Odontoid Fracture with Accompanying Severe Atlantoaxial Instability in Elderly Patients-Analysis of Treatment, Adverse Events, and Outcome.

(1) Background: In elderly patients with type II odontoid fractures, accompanying severe atlantoaxial instability (AAI) is discussed as a marker possibly warranting more aggressive surgical therapy. This study aimed to characterize adverse events as well as the radiological and functional outcomes of surgical vs. conservative therapy in patients with odontoid fracture and AAI. (2) Methods: Patients aged 65 years and older with type II odontoid fracture and AAI treated were included. AAI was assumed if the mean subluxation across both atlantoaxial facet joints in the sagittal plane was greater than 50%. Data on demographics, comorbidities, treatment, adverse events, radiological, and functional outcomes were analyzed. (3) Results: Thirty-nine patients were included. Hospitalization time was significantly shorter in conservatively treated patients compared to patients with ventral or dorsal surgery. Adverse events occurred in 11 patients (28.2%), affecting 10 surgically treated patients (35.7%), and 1 conservatively treated patient (9.1%). Moreover, 25 patients were followed-up (64.1%). One secondary dislocation occurred in the conservative group (11.1%) and three in the surgical group (18.8%). (4) Conclusions: Despite the potential for instability in this injury, conservative treatment does not seem to lead to unfavorable short-term results, less adverse events, and a shorter hospital stay and should thus be considered and discussed with patients as a treatment option, even in the presence of severe AAI.

Secondary Dislocations in Type B and C Injuries of the Subaxial Cervical Spine: Risk Factors and Treatment.

INTRODUCTION: This study analyzed the incidence of secondary dislocations (sDLs) after surgical stabilization of AO Spine type B and C injuries of the subaxial cervical spine (sCS). MATERIALS AND METHODS: Patients treated for injuries of the sCS from 2010 to 2020 were retrospectively analyzed for the incidence of sDL within 60 days after first surgery. A univariate analysis of variables potentially influencing the risk of sDL was performed. Patients with solitary anterior stabilization underwent subgroup analysis. The treatment of sDLs was described. RESULTS: A total of 275 patients were included. sDLs occurred in 4.0% of patients (n = 11) in the total sample, most frequently after solitary anterior stabilization with 8.0% (n = 10, p = 0.010). Only one sDL occurred after combined stabilization and no sDLs after posterior stabilization. In the total sample and the anterior subgroup, variables significantly associated with sDL were older age (p = 0.001) and concomitant unstable facet joint injury (p = 0.020). No neurological deterioration occurred due to sDL and most patients were treated with added posterior stabilization. sDL is frequent after solitary anterior stabilization and rare after posterior or combined stabilization. DISCUSSION: Patients of higher age and with unstable facet joint injuries should be followed up diligently to detect sDLs in time. Neurological deterioration does not regularly occur due to sDL, and most patients can be treated with added posterior stabilization.

Adverse events after surgery for injuries to the subaxial cervical spine: analysis of incidence and risk factors.

PURPOSE: To determine the incidence of severe surgical adverse events (sSAE) after surgery of patients with subaxial cervical spine injury (sCS-Fx) and to identify patient, treatment, and injury-related risk factors. METHODS: Retrospective analysis of clinical and radiological data of sCS-Fx patients treated surgically between 2010 and 2020 at a single national trauma center. Baseline characteristics of demographic data, preexisting conditions, treatment, and injury morphology were extracted. Incidences of sSAEs within 60 days after surgery were analyzed. Univariate analysis and binary logistic regression for the occurrence of one or more sSAEs were performed to identify risk factors. P-values < .05 were considered statistically significant. RESULTS: Two hundred and ninety-two patients were included. At least one sSAE occurred in 49 patients (16.8%). Most frequent were sSAEs of the surgical site (wound healing disorder, infection, etc.) affecting 29 patients (9.9%). Independent potential risk factors in logistic regression were higher age (OR 1.02 [1.003-1.04], p = .022), the presence of one or more modifiers in the AO Spine Subaxial Injury Classification (OR 2.02 [1.03-3.96], p = .041), and potentially unstable or unstable facet injury (OR 2.49 [1.24-4.99], p = .010). Other suspected risk factors were not statistically significant, among these Injury Severity Score, the need for surgery for concomitant injuries, the primary injury type according to AO Spine, and preexisting medical conditions. CONCLUSION: sSAE rates after treatment of sCS-Fx are high. The identified risk factors are not perioperatively modifiable, but their knowledge should guide intra and postoperative care and surgical technique.

Survival and Clinical Outcomes after Unconstrained Total Knee Arthroplasty for Tibial Plateau Fractures-A Retrospective Study with Minimum 4-Year Follow-Up.

This study investigated survival, complications, revisions, and patient-reported outcomes (PROs) for unconstrained total knee arthroplasty (TKA) in posttraumatic osteoarthritis (PTO) caused by intraarticular tibial plateau fractures with minimum four years follow-up. Forty-nine patients (71.4% male; 58.7 years) were included. Kaplan-Meier analysis was performed with failure defined as TKA removal. Patients without failure underwent pre- and postoperative evaluation (range of motion (ROM), Oxford Knee Score (OKS), Knee Society Score (KSS), anatomical femorotibial angle (aFTA), proximal tibial slope (PTS)) and Short Form-12 (SF-12) Physical (PCS) and Mental Component Summary (MCS) assessment at final follow-up. Fifteen (30.6%) patients had a complication, and eight (16.3%) patients underwent prosthesis removal at median 2.5 years. Cumulative survival rate of TKA was 79.6% at 20 years. A total of 32 patients with a mean follow-up of 11.8 years underwent further analyses. ROM (p = 0.028), aFTA (p = 0.044), pPS (p = 0.009), OKS (p < 0.001) and KSS (p < 0.001) improved significantly. SF-12 PCS was 42.3 and MCS was 54.4 at final follow-up. In general, one third of patients suffer a complication, and one in six patients has their prosthesis removed after TKA for PTO due to tibial plateau fractures. In patients who do not fail, TKA significantly improves clinical and radiographic outcomes at long-term follow-up.

Odontoid fracture in geriatric patients - analysis of complications and outcome following conservative treatment vs. ventral and dorsal surgery.

BACKGROUND: Different treatment options are discussed for geriatric odontoid fracture. The aim of this study was to compare the treatment options for geriatric odontoid fractures. METHODS: Included were patients with the following criteria: age ≥ 65 years, identification of seniors at risk (ISAR score ≥ 2), and odontoid fracture type A/B according to Eysel and Roosen. Three groups were compared: conservative treatment, surgical therapy with ventral screw osteosynthesis or dorsal instrumentation. At a follow-up examination, the range of motion and the trabecular bone fracture healing rate were evaluated. Furthermore, demographic patient data, neurological status, length of stay at the hospital and at the intensive care unit (ICU) as well as the duration of surgery and occurring complications were analyzed. RESULTS: A total of 72 patients were included and 43 patients could be re-examined (range: 2.7 ± 2.1 months). Patients with dorsal instrumentation had a better rotation. Other directions of motion were not significantly different. The trabecular bone fracture healing rate was 78.6%. The patients with dorsal instrumentation were hospitalized significantly longer; however, their duration at the ICU was shortest. There was no significant difference in complications. CONCLUSION: Geriatric patients with odontoid fracture require individual treatment planning. Dorsal instrumentation may offer some advantages.

Pediatric cervical spine injuries-results of the German multicenter CHILDSPINE study.

OBJECTIVES: The aim of this study was to provide epidemiological data of pediatric patients suffering from cervical spinal trauma in Germany, in order to integrate these data in future decision-making processes concerning diagnosis and therapy. MATERIALS AND METHODS: Retrospective multicenter study includes all patients up to 16 years suffering from cervical spine injuries who were treated in six German spine centers between 01/2010 and 12/2016. The clinical databases were screened for specific trauma mechanism, level of injury as well as accompanying injuries. Diagnostic imaging and the chosen therapy were analyzed. Patients were divided into three age groups for further evaluation: age group I (0-6 years), age group II (7-9 years), age group III (10-16 years). RESULTS: A total of 214 children with 265 cervical spine injuries were included during the mentioned period. The mean age at the time of injury was 11.9 (± 3.9) years. In age group I, 24 (11.2%) patients were included, age group II consisted of 22 patients (10.3%), and 168 patients belonged to age group III (78.5%). Girls and boys were equally affected. In all age groups, falls and traffic accidents were the most common causes of cervical spine injuries. A total of 180 patients (84.1%) were treated conservatively, while 34 (15.9%) children underwent surgery. Distorsion/whiplash injury was the most common entity (n = 165; 68.2%). Children aged 0-9 years had significantly (p < 0.001) more frequent injuries of the upper cervical spine (C0-C2) compared to older age groups. Patients of age group III were more likely to suffer from injuries in subaxial localizations. Neurological deficits were rarely seen in all age groups. Head injuries did represent the most common accompanying injuries (39.8%, n = 92). CONCLUSIONS: The upper cervical spine was more frequently affected in young children. Older children more often suffered from subaxial pathologies. The majority of cervical spinal column injuries were treated conservatively. Nevertheless, 15% of the hospitalized children had to be treated surgically.

Development and first application testing of a new protocol for CT-based stability evaluation of the injured upper cervical spine.

PURPOSE: For trauma surgeons, the evaluation of the stability of the upper cervical spine may be demanding. The aim of this study was to develop a protocol for decision-making on upper cervical spine stability in trauma patients based on established parameters obtained by CT imaging as well as testing the protocol by having it applied by trauma surgeons. METHODS: A structured literature search on upper cervical spine stability was performed. The best evaluated instability criteria in CT imaging were determined. Based on these parameters a protocol for stability evaluation of the injured upper cervical spine was developed. A first application testing was performed. In addition to the assessment of instability, the time required for the assessment was analyzed. RESULTS: A protocol for CT-based stability evaluation of the injured upper cervical spine based on the current literature was developed and displayed in a flow chart. Testing of the protocol found the stability of the cervical spine was correctly assessed in 55 of 56 evaluations (98.2%). In one test run, a stable upper cervical spine was judged to be unstable. Further analysis showed that this case was based on a measurement error. The assessment time of CT-images decreased significantly during repeat application of the protocol (p < 0.0001), from 336 ± 108 s (first case) to 180 ± 30 s (fourth case). CONCLUSION: The protocol can be applied quickly and safely by non-specialized trauma surgeons. Thus, the protocol can support the decision-making process in CT-based evaluation of the stability of the injured upper cervical spine.

Cervical Spine Immobilization in Patients With a Geriatric Facial Structure: The Influence of a Geriatric Mandible Structure on the Immobilization Quality Using a Cervical Collar.

INTRODUCTION: Demographic changes have resulted in an increase in injuries among geriatric patients. For these patients, a rigid cervical collar is crucial for immobilizing the cervical spine. However, evidence suggests that patients with a geriatric facial structure require a different means of immobilization than patients with an adult facial structure. This study aimed to analyze the remaining motion of the immobilized cervical spine based on facial structure. MATERIALS AND METHODS: This study was performed on 8 fresh human cadavers. Facial structure was evaluated via ascertaining the mandibular angle by computer tomography. A mandibular angle below 130°, belongs to the adult facial structure group (n = 4) and a mandibular angle above 130°, belongs to the geriatric facial structure group (n = 4). The flexion and lateral bending of the immobilized cervical spine were analyzed in both groups using a wireless motion tracker system. RESULTS: A flexion of up to 19.0° was measured in the adult facial structure group. The mean flexion in the adult vs. geriatric facial structure groups were 14.5° vs. 6.5° (ranges: 9.0-19.0 vs. 5.0-7.0°), respectively. Thus, cervical spine motion was (p = 0.0286) significantly more reduced in the adult facial structure group. No (p = 0.0571) significant difference was oberserved in the mean lateral bending of the adult facial structure group (14.5°) compared to the geriatric facial structure group (7.5°). CONCLUSION: Emergency medical service personnel should therefore follow current guidelines and recommendations and perform cervical spine immobilization with a cervical collar, including in patients with a geriatric facial structure.

Analysis of diagnostics, therapy and outcome of patients with traumatic atlanto-occipital dislocation.

BACKGROUND CONTEXT: Patients' outcome following traumatic atlanto-occipital dislocation (AOD) has been poor. In recent years, an increasing number of patients surviving the initial trauma are admitted to hospital. In order to further improve the management of these patients, the knowledge of diagnostics and therapy as well as possible complications should be increased. PURRPOSE: The aim of this study was to evaluate diagnostic parameters, therapy, early complications and outcome of patients with traumatic AOD. STUDY DESIGN: Monocentric retrospective cohort study. PATIENT SAMPLE: A total of 12 patients were included in this study. OUTCOME MEASURES: The main outcome measure was functional patient outcome. Furthermore, radiographic and treatment data were analyzed. METHODS: All patients suffering from traumatic AOD within an 8-year time period were included. Demographic data, radiological diagnostic parameters (condylar sum, basion dens interval, basion axis interval, power´s ratio, x-line method), as well as treatment data and complications of every patient were analyzed. Radiological parameters were compared with each other. Outcome was analyzed by a follow up examination. RESULTS: The accident mechanisms were motor vehicle accidents (MVA), fall from high and low height. Basion dens interval, basion axis interval, power's ratio and x-line method were not reliable in identifying traumatic AOD (only up to 33% of the patients were identified). Twelve patients could be reviewed. Three patients were treated with surgery, five patients were treated nonsurgically. Four patients died before surgical therapy. All seven surviving patients (survival rate: 58.3%) were re-examined (mean follow-up time: 6.7 months). All patients had a GCS of 15. Three surviving patients suffered from persisting neurological deficits. CONCLUSIONS: The most reliable way to diagnose AOD in Computer Topography is using the condylar sum. Surgical and nonsurgical measures can be employed with reasonable outcomes. Patient specific injury burden and clinical presentation should be taken into account when making treatment decisions for AOD.

Risk Factors for Revision Surgery Following Radial Head Arthroplasty without Cement for Unreconstructible Radial Head Fractures: Minimum 3-Year Follow-up.

BACKGROUND: Revision rates following radial head arthroplasty (RHA) for unreconstructible radial head fractures (RHFs) differ vastly in the literature, and little is known about the risk factors that are associated with revision surgery. The purposes of this study were to assess the revision rate following RHA and to determine the associated risk factors. METHODS: A total of 122 patients (mean age, 50.7 years; range, 18 to 79 years) with 123 RHAs who underwent RHA for unreconstructible RHFs between 1994 and 2014 and were ≥3 years out from surgery were included. Demographic variables, injury and procedure-related characteristics, radiographic findings, complications, and revision procedures were assessed. Cox regression analysis was performed to identify the risk factors that were associated with revision surgery following RHA. RESULTS: The median follow-up for the study cohort was 7.3 years (interquartile range [IQR], 5.1 to 10.1 years). All of the patients had unreconstructible RHFs: Mason-Johnston type-IV injuries were the most prevalent (80 [65%]). One or more associated osseous or ligamentous injuries were seen in 89 elbows (72.4%). The median time to surgery was 7 days (IQR, 3 to 11 days). Implanted prostheses were categorized as rigidly fixed (65 [52.8%]) or loosely fixed (58 [47.2%]). A total of 28 elbows (22.8%) underwent revision surgery at a median of 1.1 years (IQR, 0.3 to 3.8 years), with the majority of elbows (17 [60.7%]) undergoing revision surgery within the first 2 years. The most common reason for revision surgery was painful implant loosening (14 [29.2% of 48 complications]). Univariate Cox regression suggested that Workers' Compensation claims (hazard ratio [HR], 5.48; p < 0.001) and the use of an external fixator (HR, 4.67; p = 0.007) were significantly associated with revision surgery. CONCLUSIONS: Revision rates following RHA for unreconstructible RHFs are high; the most common cause for revision surgery is painful implant loosening. Revision surgeries are predominantly performed within the first 2 years after implantation, and surgeons should be aware that Workers' Compensation claims and the use of an external fixator in management of the elbow injury are associated with revision surgery. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Long-term outcome and survival rate of monopolar radial head replacement.

BACKGROUND: The purposes of this study were (1) to report functional outcomes; (2) to assess complications, revisions, and survival rate; and (3) to assess differences in functional outcomes between removed and retained radial head arthroplasties (RHAs), early and delayed treatment, and type of RHA used at long-term follow-up after monopolar RHA for unreconstructible radial head fractures or their sequelae. METHODS: Seventy-eight patients (mean age, 59.2 years) who were at least 6 years postoperatively after monopolar RHA for unreconstructible RHFs or their sequelae were included. The Mayo Elbow Performance Score (MEPS); Quick Disability of the Arm, Shoulder, and Hand (QuickDASH) score; visual analog scale; postoperative satisfaction (1-6, 6 = highly unsatisfied); range of motion; complications; and revisions were assessed. Radiographic findings were reported. Kaplan-Meier survival analysis was performed. Subgroups (RHA type, early vs. delayed surgery, RHA removed vs. retained) were compared. RESULTS: At a median clinical follow-up of 9.5 years (range: 6.0-28.4 years), median MEPS was 80.0 (interquartile range [IQR]: 60.0-97.5), median QuickDASH was 22.0 (IQR: 4.6-42.6), median visual analog scale was 1 (IQR: 0-4), median postoperative satisfaction was 2 (IQR: 1-3), and median arc of extension/flexion was 110° (IQR: 80°-130°). Radiographic follow-up was available for 48 patients at a median of 7.0 years (range: 2.0-15.0 years). Heterotopic ossifications were seen in 14 (29.2%), moderate-to-severe capitellar osteopenia/abrasion in 3 (6.1%), moderate-to-severe ulnohumeral degeneration in 3 (6.1%), and periprosthetic radiolucencies in 17 (35.4%) patients. Twenty-nine patients (37.2%) had complications and 20 patients (25.6%) underwent RHA exchange or removal. Kaplan-Meier analysis with failure defined as RHA exchange or removal demonstrated survival of 75.1% (95% confidence interval: 63.7-83.3) at 18 years. The highest annual failure rate was observed in the first year in which the RHAs of 7 patients (9%) were exchanged or removed. No significant differences were detected between type of RHA in MEPS (Mathys: 82.5 [75.0-100] vs. Evolve: 80.0 [60.0-95.0]; P = .341) and QuickDASH (Mathys: 12.5 [0-34.4] vs. Evolve: 26.7 [6.9-46.2]; P = .112). Early surgery (≤3 weeks) yielded significantly superior MEPS (80.0 [70.0-100.0] vs. 52.5 [30.0-83.8]; P = .014) and QuickDASH (18.6 [1.5-32.6] vs. 46.2 [31.5-75.6]; P = .002) compared with delayed surgery (>3 weeks). Patients with retained RHAs had significantly better MEPS (80.0 [67.5-100] vs. 70.0 [32.5-82.5]; P = .016) and QuickDASH (18.1 [1.7-31.9] vs. 49.1 [22.1-73.8]; P = .007) compared with patients with removed RHAs. CONCLUSIONS: Long-term outcomes for RHA are satisfactory; however, there is a high complication and revision rate, resulting in implant survival of 75.1% at 18 years with the highest annual failure rate observed in the first postoperative year.

[Diagnostics and treatment of thoracic and lumbar spine trauma in pediatric patients : Recommendations from the Pediatric Spinal Trauma Group]. / Diagnostik und Therapie von Verletzungen der Brust- und Lendenwirbelsäule im Kindesalter : Empfehlungen der AG Wirbelsäulentrauma im Kindesalter.

BACKGROUND: Spinal injuries in pediatric patients are overall very rare. Current reference studies including large patient numbers that enable the formulation of evidence-based recommendations on diagnostics and treatment of these injuries do not exist. OBJECTIVE: The aim of the current study was to formulate recommendations on the diagnostics and treatment for injuries of the thoracic and lumbar spine in pediatric patients. MATERIAL AND METHODS: Firstly, a search for primary and secondary literature on the topic of diagnostics and treatment of spinal injuries in children was carried out. From this, a literature database was established and maintained. Secondly, within the framework of 9 meetings in the time period from April 2017 to December 2019 the members of the Pediatric Spinal Trauma Group of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU) documented recommendations on diagnostics and treatment of injuries of the thoracic and lumbar spine in pediatric patients by a consensus process. RESULTS: Recommendations on the diagnostics and treatment of injuries of the thoracic and lumbar spine could be given for 3 age groups (age group I: 0-6 years; age group II: 7-9 years; age group III: 10-16 years). Diagnostic and therapeutic principles known from adult patients suffering from injuries to the thoracic or lumbar spine cannot easily be transferred to pediatric patients. CONCLUSION: Spinal injuries in childhood are rare and should be treated in specialized spine centers. Pediatric patients with a stable cardiopulmonary status should undergo magnetic resonance imaging (MRI) if a spinal trauma is suspected. The basic principles of the treatment of spinal trauma in children is the restoration of spinal stability and correct anatomical parameters as well as the protection of all neural structures. The potential for correction and regeneration of the individual spinal sections depending on the age of the patient must be considered for deciding between operative vs. conservative treatment. Whenever operative treatment is needed, it should be performed by minimally invasive techniques as a sole instrumentation without spondylodesis. An early removal of the screw-rod-system should be performed.