Treatment modality in type II odontoid fractures defines the outcome in elderly patients.

BACKGROUND: Odontoid fractures account for approximately 20% of all fractures of the cervical spine. They represent the most common cervical spine injury for patients older than 70 years, the majority being type II fractures (65-74%), which are considered to be relatively unstable. The management of these fractures is controversial. Possible treatment options are either conservative or surgical. Surgical procedures include either anterior screw fixation of the odontoid or posterior C1/C2 fusion. The aim of this study was to compare the outcome of the three treatment modalities in elderly patients. METHODS: Between June 2004 and February 2010, all patients older than 65 years (n = 47) with type II fractures of the odontoid according to the Anderson and D'Alonso classification were retrospectively reviewed. RESULTS: In the non-operatively managed cohort, 11 patients (79%) died postoperatively within a mean period of 23 months. In all other cases (n = 3), radiographs demonstrated non-union. The mean lateral displacement was 1.9 mm (range 0-5,8 mm) and a mean angulation of 29,1° (range 0-55°) was found.Anterior screw fixation was carried out in 17 patients. The non-union rate in this cohort was 77%. In patients with a posterior C1-C2 fusion, a bony fusion of the posterior elements was found in 15 of 16 cases (93%). Survival rates were significantly higher among the group of patients who were treated with anterior screw fixation or posterior C1/C2 fusion compared to the conservatively treated group. CONCLUSION: We found the best clinical results with low rates of non-union as well as low mortality rates following posterior C1/C2 fusion making this our treatment of choice especially in an elderly patient collective.

Gastrocnemius muscle herniation as a rare differential diagnosis of ankle sprain: case report and review of the literature.

BACKGROUND: Muscle herniation of the leg is a rare clinical entity. Yet, knowing this condition is necessary to avoid misdiagnosis and delayed treatment. In the extremities, muscle herniation most commonly occurs as a result of an acquired fascial defect, often due to trauma. Different treatment options for symptomatic extremity muscle herniation in the extremities, including conservative treatment, fasciotomy and mesh repair have been described. CASE PRESENTATION: We present the case of a patient who presented with prolonged symptoms after an ankle sprain. The clinical picture showed a fascial insufficiency with muscle bulging under tension. Ultrasound and MRI imaging confirmed the diagnosis of muscle hernia of the medial gastrocnemius on the right leg. Conservative treatment did not lead to success. Therefore, the fascial defect was treated surgically by repairing the muscle herniation using a synthetic vicryl propylene patch. CONCLUSIONS: Muscle hernias should be taken into consideration as a rare differential diagnosis whenever patients present with persisting pain or soft tissue swelling after ankle sprain. Diagnosis is mainly based on clinical aspect and physical examination, but can be confirmed by radiologic imaging techniques, including (dynamic) ultrasound and MRI. If conservative treatment fails, we recommend the closure with mesh patches for large fascial defects.

Correlation of psychomotor findings and the ability to partially weight bear.

BACKGROUND: Partial weight bearing is thought to avoid excessive loading that may interfere with the healing process after surgery of the pelvis or the lower extremity. The object of this study was to investigate the relationship between the ability to partially weight bear and the patient's psychomotor skills and an additional evaluation of the possibility to predict this ability with a standardized psychomotor test. METHODS: 50 patients with a prescribed partial weight bearing at a target load of 15 kg following surgery were verbally instructed by a physical therapist. After the instruction and sufficient training with the physical therapist vertical ground reaction forces using matrix insoles were measured while walking with forearm crutches. Additionally, psychomotor skills were tested with the Motorische Leistungsserie (MLS). To test for correlations Spearman's Rank correlation was used. For further comparison of the two groups a Mann-Withney test was performed using Bonferroni correction. RESULTS: The patient's age and body weight significantly correlated with the ability to partially weight bear at a 15 kg target load. There were significant correlations between several subtests of the MLS and ground reaction forces measured while walking with crutches. Patients that were able to correctly perform partial weight bearing showed significant better psychomotor skills especially for those subtests where both hands had to be coordinated simultaneously. CONCLUSIONS: The ability to partially weight bear is associated with psychomotor skills. The MLS seems to be a tool that helps predicting the ability to keep within the prescribed load limits.

Cement-augmented dorsal instrumentation of the spine as a safe adjunct to the multimodal management of metastatic pheochromocytoma: a case report.

Malignant pheochromocytoma is a neuroendocrine tumor that originates from chromaffin tissue. Although osseous metastases are common, metastatic dissemination to the spine rarely occurs.Five years after primary diagnosis of extra-adrenal, abdominal pheochromocytoma and laparoscopic extirpation, a 53-year old patient presented with recurrence of pheochromocytoma involving the spine, the pelvis, both proximal femora and the right humerus. Magnetic resonance imaging and computed tomography revealed osteolytic lesions of numerous vertebrae (T1, T5, T10, and T12). In the case of T10, total destruction of the vertebral body with involvement of the rear edge resulted in the risk of vertebral collapse and subsequent spinal stenosis. Thus, dorsal instrumentation (T8-T12) and cement augmentation of T12 was performed after perioperative alpha- and beta-adrenergic blockade with phenoxybenzamine and bisoprolol.After thorough preoperative evaluation to assess the risk for surgery and anesthesia, and appropriate perioperative management including pharmacological antihypertensive treatment, dorsal instrumentation of T8-T12 and cement augmentation of T12 prior to placing the corresponding pedicle screws did not result in hypertensive crisis or hemodynamic instability due to the release of catecholamines from metastatic lesions.To the authors' knowledge, this is the first report describing cement-augmentation in combination with dorsal instrumentation to prevent osteolytic vertebral collapse in a patient with metastatic pheochromocytoma. With appropriate preoperative measures, cement-augmented dorsal instrumentation represents a safe approach to stabilize vertebral bodies with metastatic malignant pheochromocytoma. Nevertheless, direct manipulation of metastatic lesions should be avoided as far as possible in order to minimize the risk of hemodynamic complications.

Traumatic atlantoaxial rotatory subluxation in an adolescent: a case report.

INTRODUCTION: Atlantoaxial rotatory subluxation is rarely caused by trauma in adults. Usually, the treatment of choice is traction using Halo/Gardner-Wells fixation devices for up to six weeks. CASE PRESENTATION: We present the case of a 19-year-old Caucasian woman with traumatic atlantoaxial subluxation. Early reduction three hours after trauma and immobilization using only a soft collar were performed and yielded very good clinical results. CONCLUSION: In the adult population, atlantoaxial subluxation is a rare condition but is severe if untreated. Early treatment implies a non-surgical approach and a good outcome. Conservative treatment is the recommended first step for this condition.

Is the internal rotation lag sign a sensitive test for detecting hip abductor tendon ruptures after total hip arthroplasty?

INTRODUCTION: Total hip arthroplasty (THA) is one of the most frequently performed procedures in orthopaedics and weakness of external rotators is often recognized thereafter. However, the etiology of lateral hip pain is multifaceted. For the diagnosis of abductor tendon rupture, magnetic resonance imaging (MRI) is the gold standard. As not every patient can be subjected to MRI, a clinical diagnostic test for easy detection of lesions of the abductor tendon is missing. Here, we present the internal rotation lack sign indicating abductor tendon pathology. METHODS: The patient is placed in lateral position on a stretcher with hips and knees in neutral position. The knee is flexed to 45° and the hip passively abducted and elevated by the investigator. With the foot passively abducted, the patient is then asked to bring his knee in direction to the examination table. This motion is also tested passively. The test is regarded positive, if no internal rotation is possible and/or if this is painful. If groin pain is elicited during either of the exercises, the test is also rated positive. RESULTS: We evaluated this test in 20 patients clinically and by magnetic resonance imaging (MRI). All patients demonstrated a positive internal rotation lag sign. Twelve of them lag of internal rotation and evidence of anterior abductor tendon rupture on MRI, 8 with lag of internal rotation and no evidence of abductor tendon rupture. CONCLUSION: The new clinical diagnostic sign presented here may improve the diagnosis of abductor tendon rupture in the future. LEVEL OF EVIDENCE: Diagnostic study, level I.

Treatment of femoral neck fractures in elderly patients over 60 years of age - which is the ideal modality of primary joint replacement?

BACKGROUND: Femoral neck fractures in the elderly are frequent, represent a great health care problem, and have a significant impact on health insurance costs. Reconstruction options using hip arthroplasty include unipolar or bipolar hemiarthroplasty (HA), and total hip arthroplasty (THA). The purpose of this review is to discuss the indications, limitations, and pitfalls of each of these techniques. METHODS: The Pubmed database was searched for all articles on femoral neck fracture and for the reconstruction options presented in this review using the search terms "femoral neck fracture", "unipolar hemiarthroplasty", "bipolar hemiarthroplasty", and "total hip arthroplasty". In addition, cross-referencing was used to cover articles eventually undetected by the respective search strategies. The resulting articles were then reviewed with regard to the different techniques, outcome and complications of the distinct reconstruction options. RESULTS: THA yields the best functional results in patients with displaced femoral neck fractures with complication rates comparable to HA. THA is beneficially implanted using an anterior approach exploiting the internervous plane between the tensor fasciae latae and the sartorius muscles allowing for immediate full weight-bearing. Based on our findings, bipolar hemiarthroplasty, similar to unipolar hemiarthroplasty, cannot restorate neither anatomical nor biomechanical features of the hip joint. Therefore, it can only be recommended as a second line of defense-procedure for patients with low functional demands and limited live expectancy. CONCLUSIONS: THA is the treatment of choice for femoral neck fractures in patients older than 60 years. HA should only be implanted in patients with limited life expectancy.