Odontoid Fracture with Accompanying Severe Atlantoaxial Instability in Elderly Patients-Analysis of Treatment, Adverse Events, and Outcome.

(1) Background: In elderly patients with type II odontoid fractures, accompanying severe atlantoaxial instability (AAI) is discussed as a marker possibly warranting more aggressive surgical therapy. This study aimed to characterize adverse events as well as the radiological and functional outcomes of surgical vs. conservative therapy in patients with odontoid fracture and AAI. (2) Methods: Patients aged 65 years and older with type II odontoid fracture and AAI treated were included. AAI was assumed if the mean subluxation across both atlantoaxial facet joints in the sagittal plane was greater than 50%. Data on demographics, comorbidities, treatment, adverse events, radiological, and functional outcomes were analyzed. (3) Results: Thirty-nine patients were included. Hospitalization time was significantly shorter in conservatively treated patients compared to patients with ventral or dorsal surgery. Adverse events occurred in 11 patients (28.2%), affecting 10 surgically treated patients (35.7%), and 1 conservatively treated patient (9.1%). Moreover, 25 patients were followed-up (64.1%). One secondary dislocation occurred in the conservative group (11.1%) and three in the surgical group (18.8%). (4) Conclusions: Despite the potential for instability in this injury, conservative treatment does not seem to lead to unfavorable short-term results, less adverse events, and a shorter hospital stay and should thus be considered and discussed with patients as a treatment option, even in the presence of severe AAI.

Adverse events after surgery for injuries to the subaxial cervical spine: analysis of incidence and risk factors.

PURPOSE: To determine the incidence of severe surgical adverse events (sSAE) after surgery of patients with subaxial cervical spine injury (sCS-Fx) and to identify patient, treatment, and injury-related risk factors. METHODS: Retrospective analysis of clinical and radiological data of sCS-Fx patients treated surgically between 2010 and 2020 at a single national trauma center. Baseline characteristics of demographic data, preexisting conditions, treatment, and injury morphology were extracted. Incidences of sSAEs within 60 days after surgery were analyzed. Univariate analysis and binary logistic regression for the occurrence of one or more sSAEs were performed to identify risk factors. P-values < .05 were considered statistically significant. RESULTS: Two hundred and ninety-two patients were included. At least one sSAE occurred in 49 patients (16.8%). Most frequent were sSAEs of the surgical site (wound healing disorder, infection, etc.) affecting 29 patients (9.9%). Independent potential risk factors in logistic regression were higher age (OR 1.02 [1.003-1.04], p = .022), the presence of one or more modifiers in the AO Spine Subaxial Injury Classification (OR 2.02 [1.03-3.96], p = .041), and potentially unstable or unstable facet injury (OR 2.49 [1.24-4.99], p = .010). Other suspected risk factors were not statistically significant, among these Injury Severity Score, the need for surgery for concomitant injuries, the primary injury type according to AO Spine, and preexisting medical conditions. CONCLUSION: sSAE rates after treatment of sCS-Fx are high. The identified risk factors are not perioperatively modifiable, but their knowledge should guide intra and postoperative care and surgical technique.

Secondary Dislocations in Type B and C Injuries of the Subaxial Cervical Spine: Risk Factors and Treatment.

INTRODUCTION: This study analyzed the incidence of secondary dislocations (sDLs) after surgical stabilization of AO Spine type B and C injuries of the subaxial cervical spine (sCS). MATERIALS AND METHODS: Patients treated for injuries of the sCS from 2010 to 2020 were retrospectively analyzed for the incidence of sDL within 60 days after first surgery. A univariate analysis of variables potentially influencing the risk of sDL was performed. Patients with solitary anterior stabilization underwent subgroup analysis. The treatment of sDLs was described. RESULTS: A total of 275 patients were included. sDLs occurred in 4.0% of patients (n = 11) in the total sample, most frequently after solitary anterior stabilization with 8.0% (n = 10, p = 0.010). Only one sDL occurred after combined stabilization and no sDLs after posterior stabilization. In the total sample and the anterior subgroup, variables significantly associated with sDL were older age (p = 0.001) and concomitant unstable facet joint injury (p = 0.020). No neurological deterioration occurred due to sDL and most patients were treated with added posterior stabilization. sDL is frequent after solitary anterior stabilization and rare after posterior or combined stabilization. DISCUSSION: Patients of higher age and with unstable facet joint injuries should be followed up diligently to detect sDLs in time. Neurological deterioration does not regularly occur due to sDL, and most patients can be treated with added posterior stabilization.

Paediatric spine injuries in the thoracic and lumbar spine-results of the German multicentre CHILDSPINE study.

BACKGROUND: Paediatric thoracolumbar spine injuries are rare, and meaningful epidemiological data are lacking. OBJECTIVES: The aim of this study was to provide epidemiological data for paediatric patients with thoracolumbar spinal trauma in Germany with a view to enhancing future decision-making in relation to the diagnostics and treatment of these patients. MATERIALS AND METHODS: A retrospective multicentre study includes patients up to 16 years of age who were suffering from thoracolumbar spine injuries who had been treated in six German spine centres between 01/2010 and 12/2016. The clinical database was analysed for patient-specific data, trauma mechanisms, level of injury, and any accompanying injuries. Diagnostic imaging and subsequent treatment were investigated. Patients were divided into three age groups for further evaluation: age group I (0-6 years), age group II (7-9 years) and age group III (10-16 years). RESULTS: A total of 153 children with 345 thoracolumbar spine injuries met the inclusion criteria. The mean age at the time of hospitalization due to the injury was 12.9 (± 3.1) years. Boys were likelier to be affected (1:1.3). In all age groups, falls and traffic accidents were the most common causes of thoracolumbar spine injuries. A total of 95 patients (62.1%) were treated conservatively, while 58 (37.9%) of the children underwent surgical treatment. Minimally invasive procedures were the most chosen procedures. Older children and adolescents were likelier to suffer from higher-grade injuries according to the AOSpine classification. The thoracolumbar junction (T11 to L2) was the most affected level along the thoracolumbar spine (n = 90). Neurological deficits were rarely seen in all age groups. Besides extremity injuries (n = 52, 30.2%), head injuries represented the most common accompanying injuries (n = 53, 30.8%). Regarding spinal injuries, most of the patients showed no evidence of complications during their hospital stay (96.7%). CONCLUSIONS: The thoracolumbar junction was more frequently affected in older children and adolescents. The majority of thoracolumbar spinal column injuries were treated conservatively. Nevertheless, 37.9% of hospitalized children had to be treated surgically, and there was an acceptable complication rate for the surgeries that were performed.

Survival and Clinical Outcomes after Unconstrained Total Knee Arthroplasty for Tibial Plateau Fractures-A Retrospective Study with Minimum 4-Year Follow-Up.

This study investigated survival, complications, revisions, and patient-reported outcomes (PROs) for unconstrained total knee arthroplasty (TKA) in posttraumatic osteoarthritis (PTO) caused by intraarticular tibial plateau fractures with minimum four years follow-up. Forty-nine patients (71.4% male; 58.7 years) were included. Kaplan-Meier analysis was performed with failure defined as TKA removal. Patients without failure underwent pre- and postoperative evaluation (range of motion (ROM), Oxford Knee Score (OKS), Knee Society Score (KSS), anatomical femorotibial angle (aFTA), proximal tibial slope (PTS)) and Short Form-12 (SF-12) Physical (PCS) and Mental Component Summary (MCS) assessment at final follow-up. Fifteen (30.6%) patients had a complication, and eight (16.3%) patients underwent prosthesis removal at median 2.5 years. Cumulative survival rate of TKA was 79.6% at 20 years. A total of 32 patients with a mean follow-up of 11.8 years underwent further analyses. ROM (p = 0.028), aFTA (p = 0.044), pPS (p = 0.009), OKS (p < 0.001) and KSS (p < 0.001) improved significantly. SF-12 PCS was 42.3 and MCS was 54.4 at final follow-up. In general, one third of patients suffer a complication, and one in six patients has their prosthesis removed after TKA for PTO due to tibial plateau fractures. In patients who do not fail, TKA significantly improves clinical and radiographic outcomes at long-term follow-up.

Odontoid fracture in geriatric patients - analysis of complications and outcome following conservative treatment vs. ventral and dorsal surgery.

BACKGROUND: Different treatment options are discussed for geriatric odontoid fracture. The aim of this study was to compare the treatment options for geriatric odontoid fractures. METHODS: Included were patients with the following criteria: age ≥ 65 years, identification of seniors at risk (ISAR score ≥ 2), and odontoid fracture type A/B according to Eysel and Roosen. Three groups were compared: conservative treatment, surgical therapy with ventral screw osteosynthesis or dorsal instrumentation. At a follow-up examination, the range of motion and the trabecular bone fracture healing rate were evaluated. Furthermore, demographic patient data, neurological status, length of stay at the hospital and at the intensive care unit (ICU) as well as the duration of surgery and occurring complications were analyzed. RESULTS: A total of 72 patients were included and 43 patients could be re-examined (range: 2.7 ± 2.1 months). Patients with dorsal instrumentation had a better rotation. Other directions of motion were not significantly different. The trabecular bone fracture healing rate was 78.6%. The patients with dorsal instrumentation were hospitalized significantly longer; however, their duration at the ICU was shortest. There was no significant difference in complications. CONCLUSION: Geriatric patients with odontoid fracture require individual treatment planning. Dorsal instrumentation may offer some advantages.

Pediatric cervical spine injuries-results of the German multicenter CHILDSPINE study.

OBJECTIVES: The aim of this study was to provide epidemiological data of pediatric patients suffering from cervical spinal trauma in Germany, in order to integrate these data in future decision-making processes concerning diagnosis and therapy. MATERIALS AND METHODS: Retrospective multicenter study includes all patients up to 16 years suffering from cervical spine injuries who were treated in six German spine centers between 01/2010 and 12/2016. The clinical databases were screened for specific trauma mechanism, level of injury as well as accompanying injuries. Diagnostic imaging and the chosen therapy were analyzed. Patients were divided into three age groups for further evaluation: age group I (0-6 years), age group II (7-9 years), age group III (10-16 years). RESULTS: A total of 214 children with 265 cervical spine injuries were included during the mentioned period. The mean age at the time of injury was 11.9 (± 3.9) years. In age group I, 24 (11.2%) patients were included, age group II consisted of 22 patients (10.3%), and 168 patients belonged to age group III (78.5%). Girls and boys were equally affected. In all age groups, falls and traffic accidents were the most common causes of cervical spine injuries. A total of 180 patients (84.1%) were treated conservatively, while 34 (15.9%) children underwent surgery. Distorsion/whiplash injury was the most common entity (n = 165; 68.2%). Children aged 0-9 years had significantly (p < 0.001) more frequent injuries of the upper cervical spine (C0-C2) compared to older age groups. Patients of age group III were more likely to suffer from injuries in subaxial localizations. Neurological deficits were rarely seen in all age groups. Head injuries did represent the most common accompanying injuries (39.8%, n = 92). CONCLUSIONS: The upper cervical spine was more frequently affected in young children. Older children more often suffered from subaxial pathologies. The majority of cervical spinal column injuries were treated conservatively. Nevertheless, 15% of the hospitalized children had to be treated surgically.

Post-operative Use of Cervical Orthoses for Subaxial Cervical Spine Injuries - a Survey-based Analysis at German Spine Care Centres. / Postoperative Anwendung von Zervikalorthesen bei Verletzungen der subaxialen Halswirbelsäule ­ eine umfragebasierte Analyse an deutschen Wirbelsäulenzentren.

INTRODUCTION: There are no evidence-based recommendations for the post-operative treatment and application of soft or rigid cervical collars after operative treatment of injuries of the subaxial cervical spine. Cervical collars can restrict peak range of motion and serve as a reminder to the patient. However, they can also cause pressure ulcers. The aim of this online-based survey among German spine centres was to gain an overview of post-operative treatment and the application of soft or rigid cervical collars after surgical treatment of injuries of the subaxial cervical spine. MATERIALS AND METHODS: An online-based survey was conducted among 59 spine centres certified by the German Spine Society. It comprised seven items and the option of adding remarks in the form of open-ended responses. RESULTS: The return rate was 63% (37 out of 59). Of the 37 analysed spine centres, 51% routinely apply a cervical collar post-operatively, 27% apply a soft and 16% a rigid cervical collar, 8% sequentially apply first a rigid and later a soft cervical collar. Less than half of the spine centres (43%) routinely use no cervical collar. Rigid collars are applied for more than 6 weeks and soft collars up to 6 weeks at some spine centres. Standardised post-operative treatment plans are common. The selection of the post-operative treatment plan depends primarily on the type of injury and method of operation and partly on patient age and bone quality. The satisfaction of German spine centres with the current handling of post-operative treatment of subaxial cervical spine injuries is high. DISCUSSION: The post-operative treatment of injuries of the subaxial cervical spine at German spine centres is heterogeneous, and the evidence on advantages and disadvantages of the post-operative application of cervical collars is insufficient. Planning and implementation of randomised controlled clinical trials in subaxial cervical spine injuries is challenging.

Development and first application testing of a new protocol for CT-based stability evaluation of the injured upper cervical spine.

PURPOSE: For trauma surgeons, the evaluation of the stability of the upper cervical spine may be demanding. The aim of this study was to develop a protocol for decision-making on upper cervical spine stability in trauma patients based on established parameters obtained by CT imaging as well as testing the protocol by having it applied by trauma surgeons. METHODS: A structured literature search on upper cervical spine stability was performed. The best evaluated instability criteria in CT imaging were determined. Based on these parameters a protocol for stability evaluation of the injured upper cervical spine was developed. A first application testing was performed. In addition to the assessment of instability, the time required for the assessment was analyzed. RESULTS: A protocol for CT-based stability evaluation of the injured upper cervical spine based on the current literature was developed and displayed in a flow chart. Testing of the protocol found the stability of the cervical spine was correctly assessed in 55 of 56 evaluations (98.2%). In one test run, a stable upper cervical spine was judged to be unstable. Further analysis showed that this case was based on a measurement error. The assessment time of CT-images decreased significantly during repeat application of the protocol (p < 0.0001), from 336 ± 108 s (first case) to 180 ± 30 s (fourth case). CONCLUSION: The protocol can be applied quickly and safely by non-specialized trauma surgeons. Thus, the protocol can support the decision-making process in CT-based evaluation of the stability of the injured upper cervical spine.

Evaluation of external stabilization of type II odontoid fractures in geriatric patients-An experimental study on a newly developed cadaveric trauma model.

BACKGROUND: Along with the growing geriatric population, the number of odontoid fractures is steadily increasing. However, the effectiveness of immobilizing geriatric odontoid fractures using a cervical collar has been questioned. The aim of the present study is to analyze the physiological and pathological motion in odontoid fractures and to assess limitation of motion in the cervical spine when applying a cervical collar. METHODS: Motion analysis was performed with wireless motion tracker on unfixed geriatric human cadavers. First, a new geriatric type II odontoid fracture model was developed. In this model, the type II odontoid fracture is operated via a transoral approach. The physiological and pathological flexion and lateral bending of the cervical spine resulting from this procedure was measured. The resulting motion after external stabilization using a cervical collar was analyzed. RESULTS: The new geriatric type II odontoid fracture model was successfully established using seven unfixed human cadavers. The pathological flexion of the cervical spine was significantly increased compared to the physiological flexion (p = 0.027). Furthermore, the flexion was significantly reduced when a cervical collar was applied. In case of flexion the mean remaining motion was significantly reduced (p = 0.0017) from 41° to 14°. For lateral bending the mean remaining motion was significantly reduced (p = 0.0137) from 48° to 18°. CONCLUSIONS: In case of type II odontoid fracture, flexion and lateral bending of the cervical spine are increased due to spinal instability. Thus, if an odontoid fracture is suspected in geriatric patients, the application of a cervical collar should always be considered since external stabilization can significantly reduce flexion and lateral bending.

Analysis of remaining motion using one innovative upper airway opening cervical collar and two traditional cervical collars.

The aim of this study was to compare the remaining motion of an immobilized cervical spine using an innovative cervical collar as well as two traditional cervical collars. The study was performed on eight fresh human cadavers. The cervical spine was immobilized with one innovative (Lubo Airway Collar) and two traditional cervical collars (Stifneck and Perfit ACE). The flexion and lateral bending of the cervical spine were measured using a wireless motion tracker (Xsens). With the Weinman Lubo Airway Collar attached, the mean remaining flexion was 20.0 ± 9.0°. The mean remaining flexion was lowest with the Laerdal Stifneck (13.1 ± 6.6°) or Ambu Perfit ACE (10.8 ± 5.8°) applied. Compared to that of the innovative Weinmann Lubo Airway Collar, the remaining cervical spine flexion was significantly decreased with the Ambu Perfit ACE. There was no significant difference in lateral bending between the three examined collars. The most effective immobilization of the cervical spine was achieved when traditional cervical collars were implemented. However, all tested cervical collars showed remaining motion of the cervical spine. Thus, alternative immobilization techniques should be considered.

Cervical Spine Immobilization in Patients With a Geriatric Facial Structure: The Influence of a Geriatric Mandible Structure on the Immobilization Quality Using a Cervical Collar.

INTRODUCTION: Demographic changes have resulted in an increase in injuries among geriatric patients. For these patients, a rigid cervical collar is crucial for immobilizing the cervical spine. However, evidence suggests that patients with a geriatric facial structure require a different means of immobilization than patients with an adult facial structure. This study aimed to analyze the remaining motion of the immobilized cervical spine based on facial structure. MATERIALS AND METHODS: This study was performed on 8 fresh human cadavers. Facial structure was evaluated via ascertaining the mandibular angle by computer tomography. A mandibular angle below 130°, belongs to the adult facial structure group (n = 4) and a mandibular angle above 130°, belongs to the geriatric facial structure group (n = 4). The flexion and lateral bending of the immobilized cervical spine were analyzed in both groups using a wireless motion tracker system. RESULTS: A flexion of up to 19.0° was measured in the adult facial structure group. The mean flexion in the adult vs. geriatric facial structure groups were 14.5° vs. 6.5° (ranges: 9.0-19.0 vs. 5.0-7.0°), respectively. Thus, cervical spine motion was (p = 0.0286) significantly more reduced in the adult facial structure group. No (p = 0.0571) significant difference was oberserved in the mean lateral bending of the adult facial structure group (14.5°) compared to the geriatric facial structure group (7.5°). CONCLUSION: Emergency medical service personnel should therefore follow current guidelines and recommendations and perform cervical spine immobilization with a cervical collar, including in patients with a geriatric facial structure.

[The position of the head during treatment in the emergency room-an explorative analysis of immobilization of the cervical spine]. / Die Lagerung des Kopfes während der Behandlung im Schockraum ­ eine explorative Analyse über die Immobilisation der Halswirbelsäule.

BACKGROUND: Immobilization of the cervical spine is a standard procedure in emergency medicine mostly achieved via a cervical collar. In the emergency room other forms of immobilization are utilized as cervical collars have certain drawbacks. The present study aimed to provide preliminary data on the efficiency of immobilization in the emergency room by analyzing the residual spinal motion of the patient's head on different kinds of head rests. METHODS: In the present study biomechanical motion data of the cervical spine of a test subject were analyzed. The test subject was placed in a supine position on a mobile stretcher (Stryker M1 Roll-In System, Kalamazoo, MI, USA) wearing a cervical collar (Perfit ACE, Ballerup, Denmark). Three different head rests were tested: standard pillow, concave pillow and cavity pillow. The test subject carried out a predetermined motion protocol: right side inclination, left side inclination, flexion and extension. The residual spinal motion was recorded with wireless motion trackers (inertial measurement unit, Xsens Technologies, Enschede, The Netherlands). The first measurement was performed without a cervical collar or positioning on the pillows to measure the physiological baseline motion. Subsequently, three measurements were taken with the cervical collar applied and the pillows in place. From these measurements, a motion score was calculated that can represent the motion of the cervical spine. RESULTS: When the test subject's head was positioned on a standard pillow the physiological motion score was reduced from 69 to 40. When the test subject's head was placed on concave pillow the motion score was further reduced from 69 to 35. When the test subject's head was placed on cavity pillow the motion score was reduced from 69 to 59. The observed differences in the overall motion score of the cervical spine are mainly due to reduced flexion and extension rather than rotation or lateral inclination. CONCLUSION: The motion score of the cervical spine using motion sensors can provide important information for future analyses. The results of the present study suggest that trauma patients can be immobilized in the early trauma phase with a cervical collar and a head rest. The application of a cervical collar and the positioning on the concave pillow may achieve a good immobilization of the cervical spine in trauma patients in the early trauma phase.

Analysis of diagnostics, therapy and outcome of patients with traumatic atlanto-occipital dislocation.

BACKGROUND CONTEXT: Patients' outcome following traumatic atlanto-occipital dislocation (AOD) has been poor. In recent years, an increasing number of patients surviving the initial trauma are admitted to hospital. In order to further improve the management of these patients, the knowledge of diagnostics and therapy as well as possible complications should be increased. PURRPOSE: The aim of this study was to evaluate diagnostic parameters, therapy, early complications and outcome of patients with traumatic AOD. STUDY DESIGN: Monocentric retrospective cohort study. PATIENT SAMPLE: A total of 12 patients were included in this study. OUTCOME MEASURES: The main outcome measure was functional patient outcome. Furthermore, radiographic and treatment data were analyzed. METHODS: All patients suffering from traumatic AOD within an 8-year time period were included. Demographic data, radiological diagnostic parameters (condylar sum, basion dens interval, basion axis interval, power´s ratio, x-line method), as well as treatment data and complications of every patient were analyzed. Radiological parameters were compared with each other. Outcome was analyzed by a follow up examination. RESULTS: The accident mechanisms were motor vehicle accidents (MVA), fall from high and low height. Basion dens interval, basion axis interval, power's ratio and x-line method were not reliable in identifying traumatic AOD (only up to 33% of the patients were identified). Twelve patients could be reviewed. Three patients were treated with surgery, five patients were treated nonsurgically. Four patients died before surgical therapy. All seven surviving patients (survival rate: 58.3%) were re-examined (mean follow-up time: 6.7 months). All patients had a GCS of 15. Three surviving patients suffered from persisting neurological deficits. CONCLUSIONS: The most reliable way to diagnose AOD in Computer Topography is using the condylar sum. Surgical and nonsurgical measures can be employed with reasonable outcomes. Patient specific injury burden and clinical presentation should be taken into account when making treatment decisions for AOD.

Risk Factors for Revision Surgery Following Radial Head Arthroplasty without Cement for Unreconstructible Radial Head Fractures: Minimum 3-Year Follow-up.

BACKGROUND: Revision rates following radial head arthroplasty (RHA) for unreconstructible radial head fractures (RHFs) differ vastly in the literature, and little is known about the risk factors that are associated with revision surgery. The purposes of this study were to assess the revision rate following RHA and to determine the associated risk factors. METHODS: A total of 122 patients (mean age, 50.7 years; range, 18 to 79 years) with 123 RHAs who underwent RHA for unreconstructible RHFs between 1994 and 2014 and were ≥3 years out from surgery were included. Demographic variables, injury and procedure-related characteristics, radiographic findings, complications, and revision procedures were assessed. Cox regression analysis was performed to identify the risk factors that were associated with revision surgery following RHA. RESULTS: The median follow-up for the study cohort was 7.3 years (interquartile range [IQR], 5.1 to 10.1 years). All of the patients had unreconstructible RHFs: Mason-Johnston type-IV injuries were the most prevalent (80 [65%]). One or more associated osseous or ligamentous injuries were seen in 89 elbows (72.4%). The median time to surgery was 7 days (IQR, 3 to 11 days). Implanted prostheses were categorized as rigidly fixed (65 [52.8%]) or loosely fixed (58 [47.2%]). A total of 28 elbows (22.8%) underwent revision surgery at a median of 1.1 years (IQR, 0.3 to 3.8 years), with the majority of elbows (17 [60.7%]) undergoing revision surgery within the first 2 years. The most common reason for revision surgery was painful implant loosening (14 [29.2% of 48 complications]). Univariate Cox regression suggested that Workers' Compensation claims (hazard ratio [HR], 5.48; p < 0.001) and the use of an external fixator (HR, 4.67; p = 0.007) were significantly associated with revision surgery. CONCLUSIONS: Revision rates following RHA for unreconstructible RHFs are high; the most common cause for revision surgery is painful implant loosening. Revision surgeries are predominantly performed within the first 2 years after implantation, and surgeons should be aware that Workers' Compensation claims and the use of an external fixator in management of the elbow injury are associated with revision surgery. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Long-term outcome and survival rate of monopolar radial head replacement.

BACKGROUND: The purposes of this study were (1) to report functional outcomes; (2) to assess complications, revisions, and survival rate; and (3) to assess differences in functional outcomes between removed and retained radial head arthroplasties (RHAs), early and delayed treatment, and type of RHA used at long-term follow-up after monopolar RHA for unreconstructible radial head fractures or their sequelae. METHODS: Seventy-eight patients (mean age, 59.2 years) who were at least 6 years postoperatively after monopolar RHA for unreconstructible RHFs or their sequelae were included. The Mayo Elbow Performance Score (MEPS); Quick Disability of the Arm, Shoulder, and Hand (QuickDASH) score; visual analog scale; postoperative satisfaction (1-6, 6 = highly unsatisfied); range of motion; complications; and revisions were assessed. Radiographic findings were reported. Kaplan-Meier survival analysis was performed. Subgroups (RHA type, early vs. delayed surgery, RHA removed vs. retained) were compared. RESULTS: At a median clinical follow-up of 9.5 years (range: 6.0-28.4 years), median MEPS was 80.0 (interquartile range [IQR]: 60.0-97.5), median QuickDASH was 22.0 (IQR: 4.6-42.6), median visual analog scale was 1 (IQR: 0-4), median postoperative satisfaction was 2 (IQR: 1-3), and median arc of extension/flexion was 110° (IQR: 80°-130°). Radiographic follow-up was available for 48 patients at a median of 7.0 years (range: 2.0-15.0 years). Heterotopic ossifications were seen in 14 (29.2%), moderate-to-severe capitellar osteopenia/abrasion in 3 (6.1%), moderate-to-severe ulnohumeral degeneration in 3 (6.1%), and periprosthetic radiolucencies in 17 (35.4%) patients. Twenty-nine patients (37.2%) had complications and 20 patients (25.6%) underwent RHA exchange or removal. Kaplan-Meier analysis with failure defined as RHA exchange or removal demonstrated survival of 75.1% (95% confidence interval: 63.7-83.3) at 18 years. The highest annual failure rate was observed in the first year in which the RHAs of 7 patients (9%) were exchanged or removed. No significant differences were detected between type of RHA in MEPS (Mathys: 82.5 [75.0-100] vs. Evolve: 80.0 [60.0-95.0]; P = .341) and QuickDASH (Mathys: 12.5 [0-34.4] vs. Evolve: 26.7 [6.9-46.2]; P = .112). Early surgery (≤3 weeks) yielded significantly superior MEPS (80.0 [70.0-100.0] vs. 52.5 [30.0-83.8]; P = .014) and QuickDASH (18.6 [1.5-32.6] vs. 46.2 [31.5-75.6]; P = .002) compared with delayed surgery (>3 weeks). Patients with retained RHAs had significantly better MEPS (80.0 [67.5-100] vs. 70.0 [32.5-82.5]; P = .016) and QuickDASH (18.1 [1.7-31.9] vs. 49.1 [22.1-73.8]; P = .007) compared with patients with removed RHAs. CONCLUSIONS: Long-term outcomes for RHA are satisfactory; however, there is a high complication and revision rate, resulting in implant survival of 75.1% at 18 years with the highest annual failure rate observed in the first postoperative year.

Remaining Cervical Spine Movement Under Different Immobilization Techniques.

BACKGROUND: Immobilization of the cervical spine by Emergency Medical Services (EMS) personnel is a standard procedure. In most EMS, multiple immobilization tools are available.The aim of this study is the analysis of residual spine motion under different types of cervical spine immobilization. METHODS: In this explorative biomechanical study, different immobilization techniques were performed on three healthy subjects. The test subjects' heads were then passively moved to cause standardized spinal motion. The primary endpoints were the remaining range of motion for flexion, extension, bending, and rotation measured with a wireless human motion detector. RESULTS: In the case of immobilization of the test person (TP) on a straight (0°) vacuum mattress, the remaining rotation of the cervical spine could be reduced from 7° to 3° by additional headblocks. Also, the remaining flexion and extension were reduced from 14° to 3° and from 15° to 6°, respectively. The subjects' immobilization was best on a spine board using a headlock system and the Spider Strap belt system (MIH-Medical; Georgsmarienhütte, Germany). However, the remaining cervical spine extension increased from 1° to 9° if a Speedclip belt system was used (Laerdal; Stavanger, Norway). The additional use of a cervical collar was not advantageous in reducing cervical spine movement with a spine board or vacuum mattress. CONCLUSIONS: The remaining movement of the cervical spine is minimal when the patient is immobilized on a spine board with a headlock system and a Spider Strap harness system or on a vacuum mattress with additional headblocks. The remaining movement of the cervical spine could not be reduced by the additional use of a cervical collar.

Injuries of the upper cervical spine-how can instability be identified?

OBJECTIVE: The diagnosis of instability of the injured upper cervical spine remains controversial, due to its complicated anatomical configuration and biomechanical property. Since identifying unstable injuries of the upper cervical spine is essential for immediate stabilizing therapy, this article reviews the current classification systems of upper cervical spine injuries and their statements towards instability. METHODS: A systematic review of literature concerning upper cervical spine injuries was performed on the PubMed database from inception to December 2019. An English literature search was conducted using various combinations of keyword terms. RESULTS: Numerous separate classification systems for each specific injury of the upper cervical spine were obtained. The early classifications are based primarily on injury morphology and mechanism. The recent classifications pay more attention to the investigation of ligamentous status. Various instability criteria were established as well. The determinants involve translation, vertical distraction, angulation, rotation, obliquity of fracture line, comminution, and ligamentous disruption. The status of crucial ligaments plays a key role in determining instability of upper cervical spine injuries. CT scan is more sensitive and reliable than X-ray in detecting misalignment of the upper cervical spine. CONCLUSION: Only a few classification systems support decision-making concerning instability leading to early operative treatment. The ligamentous integrity is the key element of impacting the stability of the upper cervical spine injuries. The transverse ligament serves as the most crucial element in determining the stability of occipital condyle fractures and atlas fractures as well as atlanto-axial injury. The integrity of anterior longitudinal ligament, disc, and facet joint attributes to the stability of axis fractures. The integrity of tectorial membrane and alar ligaments determines the stability of atlanto-occipital dislocation. The development of a newly classification system concerning ligamentous instability with a high clinical and scientific impact is recommended.

[Diagnostics and treatment of cervical spine trauma in pediatric patients : Recommendations from the Pediatric Spinal Trauma Group]. / Diagnostik und Therapie von Verletzungen der Halswirbelsäule im Kindesalter : Empfehlungen der AG Wirbelsäulentrauma im Kindesalter.

BACKGROUND: Severe cervical spine injuries in children under the age of 17 years are rare. Recommendations or even guidelines for the diagnostics and treatment of such injuries in children are currently not available. OBJECTIVE: The aim of the study was to formulate recommendations for diagnostics and treatment of injuries of the cervical spine in pediatric patients. MATERIAL AND METHODS: First, a search of primary and secondary literature on the topic complex of diagnostics and treatment of cervical spine injuries in children was carried out. An appropriate internal literature database was defined and maintained. Second, within the framework of 9 meetings from April 2017 to December 2019 the members of the Pediatric Spinal Trauma Group of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU) systematically formulated recommendations for the diagnostics and treatment of injuries of the cervical spine in pediatric patients by a consensus process. RESULTS: Recommendation for the diagnostics and treatment for injuries of the cervical spine could be formulated for three age groups (age group I: 0-6 years; age group II: 7-9 years; age group III: 10-16 years). The diagnostic and therapeutic principles known from adult patients suffering from injuries to the cervical spine cannot be easily transferred to pediatric patients. CONCLUSION: Injuries to the pediatric spine are rare and should be treated in specialized spine centers. Pediatric patients with a stable cardiopulmonary status should undergo magnetic resonance imaging (MRI) if a spinal trauma is suspected. Classification systems and therapeutic recommendations for injuries to the cervical spine known from adult patients could also be used for adolescent patients. This is not possible for children under the age of 10 years. Only few classification systems exist for this age group. Basic principles of the treatment of spinal trauma in children is the restoration of spinal stability and correct anatomical relationships as well as the protection of all neural structures.

[Diagnostics and treatment of thoracic and lumbar spine trauma in pediatric patients : Recommendations from the Pediatric Spinal Trauma Group]. / Diagnostik und Therapie von Verletzungen der Brust- und Lendenwirbelsäule im Kindesalter : Empfehlungen der AG Wirbelsäulentrauma im Kindesalter.

BACKGROUND: Spinal injuries in pediatric patients are overall very rare. Current reference studies including large patient numbers that enable the formulation of evidence-based recommendations on diagnostics and treatment of these injuries do not exist. OBJECTIVE: The aim of the current study was to formulate recommendations on the diagnostics and treatment for injuries of the thoracic and lumbar spine in pediatric patients. MATERIAL AND METHODS: Firstly, a search for primary and secondary literature on the topic of diagnostics and treatment of spinal injuries in children was carried out. From this, a literature database was established and maintained. Secondly, within the framework of 9 meetings in the time period from April 2017 to December 2019 the members of the Pediatric Spinal Trauma Group of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU) documented recommendations on diagnostics and treatment of injuries of the thoracic and lumbar spine in pediatric patients by a consensus process. RESULTS: Recommendations on the diagnostics and treatment of injuries of the thoracic and lumbar spine could be given for 3 age groups (age group I: 0-6 years; age group II: 7-9 years; age group III: 10-16 years). Diagnostic and therapeutic principles known from adult patients suffering from injuries to the thoracic or lumbar spine cannot easily be transferred to pediatric patients. CONCLUSION: Spinal injuries in childhood are rare and should be treated in specialized spine centers. Pediatric patients with a stable cardiopulmonary status should undergo magnetic resonance imaging (MRI) if a spinal trauma is suspected. The basic principles of the treatment of spinal trauma in children is the restoration of spinal stability and correct anatomical parameters as well as the protection of all neural structures. The potential for correction and regeneration of the individual spinal sections depending on the age of the patient must be considered for deciding between operative vs. conservative treatment. Whenever operative treatment is needed, it should be performed by minimally invasive techniques as a sole instrumentation without spondylodesis. An early removal of the screw-rod-system should be performed.