radiological examination to identify both lesions. This high-energy trauma gives severe devastating concomitant injuries and CT with contrast and reconstruction is essential after resuscitation to confirm the presence of all the lesions. The injury level occurs principally at T4–T5 and at the manubriosternal joint. These unstable fractures need early posterior stabilisation and fusion or, if treated conservatively, a very close follow-up.

Neurogenic heterotopic ossification (NHO) is a disorder of aberrant bone formation affecting one in five patients sustaining a spinal cord injury or traumatic brain injury. Ectopic bone forms around joints in characteristic patterns, causing pain and limiting movement especially around the hip and elbow. Clinical sequelae of neurogenic heterotopic ossification include urinary tract infection, pressure injuries, pneumonia and poor hygiene, making early diagnosis and treatment clinically compelling. However, diagnosis remains difficult with more investigation needed. Our pathophysiological understanding stems from mechanisms of basic bone formation enhanced by evidence of systemic influences from circulating humor factors and perhaps neurological ones. This increasing understanding guides our implementation of current prophylaxis and treatment including the use of non-steroidal anti-inflammatory drugs, bisphosphonates, radiation therapy and surgery and, importantly, should direct future, more effective ones.

We describe 261 peripheral nerve injuries sustained in war by 100 consecutive service men and women injured in Iraq and Afghanistan. Their mean age was 26.5 years (18.1 to 42.6), the median interval between injury and first review was 4.2 months (mean 8.4 months (0.36 to 48.49)) and median follow-up was 28.4 months (mean 20.5 months (1.3 to 64.2)). The nerve lesions were predominantly focal prolonged conduction block/neurapraxia in 116 (45%), axonotmesis in 92 (35%) and neurotmesis in 53 (20%) and were evenly distributed between the upper and the lower limbs. Explosions accounted for 164 (63%): 213 (82%) nerve injuries were associated with open wounds. Two or more main nerves were injured in 70 patients. The ulnar, common peroneal and tibial nerves were most commonly injured. In 69 patients there was a vascular injury, fracture, or both at the level of the nerve lesion. Major tissue loss was present in 50 patients: amputation of at least one limb was needed in 18. A total of 36 patients continued in severe neuropathic pain.

This paper outlines the methods used in the assessment of these injuries and provides information about the depth and distribution of the nerve lesions, their associated injuries and neuropathic pain syndromes.