Management of combined atlas and axis fractures: a systematic review.

Background: Combined atlas-axis fractures are rare occurrences with substantially higher rates of neurologic deficits compared with isolated injuries. Given the intricate anatomic relationship between the atlas and axis vertebra, variable fracture patterns may occur, warranting special considerations from surgeons. Methods: A systematic search of PubMed and EMBASE was performed following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Relevant studies on acute combined atlas-axis fractures that provided data on patient demographics, presentation (injury mechanism, neurologic deficits, fracture type), management, complications, and study conclusions were reviewed. Results: A total of 22 articles published from 1977 to 2022, comprising 230 patients, were included in the final analysis. Thirty-seven of the 213 patients (17%) presented with neurologic deficits. The most common atlas injuries were posterior arch fractures (54/169 patients; 32%), combined posterior arch/anterior arch fractures (44/169 patients; 26%), and anterior arch fractures (43/169 patients; 25%). The most common axis injuries were type II odontoid fractures (115/175 patients; 66%). Of the 127 patients managed operatively (127/230 patients; 55%), 45 patients (35%) were treated with C1-C2 posterior spinal fusion, 33 patients (26%) were treated with odontoid screw fixation and anterior/posterior C1-C2 trans-articular screws, 16 patients (13%) were treated with occiputocervical fusion and 12 patients (9%) were treated with odontoid screw fixation alone. Conclusions: Management strategies are generally based on the type of axis fracture as well as the condition of the transverse ligament. Patients with stable fractures can be successfully managed nonoperatively with a cervical collar or halo immobilization. Combined atlas-axis fractures with an atlantodental interval >5 mm, C1 lateral mass displacement >7 mm, C2-C3 angulation >11° or an MRI demonstrating a disrupted transverse ligament are suggestive of instability and are often successfully managed with surgical intervention. There is no consensus regarding surgical technique.

The impact of the Florida law HB21 on opioid prescribing patterns after spine surgery.

Background: The opioid epidemic represents a major public health issue in the United States and has led to significant morbidity and mortality. On July 1 2018, Florida implemented state-law House Bill 21 (HB21), limiting opioid prescriptions to a 3-day supply for acute pain or 7 days if an exception is documented. The purpose of this study is to evaluate the effects of HB21 on opioid prescribing patterns after spine surgery. Methods: Patients 18 years and older who underwent spine surgery between January 2017 and January 2021 were eligible for inclusion. Information including demographics, pills, days, and morphine milligram equivalents (MMEs) was obtained via retrospective chart review using the Florida Prescription Drug Monitoring Program and Epic Chart Review. Student's t tests and Fisher's exact tests were used for comparison of continuous variables. Multiple logistic regression was utilized to determine which variables were associated with postoperative opioid prescriptions. p<.05 was considered significant. Results: We reviewed 114 patients who underwent spine surgery from January 2017 to July 2018 and 264 patients from July 2018 to January 21. There were no significant differences between the groups in age, sex, ethnicity, body mass index, number of levels fused, or preoperative opioid use. The average number of MMEs, pills prescribed and days in the first postoperative prescription decreased significantly after HB21. Multiple logistic regression revealed that the variable most predictive of MMEs and number of pills in the first postoperative prescription was postlaw status (p=.002, p=.50). Conclusions: Florida law HB21 was successful in decreasing postoperative opioid prescriptions after spine surgery, however, the need for additional progress remains. Legislation should be combined with multimodal pain regimens, as well as patient and provider education in order to further decrease postoperative opioid requirements. Future studies should include a larger number of patients treated by multiple spine surgeons across multiple institutions in order to further evaluate the effects of HB21 on postoperative opioid prescriptions.

YouTube as an Information Source for Lumbar Disc Herniations: A Systematic Review.

OBJECTIVE: The Internet is a source of health information for patients. Quality of information available to patients is varied and uncontrolled. Physicians should be familiar with the overall quality of the information. This review provides an evaluation of YouTube's current patient accessible health information on the topic of lumbar disc herniation (LDH). METHODS: YouTube was queried using 3 different search strings: (1) "disc herniation", (2) "lumbar disc herniation", or (3) "lower back disc herniation". Video duplicates, non-English, or those that contained no audio or were not relevant to LDH were excluded. The first 50 videos per search string were evaluated. Two reviewers independently assessed videos. Parameters included duration, upload date, number of views, number of likes, views per day, and likes per day. A scoring system was used to grade the videos for their performance on diagnosis and treatment of LDH. RESULTS: The first 50 videos produced a total number of hits of 50,500, 29,100, and 22,100, respectively. Strong agreement, assessed using intraclass correlation coefficient (ICC), was demonstrated between readers for both diagnostic scores (ICC 0.921, 95% CI 0.866-0.953) and treatment scores (ICC 0.916, 95% CI 0.855-0.951). Educational Physician videos had significantly greater diagnostic and treatment scores compared to non-physician videos (9.54 vs. 7.05, P = 0.048, and 6.53 vs. 5.3, P = 0.004). CONCLUSIONS: YouTube videos pertaining to LDH were found to have low overall quality. Physicians should be cognizant about information sources readily available to patients as they may influence patient expectations and preconceptions.

Perioperative management of acetabular and pelvic fractures: evidence-based recommendations.

PURPOSE: The American Academy of Orthopaedic Surgeons does not currently provide clinical practice guidelines for management of PAF. Accordingly, this article aims to review and consolidate the relevant historical and recent literature in important topics pertaining to perioperative management of PAF. METHODS: A thorough literature review using PubMed, Cochrane and Embase databases was performed to assess preoperative, intraoperative and postoperative management of PAF fracture. Topics reviewed included: time from injury to definitive fixation, the role of inferior vena cava filters (IVCF), tranexamic acid (TXA) use, intraopoperative cell salvage, incisional negative pressure wound therapy (NPWT), intraoperative antibiotic powder use, heterotopic ossification prophylaxis, and pre- and postoperative venous thromboembolism (VTE) prophylaxis. RESULTS: A total of 126 articles pertaining to the preoperative, intraoperative and postoperative management of PAF were reviewed. Articles reviewed by topic include 13 articles pertaining to time to fixation, 23 on IVCF use, 14 on VTE prophylaxis, 20 on TXA use, 10 on cell salvage, 10 on iNPWT 14 on intraoperative antibiotic powder and 20 on HO prophylaxis. An additional eight articles were reviewed to describe background information. Five articles provided information for two or more treatment modalities and were therefore included in multiple categories when tabulating the number of articles reviewed per topic. CONCLUSION: The literature supports the use of radiation therapy for HO prophylaxis, early (< 5 days from injury) surgical intervention and the routine use of intraoperative TXA. The literature does not support the routine use of iNPWT or IVCF. There is inadequate information to make a recommendation regarding the use of cell salvage and wound infiltration with antibiotic powder. While the routine use of chemical VTE prophylaxis is recommended, there is insufficient evidence to recommend the optimal agent and duration of therapy.

Spondylolysis and Isthmic Spondylolisthesis: A Guide to Diagnosis and Management.

INTRODUCTION: Spondylolysis and isthmic spondylolisthesis are commonly implicated as organic causes of low back pain in this population. Many patients involved in sports that require repetitive hyperextension of the lumbar spine like diving, weightlifting, gymnastics and wrestling develop spondylolysis and isthmic spondylolisthesis. While patients are typically asymptomatic in mild forms, the hallmark of symptoms in more advanced disease include low back pain, radiculopathy, postural changes and rarely, neurologic deficits. METHODS: We conducted a narrative review of the literature on the clinical presentation, diagnosis, prognosis and management of spondylolysis and isthmic spondylolisthesis. RESULTS: A comprehensive physical exam and subsequent imaging including radiographs, CT and MRI play a role in the diagnosis of this disease process. While the majority of patients improve with conservative management, others require operative management due to persistent symptoms. CONCLUSION: Due to the risk of disease progression, referral to a spine surgeon is recommended for any patient suspected of having these conditions. This review provides information and guidelines for practitioners to promote an actionable awareness of spondylolysis and isthmic spondylolisthesis.

Limb salvage reconstruction: Radiologic features of common reconstructive techniques and their complications.

Limb salvage surgery refers to orthopaedic procedures designed to resect tumors and reconstruct limbs. Improvements in managing malignant bone lesions have led to a dramatic shift in limb salvage procedures. Orthopaedic surgeons now employ four main reconstructive procedures: endoprosthesis, autograft, bulk allograft, and allograft prosthetic composite. While each approach has its advantages, each technique is associated with complications. Furthermore, knowledge of procedure specific imaging findings can lead to earlier complication diagnosis and improved clinical outcomes. The aim of this article is to review leading reconstructive options available for limb salvage surgery and present a case series illustrating the associated complications.

MRI appearance of the different meniscal ramp lesion types, with clinical and arthroscopic correlation.

BACKGROUND: Meniscal ramp lesions have been defined as longitudinal vertical peripheral tears of the medial meniscus involving the posterior meniscocapsular ligament, meniscotibial ligament, and/or the red-red zone of the posterior horn. They are heavily associated with anterior cruciate ligament injuries, and because of their potentially important biomechanical role in knee stabilization, injuries to this region may require surgical repair. However, due to their location and lack of general knowledge regarding their different types and associated appearances on magnetic resonance imaging, ramp lesions are routinely underreported. This is compounded by the fact that ramp lesions are also often overlooked during conventional anterior portal arthroscopy when direct visualization is not achieved. PURPOSE: To demonstrate MRI appearances and arthroscopic findings of the different types of meniscal ramp lesions, in the hopes of improving their detection on pre-operative imaging.

Proximal Tibial Reconstruction After Tumor Resection: A Systematic Review of the Literature.

BACKGROUND: The proximal part of the tibia is a common location for primary bone tumors, and many options for reconstruction exist following resection. This anatomic location has a notoriously high complication rate, and each available reconstruction method is associated with unique risks and benefits. The most commonly utilized implants are metallic endoprostheses, osteoarticular allografts, and allograft-prosthesis composites. There is a current lack of data comparing the outcomes of these reconstructive techniques in the literature. METHODS: A systematic review of peer-reviewed observational studies evaluating outcomes after proximal tibial reconstruction was conducted, including both aggregate and pooled data sets and utilizing a Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) review for quality assessment. Henderson complications, amputation rates, implant survival, and functional outcomes were evaluated. RESULTS: A total of 1,643 patients were identified from 29 studies, including 1,402 patients who underwent reconstruction with metallic endoprostheses, 183 patients who underwent reconstruction with osteoarticular allografts, and 58 patients who underwent with reconstruction with allograft-prosthesis composites. The mean follow-up times were 83.5 months (range, 37.3 to 176 months) for the metallic endoprosthesis group, 109.4 months (range, 49 to 234 months) for the osteoarticular allograft group, and 88.8 months (range, 49 to 128 months) for the allograft-prosthesis composite reconstruction group. The mean patient age per study ranged from 13.5 to 50 years. Patients with metallic endoprostheses had the lowest rates of Henderson Type-1 complications (5.1%; p < 0.001), Type-3 complications (10.3%; p < 0.001), and Type-5 complications (5.8%; p < 0.001), whereas, on aggregate data analysis, patients with an osteoarticular allograft had the lowest rates of Type-2 complications (2.1%; p < 0.001) and patients with an allograft-prosthesis composite had the lowest rates of Type-4 complications (10.2%; p < 0.001). The Musculoskeletal Tumor Society (MSTS) scores were highest in patients with an osteoarticular allograft (26.8 points; p < 0.001). Pooled data analysis showed that patients with a metallic endoprosthesis had the lowest rates of sustaining any Henderson complication (23.1%; p = 0.009) and the highest implant survival rates (92.3%), and patients with an osteoarticular allograft had the lowest implant survival rates at 10 years (60.5%; p = 0.014). CONCLUSIONS: Osteoarticular allograft appears to lead to higher rates of Henderson complications and amputation rates when compared with metallic endoprostheses. However, functional outcomes may be higher in patients with osteoarticular allograft. Further work is needed using higher-powered randomized controlled trials to definitively determine the superiority of one reconstructive option over another. In the absence of such high-powered evidence, we encourage individual surgeons to choose reconstructive options based on personal experience and expertise. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.