Doughnut vertebroplasty for circumferential aggressive vertebral hemangiomas.

BACKGROUND: To assess the feasibility, safety and efficacy of a percutaneous doughnut vertebroplasty of circumferential aggressive vertebral hemangiomas (VHs). METHODS: We retrospectively reviewed our prospectively collected database of patients with VHs treated with vertebroplasty between January 2009 and January 2018. Patient demographics, clinical presentations and procedural details were recorded. All patients underwent preoperative computed tomography (CT) and magnetic resonance imaging (MRI). All vertebroplasties were performed under conscious sedation in the prone position, predominantly using biplane fluoroscopic guidance. A clinical and imaging evaluation (early CT scan and MRI) as well as a final follow-up clinical assessment was performed. RESULTS: Twenty-two patients with aggressive VHs who underwent circumferential vertebroplasty with cementation of the entire vertebral body and at least one posterior hemi-arch were included (six males, mean age 53 years). At 3 months follow-up, nine patients (41%) had complete, 11 (50%) had partial and two (9%) had no resolution of pain. Nine of 14 patients had a decrease in venous swelling on MRI. No complications were observed. Five patients (23%) underwent adjunctive surgery within 1 year for persistence or worsening of neurological symptoms. Clinical and radiographic improvements were maintained to final follow-up. CONCLUSIONS: Doughnut vertebroplasty offers a mini-invasive, safe and effective treatment of aggressive circumferential VHs. This technique improves pain in over 90% of patients as well as a reduction in radicular and neurological symptoms associated with a tendency to regression of the compressive epidural venous component of these lesions.

An age and sex matched study on the effect of obesity on the functional outcomes and complication rates in patients with adult spinal deformity undergoing primary multi-level thoracolumbar spinal fusion.

Background: The objective of this study was to determine the effect of obesity on the functional outcomes and complication rates of patients with adult spinal deformity (ASD) undergoing multi-level thoracolumbar fusion. Methods: An age and sex matched comparison of functional outcomes [Numeric Rating Scale (NRS) back and leg scores, Core Outcome Measurement Index (COMI) back scores, Scoliosis Research Society 22 (SRS22) satisfaction and total scores, Short Form 36 (SF36) general health scores, Physical Component Score (PCS), Mental Component Score (MCS), Oswestry Disability Index (ODI) (including all domains)] at 6 months, 1, 2, 3 and 4 years and the complication rates at final follow-up between obese [body mass index (BMI) >30] and normal BMI (18.5-24.9) patients undergoing more than 3 levels of thoracolumbar fusion with a minimum 2-year follow-up. Patients who had undergone any previous spinal surgery were excluded. Results: Thirty patients were included in each arm of the study. Baseline demographics, including the number of levels fused, were similar between the groups. Estimated blood loss (EBL) was higher in obese patients (1,916 vs. 1,099 mL, P=0.001), but operative time was similar (282 vs. 320 min, P=0.351). The functional outcomes and satisfaction scores were consistently poorer in the obese group at all time-points, but their satisfaction scores were similar. Obese patients had a higher complication rate (OR 3.05, P=0.038) predominantly due to dural tears and nerve root injuries, but a similar reoperation rate. Conclusions: In patients with ASD undergoing multi-level thoracolumbar fusion, obesity results in a higher blood loss, poorer sagittal correction, poorer post-operative functional scores and higher complication rates than patients with a normal BMI. However, obesity does not affect operative times, length of hospital stay or reoperation rates. Furthermore, patients with obesity have similar post-operative satisfaction scores to patients with normal BMIs.

Obeid-Coronal Malalignment Classification Is Age Related and Independently Associated to Personal Reported Outcome Measurement Scores in the Nonfused Spine.

OBJECTIVE: To evaluate Obeid-coronal malalignment (O-CM) modifiers according to age, sagittal alignment, and patient-reported outcome measures (PROMs), in the mobile spine. METHODS: Retrospective review of a prospective multicenter adult spinal deformity (ASD) database with 1,243 (402 nonoperative, 841 operative) patients with no prior fusion surgery. Patients were included if they were aged over 18 years and were affected by spinal deformity defined by one of: Cobb angle ≥ 20°, pelvic tilt ≥ 25°, sagittal vertical axis ≥ 5 cm, thoracic kyphosis ≥ 60°. Patients were classified according to the O-CM classification and compared to coronally aligned patients. Multivariate analysis was performed on the relationship between PROMs and age, global tilt (GT) and coronal malalignment (CM). RESULTS: Four hundred forty-three patients had CM of more than 2 cm compared to 800 who did not. The distribution of these modifiers was correlated to age. After multivariate analysis, using age and GT as confounding factors, we found that before the age of 50 years, 2A1 patients had worse sex life and greater satisfaction than patients without CM. After 50 years of age, patients with CM (1A1, 1A2) had worse self-image and those with 2A2, 2B had worse self-image, satisfaction, and 36-item Short Form Health Survey physical function. Self-image was the consistent determinant of patients opting for surgery for all ages. CONCLUSION: CM distribution according to O-CM modifiers is age dependent. A clear correlation between the coronal malalignment and PROMs exists when using the O-CM classification and in the mobile spine, this typically affects self-image and satisfaction. Thus, CM classified according to O-CM modifiers is correlated to PROMs and should be considered in ASD.

The Value of a Modified Wiltse Approach for Deformity Correction in Neuromuscular Scoliosis.

BACKGROUND: Wiltse approaches have been shown to reduce operative blood loss and enhance recovery in lumbar spinal surgery; however, their efficacy in neuromuscular scoliosis (NMS) deformity correction has never been assessed. Thus, the purpose of this study was to compare the outcomes of deformity correction requiring pelvic fixation in NMS performed through a Wiltse approach in contrast to a standard midline approach. METHODS: This is a retrospective review of 24 consecutive children with NMS undergoing deformity correction by a single surgeon in our institution. Patient demographic data, operative time, blood loss, curve correction, length of stay, and complications were recorded. RESULTS: In 16 children, the procedure was performed through a Wiltse approach and in 8 through a midline approach. There was no significant difference in age, sex, preoperative Cobb angle, or number of levels fused. Patients who underwent a Wiltse approach had significantly less blood loss yet similar curve correction. The hospital length of stay and complication rate were not significantly different between the groups. CONCLUSIONS: A modified Wiltse approach can be safely used for NMS deformity correction. This approach achieves similar curve corrections to a traditional midline approach with less blood loss and no need for iliac screw connectors. LEVEL OF EVIDENCE: 3.

Anterior Cervical Idiopathic Hyperostosis and Dysphagia: The Impact of Surgical Management-Study of a Series of 11 Cases.

OBJECTIVE: To assess the efficacy and safety of surgery for dysphagia in anterior cervical idiopathic hyperostosis. METHODS: This retrospective study included 11 consecutive patients presenting with dysphagia and anterior cervical idiopathic hyperostosis. Computed tomography scans and dynamic swallowing fluoroscopies were performed. The site of compression and the size and position of osteophytes were measured. The clinical outcomes and complications were recorded. RESULTS: Two patients with anterior esophageal compression were found to have dysphagia caused by lower esophageal sphincter dysfunction. In the remaining 9 patients, the level of maximal compression was between C3 and C5 with the size of the osteophytes ranging from 8 to 17 mm. Intubation was challenging in 7 patients. Postoperative transient worsening of dysphagia was encountered in 3 patients. Two patients experienced severe complications including aphagia and respiratory compromise. Within 2 months of the operation, all patients reported satisfactory improvement of symptoms and a considerable gain in quality of life. No recurrence had occurred at final follow-up. CONCLUSIONS: Anterior cervical hyperostosis causing dysphagia typically affects older men and results from compression between C3 and C5 from osteophytes of variable sizes. Operative intervention can provide long-lasting resolution of symptoms but is complicated by difficulty in endotracheal intubation, postoperative dysphagia, and rarely respiratory compromise. A systematic preoperative ear, nose, and throat consultation is recommended to reduce these complications.

Spinal Aneurysmal Bone Cysts (ABCs): Optimal Management.

AIM: To review the published literature on the treatment of aneurysmal bone cysts (ABCs). METHOD: A systematic review of the English literature to April 2019 for all articles, with a minimum of three patients and 2-year follow-up, reporting on the treatment of spinal ABCs. The various treatment options were compared for the rates of recurrence, complications and mortality. RESULTS: Twenty-one articles and 272 patients (mean age 16.9 years, range 3-67) were included in this review. The overall recurrence rate for ABCs following all treatments is 12.8%. This is highest in those lesions described as being treated with isolated surgiflo injection into the lesion (100%), decompression/laminectomy (42.3%), partial excision/resection (35.7%) and curettage alone (25.0%). Radiotherapy alone or in conjunction with operative intervention offers excellent cure rates. Adjuncts to operative intervention, including cryotherapy or phenol reduce the recurrence rates, whereas embolization does not. The most common complications are persistent neurological deficits, spinal deformity, and continued pain. The overall mortality rates are low (1.5%). The reoperation rates are higher in surgical than non-surgical treatments and most are performed for progressive deformity. DISCUSSION: ABCs are highly radiosensitive. However, with the unknown longer-term risk of radiotherapy, surgical treatments, ideally with complete resection, and the use of adjunctive therapies such as cryotherapy or phenol, offer the best chance of cure. SAE is a useful adjunct to reduce intraoperative bleeding, but this study suggests that it only modestly improves recurrence rates. Newer techniques including bisphosphonate and doxycycline administration offer potential benefits, but their efficacy requires further investigation.

Spontaneous Spinal Epidural Hematomas in Pregnancy: A Systematic Review.

BACKGROUND: Spontaneous spinal epidural hematomas (SSEH) are rare yet severe conditions. In pregnancy, this condition is challenging to diagnose and treat because of the risks to the mother and fetus. This study reviews the literature on SSEHs in pregnancy. METHODS: We performed a systematic review of the English literature on SSEHs from 1990 until 2018. Outcome measures were mode of presentation, risk factors, initial neurologic findings, diagnostic investigations, site and size of the SSEH, treatment, neurologic recovery, and survival. RESULTS: Fourteen publications (16 patients) were included. Two patients presented in the second trimester, with the remainder in the third trimester. All patients presented with back pain, and 15 subsequently developed spinal cord dysfunction. Magnetic resonance imaging (MRI) was performed in all cases. The cervicothoracic region was the most commonly affected, and the average hematoma size extended across 3.9 vertebral levels. All patients with neurologic dysfunction underwent surgical decompression. In women under 32 weeks' gestation, caesarean section was not routinely performed. In contrast, women of gestational age of 32 weeks or more underwent a caesarean section prior to spinal decompression. Women without neurologic dysfunction underwent a caesarean section and neurologic monitoring without decompression. All patients with abnormal neurology improved after surgery, except 1 patient. No patients died. CONCLUSIONS: In pregnancy, SSEHs typically present in the second or third trimesters with back pain, predominantly in the cervicothoracic region, followed by progressive neurologic dysfunction. MRI is diagnostic, and the treatment depends on the patient's neurologic dysfunction and gestational age.

Cerebral ischaemia following anterior upper thoracic spinal surgery utilizing a partial manubrial resection.

PURPOSE: Firstly, to describe two cases of cerebral ischaemia complicating anterior upper thoracic spinal surgery and define the likely cause of this complication. Secondly, to describe preventative measures and the effect these have had in reducing this complication within our institution. METHODS: Firstly, a review of two cases of cerebral ischaemia complicating anterior upper thoracic spinal surgery utilizing a partial manubrial resection. Secondly, cadaveric dissections of the carotid arteries to determine the effect of neck positioning and aortic arch retraction during a simulated procedure. Thirdly, a retrospective review of 65 consecutive cases undergoing this procedure and assessment of the rate of this complication before and after the adoption of preventative measures. RESULTS: Two cases of carotid artery territory cerebral ischaemia, without radiographic evidence of carotid or cardiac pathology were identified in 50 consecutive cases prior to the implementation of preventative measures. These patients revealed fluctuating hemodynamic instability after placement of the inferior retractor. Cadaveric dissection reveals significant carotid artery traction particularly with neck extension. Since the adoption of preventative measures, no cases of cerebral ischaemia have been encountered. CONCLUSIONS: Cerebral ischaemia is a potential complication of anterior upper thoracic spinal surgery requiring retraction of the aortic arch. This most likely occurs from carotid stenosis due to aortic retraction and therefore, may be reduced by positioning the patient with neck flexion. Continuous non-invasive monitoring of cerebral saturation, as well as actively monitoring for hemodynamic instability and reduced carotid pulsation after retractor placement, allows for early detection of this complication. If detected, perfusion can be easily restored by reducing the retraction of aortic arch.

The effect of increasing body mass index on the pain and function of patients with adult spinal deformity.

BACKGROUND: Both adult spinal deformity (ASD) and obesity are growing concerns internationally. This study therefore aims to determine the effect of increasing body mass index (BMI) on the pain and function of patients with ASD. METHODS: A retrospective review of prospectively collected data from a multicentre European database was undertaken. Initially a univariate analysis was performed on the effect of BMI on the initial presentation of functional scores in patients with ASD. The functional scores included the Numerical Rating Scale (NRS) back and leg score, Core Outcome Measures Index (COMI) back score, SRS22 total score, Short Form 36 (SF-36) [general health, physical component score (PCS) and mental component score (MCS)] and Oswestry Disability Index (ODI) score (including all domains). Subsequently a multivariate analysis controlling for age, sex, comorbidities, employment status, smoking status and radiological parameters [coronal cobb, coronal balance, sagittal balance, global tilt, and pelvic incidence minus lumbar lordosis (PI - LL) mismatch] was performed. RESULTS: A total of 1,004 patients were included in this study (166 male, 838 female). On univariate analysis a statistically significant (P<0.05) moderate correlation between NRS leg pain, ODI (walking, standing, sex life, social life and total score), SF-36 (physical component), sagittal balance, global tilt and age were recognised (P<0.05). A statistically significant low correlation was identified for all other outcomes, except coronal balance (P=0.640). On multivariate analysis BMI remained significantly related to all functional outcomes except ODI-pain and ODI-travelling (P>0.05). CONCLUSIONS: Increasing BMI has a significant adverse effect on the pain and functioning of patients with ASD. Clinicians should recognise this association and treat patients accordingly.

Anterior Bone Loss in Cervical Disc Arthroplasty.

STUDY DESIGN: Retrospective, longitudinal observational study. PURPOSE: To describe the natural history of anterior bone loss (ABL) in cervical disc arthroplasty (CDA) and introduce a classification system for its assessment. OVERVIEW OF LITERATURE: ABL has recently been recognized as a complication of CDA, but its cause and clinical effects remain unknown. METHODS: Patients with non-keeled CDA (146) were retrospectively reviewed. X-rays were examined at 6 weeks, 3, 6, 9, 12, 18, and 24 months, and annually thereafter for a minimum of 5 years. These were compared with the initial postoperative X-rays to determine the ABL. Visual Analog Scale pain scores were recorded at 3 months and 5 years. Neck Disability Index was recorded at postoperative 5 years. The natural history was determined and a classification system was introduced. RESULTS: Complete radiological assessment was available for 114 patients with 156 cervical disc replacements (CDRs) and 309 endplates (average age, 45.3 years; minimum, 28 years; maximum, 65 years; 57% females). ABL occurred in 57.1% of CDRs (45.5% mild, 8.3% moderate, and 3.2% severe) and commenced within 3 months of the operation and followed a benign course, with improvement in the bone stock after initial bone resorption. There was no relationship between ABL degree and pain or functional outcome, and no implants were revised. CONCLUSIONS: ABL is common (57.1%). It occurs at an early stage (within 3 months) and typically follows a non-progressive natural history with stable radiographic features after the first year. Most ABL cases are mild, but severe ABL occurs in approximately 3% of CDAs. ABL does not affect the patients' clinical outcome or the requirement for revision surgery. Surgeons should thus treat patients undergoing CDA considering ABL.

Risk factors for anterior bone loss in cervical disc arthroplasty.

OBJECTIVE The objective of this study was to identify the risk factors of anterior bone loss (ABL) in cervical disc arthroplasty (CDA) and the subsequent effect of this phenomenon. METHODS The authors performed a retrospective radiological review of 185 patients with a minimum 5-year follow-up after CDA (using Bryan, Discocerv, Mobi-C, or Baguera C). Postoperative radiographs were examined and compared to the initial postoperative films to determine the percentage of ABL. The relationship of ABL to potential risk factors was analyzed. RESULTS Complete radiological assessment was available in 145 patients with 193 CDRs and 383 endplates (average age 45 years, range 25-65 years, 54% women). ABL was identified in 63.7% of CDRs (48.7% mild, 11.9% moderate, 3.1% severe). Age (p = 0.770), sex (p = 0.200), postoperative alignment (p = 0.330), midflexion point (p = 0.509), maximal flexion (p = 0.080), and extension (p = 0.717) did not relate to ABL. There was no significant difference in the rate of severe ABL between implants. Multilevel surgery conferred an increased risk of any and severe ABL (p = 0.013 for both). The upper endplate, defined as superior to the CDA, was more commonly involved (p = 0.008), but there was no significant difference whether the endplate was between or not between implants (p = 0.226). The development of ABL did not affect the long-term range of movement (ROM) of the CDA, but did increase the overall risk of autofusion. ABL was not associated with pain or functional deficits. No patients required a reoperation or revision of their implant during the course of this study, and there were no cases of progressive ABL beyond the first year. CONCLUSIONS ABL is common in all implant types assessed, although most is mild. Age, sex, postoperative alignment, ROM, and midflexion point do not relate to this phenomenon. However, the greater the number of levels operated, the higher the risk of developing ABL. The development of ABL has no long-term effect on the mechanical functioning of the disc or necessity for revision surgery, although it may increase the rate of autofusion.

Targeted Distraction: Spinal Growth in Children With Early-Onset Scoliosis Treated With a Tail-gating Technique for Magnetically Controlled Growing Rods.

STUDY DESIGN: Prospective cohort study OBJECTIVE.: To understand the efficacy of a tail-gating technique (TGT) to mirror the normal spinal growth of children with early-onset scoliosis (EOS) treated with magnetically controlled growing rods (MCGR). SUMMARY OF BACKGROUND DATA: MCGR allow outpatient distraction and guided spinal growth without the need for repeat surgery. Two techniques (maximal and targeted) are currently employed to determine the distraction amount, however the efficacy of each is unknown. This study specifically assesses the ability of targeted distraction to achieve physiological growth. METHODS: We performed a retrospective review of European children treated with MCGR using a TGT and analyzed the post-operative clinical and radiographic outcomes, including the sitting height, standing height, coronal Cobb angle, T1-T12 and T1-S1 height. Furthermore, we compared the post-operative sitting/standing height ratio every 6 months to those reported for normal age- and sex-matched European children. RESULTS: Thirty-five children were included with a mean follow-up of 3.4 years (1.8-5.8 years). All clinical and radiographic parameters significantly (P < 0.05) improved immediately post-operatively and were maintained until final follow-up. The TGT mirrored the normative sitting/standing height ratios for expected spinal growth (Pearson correlation 0.95 for males and 0.90 for females). The mean difference between the reference values for the sitting/standing height ratio and our results was 0.0124 (P < 0.001) for males and 0.0068 (P = 0.010) for females. CONCLUSION: MCGR can reliably improve the coronal deformity in children with EOS while maintaining spinal growth. A TGT to determine the distraction amount at follow-up accurately mirrors the normal growth pattern of age-, sex-, and ethnicity-matched children. However, patients treated with this technique have a statistically significant, but clinically insignificant, shorter than physiologically normal spinal height. LEVEL OF EVIDENCE: 3.

Spondylolisthesis adjacent to a cervical disc arthroplasty does not increase the risk of adjacent level degeneration.

PURPOSE: To understand whether a spondylolisthesis in the sub-axial spine cranial to a cervical disc arthroplasty (CDA) construes a risk of adjacent level disease (ALD). METHODS: A retrospective review of 164 patients with a minimum 5-year follow-up of a cervical disc arthroplasty was performed. Multi-level surgeries, including hybrid procedures, were included. Multiple implant types were included. The two inter-vertebral discs (IVD) cranial of the CDA were monitored for evidence of radiologic degeneration using the Kettler criteria. RESULTS: The rate of ALD in CDA found in this series was 17.8%, with most affecting the immediately adjacent IVD (27.4 and 7.6%, respectively p = 0.000). Pre-operative mild spondylolisthesis adjacent to a planned CDA was not found to be a risk factor for ALD within 5 years. Those with a degenerative spondylolisthesis are at higher risk of ALD (33%) than those with a non-degenerative cause for their spondylolisthesis (11%). Post-operative CDA alignment, ROM or induced spondylolisthesis do not affect the rate of ALD in those with an adjacent spondylolisthesis. Patients with ALD experience significantly worse 5-year pain and functional outcomes than those unaffected by ALD. CONCLUSIONS: A pre-operatively identified mild spondylolisthesis in the sub-axial spine cranially adjacent to a planned CDA is not a risk factor for ALD within 5 years. These slides can be retrieved under Electronic Supplementary Material.

Systematic review of the complications associated with magnetically controlled growing rods for the treatment of early onset scoliosis.

PURPOSE: To analyse the complication profile of magnetically controlled growing rods (MCGRs) in early onset scoliosis (EOS). METHODS: This is a systematic review using PUBMED, Medline, Embase, Google Scholar and the Cochrane Library (keywords: MAGEC, Magnetically controlled growing rods and EOS) of all studies written in English with a minimum of five patients and a 1-year follow-up. We evaluated coronal correction, growth progression (T1-S1, T1-T12) and complications. RESULTS: Fifteen studies (336 patients) were included (42.5% male, mean age 7.9 years, average follow-up 29.7 months). Coronal improvement was achieved in all studies (pre-operative 64.8°, latest follow-up 34.9° p = 0.000), as was growth progression (p = 0.001). Mean complication rate was 44.5%, excluding the 50.8% medical complication rate. The unplanned revision rate was 33%. The most common complications were anchor pull-out (11.8%), implant failure (11.7%) and rod breakage (10.6%). There was no significant difference between primary (39.8%) and conversion (33.3%) procedures (p = 0.462). There was a non-statistically significant increased complication rate with single rods (40 vs. 27% p = 0.588). CONCLUSIONS: MCGRs improve coronal deformity and maintain spinal growth, but carry a 44.5% complication and 33% unplanned revision rate. Conversion procedures do not increase this risk. Single rods should be avoided. These slides can be retrieved under Electronic Supplementary material.

Identifying the superior and inferior gluteal arteries during a sacrectomy via a posterior approach.

BACKGROUND: Identifying the gluteal vessels during a posterior sacrectomy can be challenging. This study defines anatomical landmarks that can be used to approximate the location of the superior and inferior gluteal arteries (SGA and IGA) during a posterior sacrectomy. METHODS: Cadaveric dissection of six fresh adult pelvises to determine the location of the SGA and IGA in relation to the posterior-inferior aspect of the sacroiliac joint (PISIJ), lateral sacral margin and sacrococcygeal joint (SCJ). RESULTS: The anatomical landmarks are easily palpable. The position of the SGA to the PISIJ is relatively constant as it is tethered by a posterior branch of the artery, which runs inferior to the PISIJ. The IGA position is also relatively constant below the mid-point of the PISIJ and SCJ. The vessels are separated from the sacrospinous/sacrotuberous ligament complex (SSTL) in the perisacral region and as a result an anatomical plane exists anterior to the SSTL, which affords protection of the vessels during SSTL transection. The distance between the vessels and the SSTL increases the more medial the dissection. CONCLUSIONS: The described anatomical landmarks can be used to predict the location of the SGA and IGA during posterior sacrectomy. An anatomical plane exists anterior to the SSTL, which provides protection to the vessels during SSTL transection. Furthermore, the distance between the vessels and the SSTL increases the more medial the dissection, thus, resection of the SSTL as close to the lateral sacral margin as the pathology permits, is advocated.

Noninvasive management of an odontoid process fracture in a toddler: case report.

Study Design Case report. Objective Odontoid process fractures represent an uncommon injury in small children, with their optimal management remaining unclear. We present a case of conservatively managed displaced type 2 odontoid process fracture in a small child. Methods We analyzed clinical and radiographic outcomes of a restrained 2-year-old girl involved in a motor vehicle accident who sustained a displaced type 2 odontoid process fracture and was treated conservatively in a semirigid Aspen collar. Results The fracture progressively healed with callus formation evident at 6 weeks. By 12 weeks, the patient was asymptomatic and had regained head control and a full range of movement. Radiographic remodeling of the fracture was seen to improve over the 6-month follow-up. Conclusion This case illustrates that displaced type 2 odontoid process fractures can be successfully managed conservatively in small children.

Displaced tibial intercondylar eminence fractures.

PURPOSE: To review outcomes of 19 patients with tibial eminence fractures. METHODS: Records of 10 female and 9 male patients with type II (n=3) and type III (n=16) displaced tibial intercondylar eminence fractures were reviewed. Nine of whom were skeletally immature aged 6 to 15 (mean, 12) years; the remaining 10 patients were aged 19 to 55 (mean, 32) years. 14 involved the left knee. All patients presented with a painful haemarthrosis and reduced range of movement. RESULTS: The most common activity causing this injury was skiing (n=7, primarily in adult females [n=5]), followed by cycling or motocrossing (n=6) and falling or other sporting activities (n=6). The injury mechanisms entailed forced flexion with rotation (n=7), hyperextension with rotation (n=7, primarily in skeletally immature males [n=4]), and direct trauma (n=5, primarily in adult males [n=4]). Eight patients (60% of adults and 22% of children) had associated injuries of the knee, which commonly occurred after direct trauma. Two patients were treated in a cast or brace after closed or open reduction without fixation. Two patients underwent arthroscopic reduction and internal fixation, and 15 underwent open reduction and internal fixation (2 after failed arthroscopic reduction and 11 proceeded directly). Postoperatively, 7 patients had a positive Lachman test, but none complained of subjective instability. Ten patients had knee stiffness; all except one had been immobilised for 4 to 6 weeks. Seven patients had extension impingement; 6 of them had been treated with open reduction and internal fixation. Two patients underwent further surgery for debridement and screw removal at years 1 and 3. One patient developed arthrofibrosis and underwent arthrolysis at month 6, but knee stiffness remained. No patient underwent subsequent anterior cruciate ligament reconstruction. CONCLUSION: Tibial eminence fractures are as common in adults as in children. Female skiers are at higher risk. Stiffness is a more common complication than laxity. Early range-of-motion exercise may reduce stiffness and extension impingement.

Leading wound care technology: The ARANZ medical silhouette.

Despite major advances in medical technology and wound care, wound assessment and documentation still rely mainly on rudimentary measures. Many practitioners continue to estimate wound size using maximal length, width, and depth measurements with rulers and probes. Others use acetate tracings or equivalent measures to outline the wound onto a grid to estimate surface area and document wound border changes. Even fewer practitioners seem to routinely photograph wounds with an included scale for more visual records. This article presents a recently developed device that is changing clinical documentation, assessment, auditing, and interservice communication-the ARANZ Medical Silhouette (ARANZ Medical Limited, Christchurch, New Zealand).