Anatomical considerations of C2 lamina for the placement of translaminar screw: a review of the literature.

PURPOSE: The thorough knowledge of C2 lamina anatomy is essential for the avoidance of complications during screw fixation. We performed a review of the literature, aiming to detect what was found about anatomical feasibility of C2 translaminar fixation in different populations, along with possible recommendations for the avoidance of complications, and to detect whether factors such as race or gender could influence axis lamina anatomy and fixation feasibility. METHODS: We performed a search in PubMed and Cochrane database of systematic reviews for studies which correlated axis lamina anatomy with fixation feasibility. We extracted data concerning measurements on C2 lamina, the methods and conclusions of the studies. RESULTS: Twenty-six studies met our inclusion criteria. The studies mainly focused on Asian populations. Male gender was generally related to larger anatomical parameters of C2 lamina. The use of a C2 translaminar screw with a diameter of 3.5 mm was generally feasible, even in children, but there was disagreement about risk of vertebral artery injury. Computed tomography was most frequently recommended preoperatively. Three-dimensional reconstruction was suggested by some authors. CONCLUSION: C2 lamina anatomy generally permitted screw fixation in most studies, but there was disagreement about risk of vertebral artery injury. Preoperative computed tomography was generally recommended, while, according to some authors, three-dimensional reconstruction could be essential. However, there is a relative lack of studies about non-Asian populations. More research could further illustrate the anatomy of C2 lamina, clarify the safety of axis fixation for more populations and perhaps modify preoperative imaging protocols.

Morphometric analysis of the odontoid process: using computed tomography--in the Greek population.

AIM: A morphometric analysis of the odontoid process of the A2 vertebra, in the Greek population, was conducted using CT scan. We aimed to determine the feasibility to use one or two screws when treating fractures of this anatomic element. PATIENTS AND METHODS: One hundred and fifteen patients (57 men) of a mean age of 48 years (16-95 years) underwent a cervical spine CT scan examination. The anterior-posterior and transverse diameters of the odontoid process were measured from the base, at 1-mm interval upward on axial CT images. The length from the tip of the odontoid process to the anterior-inferior angle of the body of the axis was calculated. Data concerning the height and weight of the examined patients were collected. RESULTS: The mean transverse and anterior-posterior distances were found to be 11.46 and 10.45 mm, respectively, for the upper end of the odontoid process. At the neck level of the odontoid process, the equivalent mean values were 11.12 and 8.73 mm, respectively, while at the base, these distances were found to be 13.84 and 12.3 mm, respectively. The mean distance from the tip of the odontoid to its base was 17.25 and 17.28 mm, respectively, while the mean distance from the tip of the dens to the anterior-inferior corner of the axis' body was 39.2 mm. Men showed greater values than women. CONCLUSIONS: In this study, it was shown that in the Greek population there is enough room for one 4.5-mm or one 3.5-mm cannulated screw to be used. The application of two 3.5-mm screws is feasible in 58.6 % of the male and 26.3 % of the female population. This confirms that the knowledge of the true dimensions of the odontoid process is of paramount importance before the proper management of fractured dens using the anterior screw technique.

Patient radiation doses in various fluoroscopically guided orthopaedic procedures.

All orthopaedic fluoroscopic procedures performed using C-arm guidance were monitored for 1 y. The type of procedure, fluoroscopy time (T), kerma-area product (KAP) values and number of radiographs (F) were recorded. The two most often performed techniques were as follows: intramedullary nailing (IMN) of intertrochanteric/peritrochanteric (IP) fractures (101 cases, 49.3 %) and antergrade IMN of femur or tibia shaft (TS) fractures (28 cases, 13.7 %). For the remaining procedures, none accounted for >5 %, categorised as 'various' (76 cases, 37 %). Large variations in T, KAP and F were observed. For IMN of IP fractures, antergrade IMN of femur and TS fractures and for various procedures, respectively, median values were T--2.1, 2.2 and 0.6 min, KAP--6.3, 6.3 and 0.6 Gy cm(-2) and F--21, 2.2 and 6.7. The patient doses during fluoroscopically guided procedures are relatively low compared with other interventional procedures.

Successful treatment of congenital pseudarthrosis of the tibia: still a challenge.

The congenital pseudarthrosis of the tibia (CPT) is one of the most challenging problems in pediatric orthopedics. The primary treatment goals are outlined as osteosynthesis, stabilization of the ankle mortise by fibular stabilization and lower-limb-length equalization. Despite the fact that each of the aforementioned goals is difficult to be achieved regardless the surgical option, the main biological consideration is the same: pseudarthrosis resection, biological bone bridging of the defect by stable fixation and the correction of any angular deformity. The external fixation method is suggested as valuable treatment of CPT because it can address not only pseudarthrosis but also all complex deformities associated with this condition. However, treatment of CPT is impaired with complications due to the complex nature of the disease thus failure is common. The most common of these are refracture, growth disturbance, poor foot and ankle function with stiffness. Of these, refracture is the most common and serious complication after primary healing and might result in the reestablishment of pseudarthrosis. Therefore, an effective, safe and practical treatment method that minimizes the residual challenges after healing and accomplishes the multiple goals of treatment is needed. In this article, we report a patient with CPT treated successfully with external fixation. Level of evidence IV retrospective.

The anatomy of the ACL and its importance in ACL reconstruction.

The anterior cruciate ligament (ACL) anatomy is very significant if a reconstruction is attempted after its rupture. An anatomic study should have to address, its biomechanical properties, its kinematics, its position and anatomic correlation and its functional properties. In this review, an attempt is made to summarize the most recent and authoritative tendencies as far as the anatomy of the ACL, and its surgical application in its reconstruction are concerned. Also, it is significant to take into account the anatomy as far as the rehabilitation protocol is concerned. Separate placement in the femoral side is known to give better results from transtibial approach. The medial tibial eminence and the intermeniscal ligament may be used as landmarks to guide the correct tunnel placement in anatomic ACL reconstruction. The anatomic centrum of the ACL femoral footprint is 43 % of the proximal-to-distal length of lateral, femoral intercondylar notch wall and femoral socket radius plus 2.5 mm anterior to the posterior articular margin. Some important factors affecting the surgical outcome of ACL reconstruction include graft selection, tunnel placement, initial graft tension, graft fixation, graft tunnel motion and healing. The rehabilitation protocol should come in phases in order to increase range of motion, muscle strength and leg balance, it should protect the graft and weightbearing should come in stages. The cornerstones of such a protocol remain bracing, controlling edema, pain and range of motion. This should be useful and valuable information in achieving full range of motion and stability of the knee postoperatively. In the end, all these advancements will contribute to better patient outcome. Recommendations point toward further experimental work with in vivo and in vitro studies, in order to assist in the development of new surgical procedures that could possibly replicate more closely the natural ACL anatomy and prevent future knee pathology.

Comparative study of internal and hybrid external fixation in tibial condylar fractures.

BACKGROUND: The spectrum of injuries to the tibial plateau is so great that no single method of treatment has been proven to be uniformly successful. The purposes of this study were to evaluate the clinical results, to identify the advantages and disadvantages and to take out useful conclusions of the application of the internal and hybrid external fixation in the treatment of these fractures. METHOD: Sixty tibial condylar fractures, of all types, according to Schatzker's classification were treated with open reduction and internal fixation (30 patients) or with hybrid external fixation (30 patients). The following parameters were recorded: time of surgical procedure, time of postoperative hospitalization, time of starting of weight bearing on the affected extremity, complications, and postoperative functional (according to Knee Society Score) and radiological results (according to Rasmussen's Radiological Score). The average time of follow-up was 12 months. RESULTS: Neither of the two methods showed superiority regarding the duration of the surgical procedure [mean difference 4.4 ± 5.4 (min), P = NS], the postoperative hospitalization time [0.6 ± 0.7 (days), P = NS], and the radiological and functional evaluation (χ(2), P = NS for all comparisons). However, the internal fixation method proved to be superior to the hybrid external fixation regarding the time of starting the weight bearing [3.1 ± 0.4 (weeks), P < 0.001]. CONCLUSION: Internal fixation showed superiority to the time starting of weight bearing as it occurred at an earlier time than that of hybrid external by almost 3 weeks whereas no other differences were identified in the other parameters regarding patients' rehabilitation.

Computerized tomographic morphometric analysis of the cervical spine.

BACKGROUND: Detailed knowledge of cervical canal and transverse foramens' morphometry is critical for understanding the pathology of certain diseases and for proper preoperative planning. Lateral x-rays do not provide the necessary accuracy. A retrospective morphometric study of the cervical canal was performed at the authors' institution to measure mean dimensions of sagittal canal diameter (SCD), right and left transverse foramens' sagittal (SFD) and transverse (TFD) diameters and minimum distance between spinal canal and transverse foramens (dSC-TF) for each level of the cervical spine from C1-C7, using computerized tomographic scans, in 100 patients from the archives of the Emergency Room. RESULTS: Significant differences for SCD were detected between C1 and the other levels of the cervical spine for both male and female patients. For the transverse foramen, significant differences in sagittal diameters were detected at C3, C4, C5 levels. For transverse diameters, significant differences at C3 and C4 levels. A significant difference of the distance between the transverse spinal foramen and the cervical canal was measured between left and right side at the level of C3. This difference was equally observed to male and female subjects. CONCLUSION: CT scan can replace older conventional radiography techniques by providing more accurate measurements on anatomical elements of the cervical spine that could facilitate diagnosis and preoperative planning, thus avoiding possible trauma to the vertebral arteries during tissue dissection and instrument application.

Fixed versus mobile bearing knee arthroplasty: a review of kinematics and results.

There are several total knee arthroplasty designs available with wide variation in features. The long-term results of total knee replacement with a fixed bearing design have shown a high degree of clinical success. However, implant loosening and polyethylene wear became recognized as long-term causes of late failure. Mobile bearing knee replacements were designed to create a durable surface articulation by using a polyethylene insert that articulates with a metallic femoral component and a metallic tibial tray. The purpose of this article is to review clinical and basic scientific studies comparing the clinical results, the biomechanical features, and the kinematic patterns of fixed versus mobile bearing knee designs. Beside the fact that in vitro kinematic studies have shown reduced polyethylene wear in mobile bearings due to increased implant conformity and reduced polyethylene contact stresses, which should hypothetically prolong polyethylene life, various independent studies for both mobile bearing and fixed bearing prostheses have documented results that are comparable in terms of survival and performance.

Lesión anterior de pelvis asociada a una fractura poco habitual del sacro / Anterior pelvic ring injury associated with an unusual sacral fracture

Hombre de 52 años que sufrió un accdente de tráfico mientras conducía una motocicleta. Las radiografías simples de pelvis tomadas a su ingreso evidenciaron una amplia diastasis de la sínfisis púbica, una fractura mediosagital del sacro y otra fractura de la apófisis transversa derecha de la quinta vértebra lumbar. Presentamos el tratamiento utilizado para abordar esta inusual lesión (AU)

A 52-year-old male sustained a road traffic accident riding a motorbike. At his admission, plain radiograph of the pelvis showed wide diastasis of the pubic symphysis, a midsagittal fracture of the sacrum and a fracture of the right transverse process of the fifth lumbar vertebra. We discuss the treatment of this rare injury (AU)

Accelerometry for evaluation of gait pattern in healthy soccer athletes.

An accelerometer system was used to measure the characteristics of the motion of 133 healthy male soccer athletes in a 30-s walking test and the data obtained were analysed using the gait evaluation differential entropy method (GEDEM). GEDEM processes gait acceleration data and calculates an index that provides a quantitative evaluation of a subject's gait, at low cost and with negligible effect on the subject. The GEDEM index was not significantly correlated with age, body weight, body mass index, or the number of years of active training. The GEDEM value for the anterior-posterior axis showed a small negative statistically significant correlation with height and the vertical axis was moderately and statistically significantly positively correlated with the time spent training per week. The triaxial accelerometry system described here is easy for subjects and testers to use, and enables measurements to be made on the sports field to evaluate an athlete's musculoskeletal condition with respect to gait stability.

Early apoptosis of monocytes contributes to the pathogenesis of systemic inflammatory response and of bacterial translocation in an experimental model of multiple trauma.

The objective of this study was to investigate the occurrence of apoptosis of monocytes in an experimental model of multiple trauma and its probable correlation to bacterial translocation. Thirty-two rabbits were applied in three groups: A, controls; B, myotomy of the right femur; and C, myotomy and fracture of the right femur. Blood was sampled for the estimation of endotoxins [lipopolysaccharide (LPS)], tumour necrosis factor (TNF)-alpha, malondialdehyde (MDA) and isolation of peripheral blood mononuclear cells (PBMCs). PBMCs, derived after centrifugation over Ficoll, were incubated in flasks and apoptosis of non-adherent lymphocytes and adherent monocytes was estimated after staining for Annexin-V and flow cytometry. TNF-alpha of supernatants of cultured monocytes was also determined. Tissue segments were cultured after death. Median survival of groups A, B and C was > 14, > 14 and 9.00 days, respectively. Apoptosis of lymphocytes in group C was higher than group A at 2, 4 and 48 h and of monocytes in group C higher than group A at 2 and 4 hours. LPS in group C was higher than group A at 2, 4 and 48 h. Apoptosis of lymphocytes and monocytes was correlated positively with serum TNF-alpha and negatively with TNF-alpha of monocyte supernatants. Cultures of organ segments of group A were sterile. Pseudomonas aeruginosa was isolated from liver, lung and spleen in five animals in group B (45.45%) and in six in group C (54.54%). Early apoptosis of blood monocytes supervened after multiple trauma; the phenomenon was accompanied by apoptosis of blood lymphocytes and subsequent bacterial translocation.

A bioresorbable calcium phosphate delivery system with teicoplanin for treating MRSA osteomyelitis.

To assess the effectiveness of calcium phosphate as a delivery system of teicoplanin, methicillin-resistant Staphylococcus aureus osteomyelitis was induced in 36 rabbits. Osteomyelitis was induced by inoculating 10 cfu of methicillin-resistant Staphylococcus aureus isolate into a 2-mm hole at the upper 1/3 of the femur for 3 weeks, when all animals had reoperations, and calcium phosphate cement with 3% teicoplanin was implanted. Animals were divided into six groups of six animals each, sacrificed at Weeks 1, 2, 3, 4, 5, and 6, respectively, after implantation. One rabbit in each group was used as a control. Substantial clinical improvement of the rabbits was observed after implantation, accompanied with sterile cultures of bone after the second week of treatment. Throughout the same period, 10 to 10 cfu/g of methicillin-resistant Staphylococcus aureus isolate was cultured from the control samples. Bacterial eradication signified a considerable decrease of the total histologic scores of osteomyelitis compared with controls, accompanied with newly growing host bone. The calcium phosphate with teicoplanin delivery system seems promising for treatment of bone infection attributable to methicillin-resistant Staphylococcus aureus. In addition, this mixture allows filling of bone defects by new host bone.

Reconstruction of anterior cruciate ligament using the doubled tendon graft technique: an experimental study in rabbits.

In an attempt to assess reconstruction of the anterior cruciate ligament (ACL) by a new method, 18 New Zealand white rabbits underwent ACL replacement using the medial one-third of the patellar tendon and the semitendinosus tendon, thus partly reproducing the anatomical configuration of the ACL, with the semitendinosus tendon replacing the posterolateral bundle of the ACL and the patellar tendon replacing the anteromedial bundle. The Noulis-Trillat-Lachman test was performed before and after transection of the ACL, after reconstruction and before sacrifice. The animals were divided into four groups and were killed at 3, 6, 12 and 22 weeks after surgery. Femur-ligament-tibia complexes were evaluated postoperatively for gross morphology and histological appearance. The tendons of the first group showed compact parallel fibres with no definitive separation of their bundles and areas of disorganized collagen matrix. Tendons were surrounded by trabecular lamellar bone haphazardly arranged. The tendons of the second, third and fourth groups looked more like normal tendon. The trabecular bone surrounding the tendons formed a tunnel. The Noulis-Trillat-Lachman test result was negative before the procedure, 6.5 +/- 0.5 mm on average after transection of the ACL, 1.5 +/- 0.6 mm after the procedure, and negative again before sacrifice. The joints of the animals killed at 12 and 22 weeks showed signs of osteoarthritic lesions.

Late results of surgical repair in recent ruptures of the lateral ligament of the ankle.

Between 1979 and 1994, 75 patients underwent primary repair of a Grade III rupture of the lateral ligament of the ankle. The operation was indicated after the demonstration of ankle instability on stress X-rays by anterior displacement of the talus by more than 8 mm or/and a talar tilt of more than 10 degrees. The patients were either young or engaged in sports activities or physically demanding jobs. An end-to-end suture of the torn ligament was undertaken under general anaesthesia. A non-weight-bearing cast was used for the first 2 weeks, followed by a walking cast until 6 weeks postoperatively. Sixty-one patients were followed up for 1-15 years (mean 10.3 years). At follow-up all but one patient had returned to their pre-injury level of activity without complaint or restriction.

The modified Bosworth technique for the treatment of acute traumatic Achilles tendon rupture.

Between 1983 and 1994, 15 patients (range 18 to 62 years) with acute traumatic Achilles tendon rupture, were treated surgically in our Department. We employed a modified Bosworth technique. The modifications were the use of a shorter strip of tendon and more secure fixation of the proximal and distal stump, than the original Bosworth technique. Postoperatively an above - knee plaster cast was applied with the knee flexed 30°-40° and the foot in a relaxed equinus position. The plaster cast was changed to a below - knee after 4 weeks and the foot gradually dorsiflexed to a neutral position until the 8th week, and then the plaster cast was removed. No patient had wound separation, infection or skin sloughs. After an average follow-up of 9 years, no rerupture has been reported and all the patients have returned to their pre injury activities.

Correlation of spinal canal post-traumatic encroachment and neurological deficit in burst fractures of the lower cervical spine (C3-7).

Burst fractures of the lower cervical spine (C3-7) are often associated with severe neurological injury. During the last 5 years (1987-1992) we operated on 11 patients who had sustained burst fractures together with neurological deficit. The operations were performed through an anterior approach. The burst vertebra was excised, and the defect was filled with bone graft. Implants (plates and screws) were used in 10 cases. The preoperative examination was conducted by computed tomography and revealed that in 4 patients with complete tetraplegia (Frankel grade A) there was more than 50% spinal canal narrowing, whilst in the remaining 7 patients, with various levels of incomplete tetraplegia, there was less than 50% spinal canal narrowing, resulting in considerable improvement. The above results support the hypothesis that a correlation exists between the magnitude of the spinal canal encroachment, the initial neurological deficit and the final outcome.