Removing a Retained Antibiotic Cement Nail from a Tibia: A Case Report.

CASE: We present a case of osteomyelitis after a grade 3A open tibial shaft fracture complicated by incomplete removal of an antibiotic intramedullary rod. The authors are unaware of any reports with this specific complication and provide a novel technique for cement mantle removal involving a distal tibial corticotomy and antegrade cement impaction. CONCLUSION: Antibiotic nails can successfully treat intramedullary osteomyelitis, but surgeons may encounter unexpected issues due to custom, intraoperative fabrication. This case describes one example of how to solve the intraoperative problem of a retained cement mantle during antibiotic rod extraction.

Clinical correlates of atypical femoral fracture.

BACKGROUND: Reports of atypical femur fracture in bisphosphonate-exposed women have prompted interest in characterizing the clinical profiles of these patients. METHODS: Among women age ≥60 years with hip or femur fracture during 2007-2008, we identified 79 with low-trauma subtrochanteric or femoral shaft fracture. Radiographic images were reviewed to assign fracture pattern and distinguish atypical femur fracture from non-atypical femur fracture. Differences in clinical characteristics and pharmacologic exposures were compared. RESULTS: Among 79 women (38 subtrochanteric and 41 femoral shaft fracture), 38 had an atypical femur fracture. Compared to those with a non-atypical femur fracture, women with atypical femur fracture were significantly younger (74.0 vs 81.0 years), more likely to be Asian (50.0 vs 2.4%) and to have received bisphosphonate therapy (97.4 vs 41.5%). Similarly, the contralateral femur showed a stress or complete fracture in 39.5% of atypical femur fractures vs 2.4% non-atypical femur fracture, and focal cortical hypertrophy of the contralateral femur in an additional 21.1% of atypical cases. CONCLUSIONS: Women suffering atypical femur fractures have a markedly different clinical profile from those sustaining typical fractures. Women with atypical femur fracture tend to be younger, Asian, and bisphosphonate-exposed. The high frequency of contralateral femur findings suggests a generalized process.

A prospective cohort analysis of adjacent vertebral body bone mineral density in lumbar surgery patients with or without instrumented posterolateral fusion: a 9- to 12-year follow-up.

STUDY DESIGN: A prospective, cohort study of 11 patients who underwent either a posterior lumbar spinal fusion with instrumentation (n = 7) or a lumbar laminotomy and discectomy alone (n = 4) and who were evaluated by dual energy radiograph absorptiometry (DEXA) to determine bone mineral density (BMD) at the adjacent three cephalad vertebral levels. OBJECTIVES: To determine long-term BMD changes that occur at the adjacent three levels above an instrumented posterolateral lumbar fusion or an isolated laminotomy and lumbar discectomy. SUMMARY OF BACKGROUND DATA: No long-term prospective study has evaluated the affects of instrumented lumbar fusions on bone remodeling at adjacent vertebral levels. Several studies in animals and humans have reported a decrease in BMD at the adjacent level during the first 6 months after spinal fusion with a return to baseline at 1-year follow-up in up to 60% of patients. METHODS: DEXA was performed initially at a mean postoperative follow-up of 4 years (range, 2.3-5.5 years) and again at a mean of 10.8 years (range, 9.1-2.4 years). Eleven patients were divided into two groups: laminotomy and discectomy (n = 4) and instrumented posterior spinal fusion (n = 7). All patients underwent surgical procedures at the L4-L5 or L5-S1 levels with DEXA analysis being performed on the adjacent three cephalad levels. The discectomy group (mean age, 57.8 years) underwent lumbar hemilaminotomy without fusion whereas the other group (mean age, 60 years) underwent pedicle-screw instrumentation and posterolateral lumbar fusion. Peripheral sites, including the femoral neck, were included in the DEXA analysis to normalize for individual differences in bone mineral metabolism. RESULTS: At the mean 10.8-year follow-up, the fusion group was noted to have at the adjacent level, two levels cephalad, and three levels cephalad normalized BMDs of 1.47, 1.39, and 1.27, respectively. A 14.8%, 10.8%, and 9.5% increase respectively in normalized BMD was observed when compared with the mean 4-year fusion values (P < 0.05). This increase was also noted on comparative T-score, Z-score, and absolute BMD values (P < 0.05). The discectomy group when evaluated revealed no statistically significant change from the mean 4 to 10.8-year follow-up (BMD, normalized BMD, T-score, Z-score). No statistically significant difference was noted in hip BMD at the mean 4-year and 10.8-year follow-up (1.05 versus 1.03), suggesting that the effects were local. CONCLUSIONS: The local BMD adjacent to an instrumented lumbar fusion is increased at a mean of 10.8-years after surgery. There is a gradual decrease in BMD changes with increasing distance from the fusion level. Alterations in fusion site biomechanics and modulus mismatch between the host bone and the spinal instrumentation most likely result in chronic, localized bone remodeling with an increased BMD that decreases the greater the distance from the fusion mass.