Does the pronator-sparing approach improve functional outcome, compared to a standard volar approach, in volar plating of distal radius fractures? A prospective, randomized controlled trial.

BACKGROUND: This study aimed to compare functional outcomes of a volar plate osteosynthesis for distal radius fractures (DRF) performed with either a standard volar approach (SVA), which required detachment of the pronator quadratus muscle, or a pronator-sparing approach (PqSA). MATERIALS AND METHODS: This prospective randomized controlled study included 106 patients scheduled for volar plate osteosyntheses. Patients were allocated to either the SVA group (n = 53) or the PqSA group (n = 53). Patients were blinded to treatment until completion of the study. The primary outcome measure was the Patient-Rated Wrist Evaluation (PRWE). Secondary outcome parameters were the Disabilities of the Arm, Shoulder, and Hand (DASH) score and the Modified Mayo Wrist Score (MMWS). Follow-up examinations were performed at 8 weeks and 3, 6, and 12 months postoperatively. RESULTS: Overall, 91 patients were included in the final analysis: 48 in the SVA group and 43 in the PqSA group. The two cohorts were not significantly different in demographic characteristics, including age, sex, injuries on the dominant side, type of injury, and fracture classification. We found significant differences between groups at 6 months in the mean PRWE (SVA: 12.3 ± 10.4, PqSA: 18.9 ± 14.11 points) and in the mean DASH score (SVA: 12.3 ± 11.9, PqSA: 19.3 ± 16.7 points), which favoured the SVA. We found no significant differences between groups in the MMWS or in the PRWE and DASH scores at any other time points. CONCLUSIONS: This randomized comparative clinical trial failed to demonstrate that a volar plate osteosynthesis performed with a PqSA could improve the outcome, compared to the SVA, in patients with DRF. LEVEL OF EVIDENCE: II Trial registration Comparison of Two Volar Plating Systems for Distal Radius Fractures, ClinicalTrials.gov (NCT03474445), registered 22 March 2018, retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03474445?cond=radius&cntry=AT&draw=2&rank=1.

Standard radiographic assessments of distal radius fractures miss involvement of the distal radioulnar joint: a diagnostic study.

INTRODUCTION: Distal radius fractures account for one-fifth of all fractures in the emergency department. Their classification based on standard radiographs is common practice although low inter-observer reliabilities and superiority of computer tomography (CT) scanning in evaluation of joint congruency have been reported. MATERIALS AND METHODS: We retrospectively analyzed 96 displaced distal radius fractures scheduled for open reduction and internal fixation using standard radiographic assessment. The radiographs were classified with the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA), Fernandez and Frykman classifications by three observers and inter-rater reliabilities were calculated. Additional CT scanning was performed in all cases and the following parameters were assessed: radiocarpal joint involvement, fracture extent into the radial sigmoid notch, i.e. the distal radio-ulnar joint, comminution of the metaphysis, and concomitant ulnar styloid fracture. The CT scans were used as a reference standard to determine sensitivity and accuracy of standard radiographic assessment in evaluation of distal radius fractures. RESULTS: The inter-rater agreement for the AO classification was 35.4%, 68.8% for the Fernandez and 38.5% for the Frykman classification. Fracture extension into the radiocarpal joint was present in 81 cases (84.4%). Sigmoid notch involvement was found in 81 fractures (84.4%). Involvement of both joints was present in 72 cases (75%). The sensitivity of standard radiographs regarding radiocarpal joint involvement was 93.8%. Considering involvement of the distal radio-ulnar joint the false-negative rate using standard radiographs was 61.7% and the test's accuracy for sigmoid notch involvement was 45.8%. CONCLUSION: This study demonstrates that involvement of the sigmoid notch is frequently missed in standard radiographs. The presented data support the frequent use of CT imaging to allow the holistic illustration of a fracture's complexion and to ensure optimal pre-operative planning.

Mid- and Long-Term Outcome After Arthroscopically Assisted Transosseous Triangular Fibrocartilage Complex Refixation-Good to Excellent Results in Spite of Some Loss of Stability of the Distal Radioulnar Joint.

PURPOSE: To evaluate mid- and long-term outcomes after arthroscopically-assisted transosseous reattachment of the triangular fibrocartilage complex (TFCC) and to analyze the association of distal radioulnar joint (DRUJ) stability with the clinical outcome. METHODS: Patients treated with an arthroscopically-assisted transosseous reattachment of the deep layer of the TFCC between 2000 and 2009 and a minimum follow-up of 12 months at mid-term and 4 years at long-term follow-up were retrospectively reviewed. Mayo Modified Wrist Score (MMWS); Disabilities of the Arm, Shoulder and Hand (DASH) score; pain visual analogue scale (VAS); grip strength and stability of the DRUJ were assessed at 2 follow-up clinical examinations. At the last follow-up, the Patient-Rated Wrist Evaluation score was additionally recorded. RESULTS: Thirty patients with a mean age of 29 (±13) years were included. Most of the patients were female (70%, n = 21). The mid-term evaluation took place at a median of 30 months (range, 12-83 months). The assessed scores showed statistically significant clinical improvement (MMWS, P < .001; DASH score P < .001; VAS P < .001). Stability assessment showed a stable DRUJ in 23 (76.7%) patients. At a median of 106 months (range 52-215 months), the long-term clinical assessment was performed. The evaluated scores demonstrated persisting significant improvement (MMWS P < .001; DASH score P < .001; VAS P < .001). Stability assessment showed a stable DRUJ in 19 patients (63.3%). DRUJ instability did not correlate with clinical outcome. No permanent surgery-related complications occurred. CONCLUSION: Arthroscopically-assisted transosseous reattachment of the deep fibers of radioulnar ligaments leads to excellent and good clinical results in mid- and long-term follow-up. In 95.5% of the analyzed patients, the measured improvement in the DASH score exceeded the in literature reported minimal clinically important difference of 13.5. Loss of DRUJ stability during follow-up was not associated with deterioration of clinical parameters and patient satisfaction. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Disinfection of contaminated metal implants with an Er:YAG laser.

Infections related to orthopedic procedures are considered particularly severe when implantation materials are used, because effective treatments for biofilm removal are lacking. In this study, the relatively new approach for infection control by using an erbium:yttrium-aluminum-garnet (Er:YAG) laser was tested. This laser vaporizes all water containing cells in a very effective, precise, and predictable manner and results in only minimal thermal damage. For preliminary testing, 42 steel plates and 42 pins were seeded with mixed cultures. First, the minimally necessary laser energy for biofilm removal was determined. Subsequently, the effectiveness of biofilm removal with the Er:YAG laser and the cleansing of the metal implants with octenidine-soaked gauze was compared. Then, we compared the effectiveness of biofilm removal on 207 steel pins from 41 patients directly after explantation. Sonication and scanning electron microscopy were used for analysis. Laser fluences exceeding 2.8 J/cm2 caused a complete extinction of all living cells by a single-laser impulse. Cleansing with octenidine-soaked gauze and irradiation with the Er:YAG laser are both thoroughly effective when applied to seeded pins. In contrast, when explanted pins with fully developed biofilms were analyzed, we found a significant advantage of the laser procedure. The Er:YAG laser offers a secure, complete, and nontoxic eradication of all kinds of pathogens from metal implants without damaging the implant and without the possible development of resistance. The precise noncontact removal of adjacent tissue is a decisive advantage over conventional disinfectants. Therefore, laser irradiation could become a valuable method in every debridement, antibiotics, and implant retention procedure.

Incidence and analysis of radial head and neck fractures.

AIM: To investigate several complications like persistent radial head dislocation, forearm deformity, elbow stiffness and nerve palsies, associated with radial head fractures. METHODS: This study reviewed the clinical records and trauma database of this level I Trauma Center and identified all patients with fractures of the radial head and neck who where admitted between 2000 and 2010. An analysis of clinical records revealed 1047 patients suffering from fractures of the radial head or neck classified according to Mason. For clinical examination, range of motion, local pain and overall outcome were assessed. RESULTS: The incidence of one-sided fractures was 99.2% and for simultaneous bilateral fractures 0.8%. Non-operative treatment was performed in 90.4% (n = 947) of the cases, surgery in 9.6% (n = 100). Bony union was achieved in 99.8% (n = 1045) patients. Full satisfaction was achieved in 59% (n = 615) of the patients. A gender related significant difference (P = 0.035) in Mason type distribution-type III fractures were more prominent in male patients vs type IV fractures in female patients-was observed in our study population. CONCLUSION: Mason type I fractures can be treated safe conservatively with good results. In type II to IV surgical intervention is usually considered to be indicated.

Seymour fractures: retrospective analysis and therapeutic considerations.

PURPOSE: To analyze the management of Seymour fractures (juxta-epiphyseal fractures of the terminal phalanx of the finger in conjunction with flexion deformity at the fracture site, laceration of the nail bed, and frequently ungual subluxation) and to determine clinical and radiographic results following operative or conservative treatment. METHODS: Clinical and radiological results of 24 skeletally immature patients (7 girls and 17 boys; mean age, 8.5 y) with Seymour fractures were evaluated. Assessment after a mean follow-up of 10 years (range, 1-18 y) included the range of motion, the modified Kapandji index, growth disturbance of the effected digit and nail, pain according to the visual analog scale, and patients' satisfaction. RESULTS: Nine patients received nonoperative treatment. Operative management included debridement, open reduction, and fixation in 9. Owing to instability, an additional K-wire passing across the distal interphalangeal joint was used in 5. In 1 patient, the nail was removed. All surgically treated patients received a splint and perioperative cephalosporin. Twenty-three patients out of 24 gained full motion (mean, 80°; range, 65°-90°). The average modified Kapandji index was 5.0 for extension and 4.8 for flexion. Long-term minor growth disturbance of the distal phalanx (seen on radiographs at high amplification only) and nail were noted in 5 patients, and solitary nail dystrophies were observed in 6 patients. Nine of the 11 nail growth irregularities were not a relevant cosmetic problem for the patients. Patients' satisfaction assessment revealed a good clinical outcome. There was neither flexion deformity nor infection in our collective. At the 1-year follow-up examination, the average visual analog score was 0.6 (range, 0-2). CONCLUSIONS: According to the literature, the Seymour fracture is an often-underestimated injury, and open cases are prone to infection. Evaluation of the outcome in our collective demonstrated good results with the treatment approaches described. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Crossed pinning in paediatric supracondylar humerus fractures: a retrospective cohort analysis.

PURPOSE: The aim of this study was to analyse the management of displaced paediatric supracondylar humerus fractures at our Level I Trauma Centre and to determine clinical and radiographic long-term results following operative treatment. METHODS: Clinical and radiological results of 78 paediatric patients (29 female, 49 male; mean age 5.1 years) with supracondylar humerus fractures, treated from 1992 to 2004, were evaluated. Gartland's classification yielded 32 type II, 44 type III and further two flexion injuries. In all patients the follow-up period exceeded 12 months. Assessment after an average of 8.1 years (1.1-19.5) included neurovascular examination, Flynn's criteria (elbow function and carrying angle), pain, complications (infections, growth disturbances or iatrogenic nerve injuries) and measurement of the humeroulnar angle. RESULTS: According to Flynn's criteria 73 patients (93.5 %) had a satisfactory outcome, while five (6.4 %) were graded as unsatisfactory (two due to cubitus varus and three because of limited elbow motion). The visual analogue scale (VAS) score averaged 0 (range 0-1) and the mean carrying angle measured 8.4° (-8 to 20°), compared to 10.8° on the contralateral side (2-20°). Injury-related complications yielded absent pulses in four (5.1 %), five (6.4 %) primary median, two (2.6 %) primary radial and one (1.3 %) primary ulnar nerve injury. Treatment-related complications included a secondary displacement and one iatrogenic radial nerve palsy. Based on primary nerve lesion as a dependent variable, statistical analysis showed that age had a significant influence revealing that older paediatric patients had a significantly higher risk (p = 0.02). Functional outcome as a dependent variable revealed an indirect proportion to the clinical carrying angle, achieving statistical significance (p < 0.01). CONCLUSIONS: Crossed pinning in paediatric supracondylar humerus fractures is an effective method. Evaluation of the outcome in our study group demonstrated good results with the treatment approach described.

Incidence and analysis of simultaneous bilateral radial head and neck fractures at a level I trauma center.

BACKGROUND: Reviewing the current literature, very few reports are given on simultaneous bilateral radial head and neck fractures. There are no reports on this entity's incidence. Thus, the purpose of this study was to analyze the incidence and outcome of simultaneous bilateral radial head fractures. METHODS: This study reviewed the clinical records and trauma database of this Level I Trauma Center and identified all adult patients with fractures of the radial head or neck who were admitted between 1992 and 2007. From a database of 2,296 adult trauma victims with radial head or neck fractures, an analysis of clinical records revealed 34 patients suffering from simultaneous bilateral injuries (68 fractures) being classified according to Mason. For clinical examination, range of motion, local pain, and activities of daily living were assessed. To quantify the clinical results, the patients were asked to grade their functional outcome according to the Mayo Elbow Performance Score (MEPS). RESULTS: The incidence of simultaneous bilateral fractures was 1.48%. Nonoperative treatment was performed in 86.8% (n = 59) of the cases. Solid bony union was achieved in all patients. Full satisfaction concerning treatment was achieved in 97% of the patients. The Mayo Elbow Performance Score showed an overall functional outcome score of 97.1. DISCUSSION: Reviewing the literature, the frequency of this injury was assessed for the first time. An incidence of 1.48% of all radial head fractures was explored. Our material was representative and included 2,296 injuries covering a 15-year period.

Plate fixation of odontoid fractures without C1-C2 arthrodesis: practice of a novel surgical technique for stabilization of odontoid fractures, including the opportunity to extend the fixation to C3.

OBJECTIVE: Surgical treatment of odontoid fractures that do not allow interfragmentary fracture compression involves either posterior atlantoaxial arthrodesis or additional anterior stabilization using a plate construct. The purpose of this study was to determine the clinical and radiographic outcome after anterior plate fixation of odontoid fractures that were not suitable for anterior screw fixation. METHODS: We reviewed the clinical and radiographic records of 9 patients with an average age of 54 years at the time of surgery who had undergone anterior plate fixation of an odontoid fracture. Indications for using a plate construct were odontoid fractures with anterior oblique fracture lines, fractures with comminution or major displacement, and pathological fractures. RESULTS: Eight patients returned to their preinjury activity level and were satisfied with their treatment. One patient reported chronic pain symptoms and a notable decrease in cervical spine motion. Using the Smiley-Webster Scale to quantify their clinical outcome, we achieved an overall outcome score of 1.6. Bony fusion was achieved in all patients. Reduction or fixation failed in 2 patients. Reoperation for technical failures was not necessary in any of the patients. CONCLUSION: We had promising results using anterior plate fixation for surgical treatment of odontoid fractures that did not allow interfragmentary fracture compression. Because this method avoids the rigid fixation of the atlantoaxial joint in contrast to techniques of posterior cervical arthrodesis, it seems to be a practical option for the management of fracture types that require additional stabilization of the odontoid.

Angular stable fixation of proximal humeral fractures.

BACKGROUND: Proximal humeral fractures requiring surgical stabilization remain a therapeutic challenge. High rates of treatment-related complications have been reported to be associated, particularly in elderly patients with unstable fracture types and diminished bone quality. In recent years, angular stable implants have been introduced to improve the patients' outcome. The purpose of this study was to assess the clinical and radiographic long-term results after angular stable plate fixation of proximal humeral fractures at this Level I trauma center, with special emphasis on fracture healing, functional outcome and treatment related complications. METHODS: We retrospectively analyzed functional and radiographic results of 42 patients (average age: 57.8 years) after angular stable plate fixation of proximal humeral fractures at an average time of 3.2 (+/-0.8) years after trauma. Functional results were defined by the Constant shoulder score (CS) and the individual Constant score (CSindiv). Radiographic results were assessed by a three-view trauma series (anteroposterior, lateral, and axillary view). For operative treatment, two different angular stable implants were used. Twenty-seven patients were stabilized by a HOFER plate, fifteen patients by a Locking Proximal Humerus Plate. RESULTS: Clinical results revealed an average CS of 74.0 points and an average individual CSindiv of 79.2% points. Fourteen patients had an excellent functional outcome, eight patients a good outcome and fourteen patients had moderate functional results. Six patients (14%) had a poor outcome with less than 55% on CSindiv. Regarding the radiographic outcome, we had an overall union rate of 95% (40 of 42). Failures of reduction and fixation occurred in fourteen patients (33%), and in nine patients (21%) we had signs of a humeral head necrosis. Re-operation due to treatment-related complications was necessary in two patients (5%). Statistical analysis revealed that the fracture type and the age of the patients had a significant influence on the clinical outcome and on the incidence of treatment-related complications. CONCLUSION: With regards to fracture healing and functional outcome of the patients, we had a satisfactory outcome after angular stable plate fixation of proximal humeral fractures. However, we experienced a notably high rate of technical failures and partial humeral head necrosis. Advanced surgical skills and experiences are necessary to achieve correct anatomic reduction and implant fixation, to reduce the risk of these treatment-related complications.

Femoral shortening after surgical treatment of trochanteric fractures in nongeriatric patients.

BACKGROUND: Femoral shortening is a well-known clinical finding after surgical treatment of per- and intertrochanteric fractures. Particularly, in geriatric patients with poor bone quality and unstable fracture types, secondary compression of these fractures often leads to length inequality of the lower limbs. In younger patients with good bone quality and mobilization with delayed weight bearing, limb length shortening is expected to be a rare complication. The purpose of this study was to analyze incidence and degree of femoral shortening in patients younger than 60 years of age after fixation of different types of per- and intertrochanteric fractures. In addition, we compared the results of two different implants, which were used for operative treatment. METHODS: Ninety-five patients, younger than 60 years of age, were evaluated for femoral shortening after surgical treatment of per- and intertrochanteric fractures between 1997 and 2002. Follow-up examinations took place at an average of 3.2 years (2-5 years) after trauma. Fractures were classified by the AO/OTA system and divided into sub-types 31 A1, 31 A2, and 31 A3. Two different implants (dynamic hip screw and cephalomedullary nail) were used for operative treatment, mainly depending on type and stability of the fracture. Femoral shortening was analyzed by standardized lower extremity radiographs measuring the distance from the top of the femoral head to the center of a line drawn between the most distal part of the medial and lateral femoral condyles. RESULTS: Fifty-seven patients were treated by a cephalomedullary nail, 38 by dynamic hip screw. Femoral shortening was seen in 46 patients (48%) with a mean value of 11 mm. Twenty-two patients had a femoral inequality of less than 10 mm, 17 patients an inequality between 10 mm and 20 mm, and 7 patients a shortening of more than 20 mm. Statistical analysis revealed that fracture type and implant had a significant influence on the shortening: In patients with fracture types 31 A2 and A3 femoral shortening was found to be more severe than in patients with fracture type 31 A1. Additionally, in unstable fracture types (31 A2 and A3) femoral shortening was significantly larger, if patients were treated by dynamic hip screw than by a cephalomedullary nail. CONCLUSION: Femoral shortening after operative treatment of per- and intertrochanteric fractures was found to be a common clinical finding in nongeriatric patients. Nearly half of them showed a lower limb length inequality after fracture fixation. The degree of the shortening was rather low and depended mainly on the fracture type. Comparing the two different implants used for operative treatment, a cephalomedullary nail was more successful in preventing limb length discrepancy in unstable fracture types than dynamic hip screw.

Posterior atlanto-axial arthrodesis for fixation of odontoid nonunions.

STUDY DESIGN: A retrospective case series. OBJECTIVE: To determine the clinical and radiographic long-term results after posterior atlanto-axial arthrodesis of odontoid nonunions. SUMMARY OF BACKGROUND DATA: Nonunion of odontoid fractures is a relatively common and dreaded complication after surgical and nonoperative treatment of these injuries. Although there might be a significant rate, which require surgical stabilization due to atlanto-axial instability, only few publications have covered this issue and presented reliable long-term results. METHODS: We retrospectively analyzed the clinical and radiographic records of 9 (4 women and 5 men) patients with an average age of 68 (42-78) years at the time of injury who had undergone posterior atlanto-axial arthrodesis for surgical treatment of odontoid nonunions between 1988 and 2004. For posterior atlanto-axial arthrodesis, we performed either C1-C2 transarticular screw fixation, or posterior wiring and bone grafting, or a combination of these 2 techniques. RESULTS: Eight patients achieved a satisfactory clinical outcome and returned to their preinjury activity level. The Smiley-Webster scale showed an overall functional outcome score of 2.2, which was 0.9 points superior to the outcome score before surgery. Neurologic deficits after operative treatment of the odontoid nonunion were evaluated in 2 patients. In all the other patients with primary neurologic deficits or delayed neurologic sequelae we saw a full recovery. Solid bony fusion of the cervical arthrodesis was achieved in all of the patients. Failures of reduction or fixation were noted in 2 patients, but no reoperations were necessary. CONCLUSION: In summary, we had a satisfactory outcome after surgical treatment of odontoid nonunions in patients with atlanto-axial instability and severe motion pain at the cervical spine. With a bony union rate of 100% and a noticeable improvement of clinical results and neurologic function, posterior atlanto-axial arthrodesis seems to be an appropriate option for nonunited odontoid fractures that require surgical stabilization.

Displaced fractures of the greater tuberosity: a comparison of operative and nonoperative treatment.

BACKGROUND: Displaced two-part fractures of the greater tuberosity requiring surgical intervention are rare and the literature gives only few data of functional results after operative treatment. The purpose of this study was to analyze functional and radiographic long-term results in patients who had undergone surgical treatment of displaced greater tuberosity fractures and to compare those results with the results of patients who had been treated nonoperatively. MATERIAL: From a prospectively gathered database, we retrospectively analyzed functional and radiographic results of 52 patients with operative treatment of displaced greater tuberosity fractures at an average time of 5.5 years (range, 2-11 years) after trauma. Those results were compared with the functional and radiographic outcome of nine patients with equal injuries, who had been treated nonoperatively. Functional results were defined by three supplementary shoulder scores: the Vienna Shoulder Score (VSS), the Constant Score (CS), and the University of California, Los Angeles (UCLA)-Score. Radiographic results were assessed based on accurate radiographs in two planes (anteroposterior and axillary). Patients underwent either open reduction and internal fixation (n = 30) or closed reduction and percutaneous internal fixation (n = 22). RESULTS: Thirty-four patients (65%) achieved good functional results (CS >80 points, VSS <8 points, UCLA >28 points) and eight patients (15%) had excellent results with a maximum of points on two of three shoulder scores. Ten patients (20%) experienced satisfactory results with two-thirds points on two of three shoulder scores. All fractures healed without any signs of nonunion or relevant loss of reduction. In nine patients (17%) we had a minimal loss of reduction (<5 mm) to superior, but there was no significant influence on shoulder function. In comparison of the operative techniques, patients with open reduction and internal fixation had slightly better functional results than did those with closed reduction and percutaneous internal fixation, but this was statistically not significant (p > 0.05). In comparison of the results of the surgical study group and the nonoperative control group, patients with reduction and fixation of greater tuberosity fractures had significantly better results on shoulder function than did those with conservative treatment (p < 0.05). CONCLUSION: Surgical treatment of displaced greater tuberosity fractures revealed good functional and radiographic results. Reduction and fixation of those fractures is recommended because patients with nonoperative treatment showed significantly worse results. Similar results can be achieved for open reduction and internal fixation, or closed reduction and percutaneous fixation.

Nonoperative management of odontoid fractures using a halothoracic vest.

OBJECTIVE: Despite various reports in the literature, the appropriate treatment of Type II odontoid fractures remains controversial. Although there is an increasing tendency toward surgical treatment of these fractures in recent years, nonoperative treatment strategies are still regarded as a practicable method, particularly in elderly patients with significant comorbidities. One purpose of this study was to determine the functional and radiographic long-term results after rigid immobilization of Type II odontoid fractures using a halothoracic vest. The second aim was to present a case-control series of patients with nonunion of Type II odontoid fractures compared with patients with successful fracture healing to determine specific risk factors for failure of halo immobilization. METHODS: We reviewed the clinical and radiographic records of 90 patients with an average age of 69 years at the time of injury who had undergone nonoperative treatment of odontoid fractures using a halothoracic vest between 1988 and 2004. To identify potential risk factors for failure of halo fixation, patients were divided into "cases" and "controls." Cases were defined as patients with nonfusion after halo immobilization, and controls were patients with successful fracture healing attained with this treatment option. RESULTS: Seventy-five patients returned to their preinjury activity level and were satisfied with their treatment. The Smiley-Webster scale showed an overall functional outcome score of 1.64. Successful fracture healing was achieved in 76 patients (84%). In 14 patients, nonunion was diagnosed by standard x-rays and additional computed tomographic scans within 6 to 12 months after trauma. Referring to possible risk factors for failure of halo fixation, nonunion was found significantly more often in older patients and in those with displaced fractures of the odontoid. Secondary loss of reduction and delay of treatment were identified as further risk factors for nonfusion. CONCLUSION: With regard to successful fracture healing and functional results of the patients, we had a satisfactory outcome after halo fixation of Type II odontoid fractures. Although a fusion rate of 84% should not be deemed as optimal, nonoperative management of these fractures using a halothoracic vest seems to be an appropriate treatment strategy in patients who are not suitable for surgical treatment.

Surgical treatment of dens fractures in elderly patients.

BACKGROUND: A dens fracture is the most common cervical fracture in elderly patients. The purposes of this study were to analyze the functional and radiographic results after surgical treatment of dens fractures in patients over sixty-five years of age and to compare the two methods that were used for operative treatment. METHODS: We reviewed the cases of fifty-six patients, with an average age of 71.4 years at the time of surgery, who had undergone surgical treatment of a dens fracture from 1988 to 2002. Thirty-seven fractures were stabilized with anterior screw fixation, and nineteen fractures had posterior cervical arthrodesis. RESULTS: Forty-five patients returned to their preinjury activity level and were satisfied with their treatment. Thirty-five patients had a full range of neck movement, and forty-seven patients were free of pain. Technical failures occurred in eight patients. The thirty-seven patients treated with anterior screw fixation had a good clinical outcome, with fracture-healing in thirty-three patients (89%) and technical failure in five patients (14%). All nineteen patients treated with posterior cervical arthrodesis had fracture union, with technical failure in three patients, but the functional results were worse than those after anterior screw fixation. With the inclusion of the six patients who had been excluded from the clinical and radiographic review, the overall morbidity rate was 16% (ten of sixty-two patients) and the overall mortality rate was 6% (four of sixty-two patients). CONCLUSIONS: A satisfactory outcome can be achieved with surgical treatment of a dens fracture in geriatric patients. It appears that anterior screw fixation may maintain better mobility of the cervical spine, but it appears to be associated with a higher rate of fracture nonunion and a greater potential for reoperation.

Anterior screw fixation of odontoid fractures comparing younger and elderly patients.

STUDY DESIGN: A retrospective, comparative study. SUMMARY OF BACKGROUND DATA AND OBJECTIVES: Anterior screw fixation has become an accomplished treatment option for the management of odontoid fractures. In younger patients, it has shown encouraging results with low complication rates; whereas in geriatric trauma victims, it remains the subject of controversy. The purpose of this study was to determine functional and radiographic results after anterior screw fixation of Type II odontoid fractures, with the particular interest to compare the outcome between younger and elderly patients. MATERIAL/METHODS: We reviewed clinical and radiographic records of 110 patients with an average age of 54 years at the time of surgery after anterior double screw fixation of their odontoid fractures between 1990 and 2004. To compare functional and radiographic results between nongeriatric and geriatric patients, they were divided by age into 2 groups: Group A included patients 65 years of age or younger and Group B contained patients older than 65 years. RESULTS: A total of 95 patients had returned to their preinjury activity level and were satisfied with their treatment. The Smiley-Webster scale showed an overall outcome score of 1.42 with similar results in both groups (Group A, 1.34; Group B, 1.50). Bony fusion was achieved in 102 patients, failures of reduction or fixation occurred in 12 patients. Comparing between the 2 groups, we had a nonunion rate of 4% in younger individuals and a significantly higher rate of 12% in geriatric patients. Reoperation due to nonunion or technical failures was necessary in 8 patients. CONCLUSION: We had encouraging results using anterior screw fixation for surgical treatment of odontoid fractures and favor this method as preferred management strategy for stabilization of these fractures. Comparing between age groups, we had similar results on cervical spine function. With regards to fracture healing as well as morbidity and mortality, younger patients had a superior outcome.

Cervical spine injuries in pediatric patients.

BACKGROUND: Cervical spine injuries are uncommon in pediatric trauma patients. Previous studies were often limited by the small numbers of patients available for evaluation. The aim of this study was to determine the incidence and characteristics of pediatric cervical spine injuries at this Level 1 trauma center and to review the authors' experiences with documented cases. METHODS: This study retrospectively analyzed the clinical records of all pediatric trauma patients with skeletal and/or nonskeletal injuries of the spine that were admitted to this Level 1 trauma center between 1980 and 2004. Those with significant injuries of the cervical spine were identified and included in this study. Pediatric patients were defined as patients younger than the age of 17 years. In addition, they were stratified by age into two study groups: group A included patients aged 8 years or fewer and group B contained patients from the ages of 9 to 16 years. RESULTS: We found 56 pediatric patients with injuries of the cervical spine that met criteria for inclusion. Thirty-one female and 25 male patients with an average age of 8.9 years (range, 1-16 years) sustained significant skeletal and/or nonskeletal injuries of the cervical spine and were entered in this study. Thirty patients (54%) were aged 8 years or fewer and entered into study group A, whereas 26 patients (46%) from the ages of 9 to 16 met criteria for inclusion in study group B. An analysis of data revealed that younger patients (group A) showed significantly more injuries of the upper cervical spine, whereas older children (group B) sustained significantly more injuries of the lower level. Spinal cord injuries without radiographic findings were only found in study group A. In addition, younger children were more likely injured by motor vehicle crashes, whereas older children more commonly sustained C-spine injuries during sports activities. Two-thirds of our patients showed neurologic deficits, and the overall mortality was 28%. CONCLUSION: The results of our study were similar to several previous reports, underscoring a low incidence (1.2%) and age-related characteristics. Younger children had a predilection for injuries of the upper cervical spine, whereas children in the older age group sustained significantly more injuries of the lower cervical spine. Spinal cord injuries without radiographic abnormalities were only seen in the younger age group. Despite the low incidence of cervical spine injuries in pediatric patients, increased efforts at prevention are demanded because mortality rate (27%) and incidence of neurologic deficits (66%) were dreadfully high in our series.

Thromboembolic complications after spinal surgery in trauma patients.

BACKGROUND: Deep venous thrombosis (DVT) and pulmonary embolism (PE) may be significant complications following spinal surgery. The incidence rate ranges from 0.5% to 2.5% in patients with symptomatic thromboembolic disease and up to 15% in patients with non-symptomatic thrombotic complications. We determined the incidence of symptomatic thromboembolism after spinal surgery in patients with postoperative systemic prophylaxis and investigated general and specific risk factors for development of this disease. PATIENTS AND METHODS: We analyzed the clinical records of 978 patients who had undergone surgery of the spine because of trauma and who had been admitted to our level-I trauma center between 1980 and 2004. Spinal procedures included anterior and/or posterior spinal fusion, video-assisted thoracoscopic fusion, and spinal decompression. Symptomatic thromboembolic disease was diagnosed when patients showed significant clinical signs or symptoms of DVT or PE. In cases of DVT, diagnosis was confirmed by duplex scan of the lower limbs; in cases of PE, diagnosis was confirmed by CT-scanning of the thorax or at post mortem. RESULTS: The incidence rate of symptomatic thromboembolic complications was 2.2% (n 22). 17 patients showed clinical signs of deep venous thrombosis, with 4 of them developing pulmonary embolism subsequently. The other 5 patients developed pulmonary embolism without prior clinical signs of deep venous thrombosis. 6 patients died because of thromboembolic disease. Thromboembolic complications were more frequent in older patients and among males, as well as in patients with regular tobacco consumption and obesity. Thromboembolic complications were also seen more frequently in patients with surgical procedures at the lumbar spine, in patients with anterior spinal fusion, and in those with motor deficits in the lower extremities. INTERPRETATION: We found a rather low rate of clinically significant thromboembolic complications after spinal surgery because of trauma, compared to the results reported in the literature. Level of spinal surgery, surgical approach, and motor deficits in the lower extremities were identified as specific risk factors for DVT or PE. Age, sex, obesity and regular smoking were identified as general risk factors.

Clearing the cervical spine in critically injured patients: a comprehensive C-spine protocol to avoid unnecessary delays in diagnosis.

Clearing the cervical spine in polytrauma patients still presents a challenge to the trauma team. The risk of an overlooked cervical spine injury is substantial since these patients show painful and life-threatening injuries to one or more organ systems so that clinical examination is usually not reliable. A generally approved guideline to assess the cervical spine in polytrauma patients might significantly reduce delays in diagnosis, but a consistent protocol for evaluating the cervical spine has not been uniformly accepted or followed by clinicians. One purpose of this study was to analyse the common methods for cervical spine evaluation in critically injured patients and its safety and efficacy at this trauma centre. The second purpose was to present a comprehensive diagnostic C-spine protocol, based on the authors' experiences with documented cases. From a prospectively gathered polytrauma database, we retrospectively analysed the clinical records of all polytrauma patients, with skeletal and/or non-skeletal cervical spine injuries, who were admitted to this level I trauma centre between 1980 and 2004. All patients were assessed following the trauma algorithm of our unit (modified by Nast-Kolb). Standard radiological evaluation of the cervical spine consisted of either a single lateral view or a three-view cervical spine series (anteroposterior, lateral, odontoid). Further radiological examinations (functional flexion/extension views, oblique views, CT scan, MRI) were carried out for clinical suspicion of an injury or when indicated by the standard radiographs. Sixteen patients (14%) had a single cross-table lateral view for radiological assessment of the cervical spine during initial trauma evaluation, Twenty-nine patients had a three-view cervical spine series (anteroposterior, lateral, odontoid) and 81 patients underwent extended radiological examinations by cervical CT scan (n=52), functional flexion/extension views (n=26) or MRI (n=3). Correct diagnosis was made in 107 patients (91%) during primary trauma evaluation, whereas in 11 patients (9%) our approach to clear the cervical spine failed to detect significant cervical spine injuries. In six patients skeletal injuries were missed by a single lateral view and in two patients by a three-view standard series because inadequate radiographs with poor technical quality or incomplete visualization of the cervical spine did not show the extent of the injury. In three cases ligamentous injuries were missed despite complete sets of standard radiographs and cervical CT scan, but without functional radiography. Common methods for cervical spine evaluation in critically injured patients were plain radiographs, cervical CT scan and functional flexion/extension views. Cervical CT scan was the most efficient imaging tool in detecting skeletal injuries, showing a sensitivity of 100%. A single cross-table lateral view appeared to be insufficient, as we found a sensitivity of only 63%. Functional radiography or MRI was also necessary, as plain radiographs and CT scan failed to detect significant ligamentous injuries in 6% of the patients. For more comprehensive assessment of the C-spine, we presented a new C-spine protocol based on the authors' experiences, with the aim to avoid unnecessary delays in diagnosis.