Intraoperative calprotectin lateral flow immunoassay can assist decision-making between one- and two-stage revision total hip arthroplasty for patients with suspected periprosthetic joint infection.

Aims: Accurate diagnosis of chronic periprosthetic joint infection (PJI) presents a significant challenge for hip surgeons. Preoperative diagnosis is not always easy to establish, making the intraoperative decision-making process crucial in deciding between one- and two-stage revision total hip arthroplasty (THA). Calprotectin is a promising point-of-care novel biomarker that has displayed high accuracy in detecting PJI. We aimed to evaluate the utility of intraoperative calprotectin lateral flow immunoassay (LFI) in THA patients with suspected chronic PJI. Methods: The study included 48 THAs in 48 patients with a clinical suspicion of PJI, but who did not meet European Bone and Joint Infection Society (EBJIS) PJI criteria preoperatively, out of 105 patients undergoing revision THA at our institution for possible PJI between November 2020 and December 2022. Intraoperatively, synovial fluid calprotectin was measured with LFI. Cases with calprotectin levels ≥ 50 mg/l were considered infected and treated with two-stage revision THA; in negative cases, one-stage revision was performed. At least five tissue cultures were obtained; the implants removed were sent for sonication. Results: Calprotectin was positive (≥ 50 mg/l) in 27 cases; out of these, 25 had positive tissue cultures and/or sonication. Calprotectin was negative in 21 cases. There was one false negative case, which had positive tissue cultures. Calprotectin showed an area under the curve of 0.917, sensitivity of 96.2%, specificity of 90.9%, positive predictive value of 92.6%, negative predictive value of 95.2%, positive likelihood ratio of 10.6, and negative likelihood ratio of 0.04. Overall, 45/48 patients were correctly diagnosed and treated by our algorithm, which included intraoperative calprotectin measurement. This yielded a 93.8% concordance with postoperatively assessed EBJIS criteria. Conclusion: Calprotectin can be a valuable tool in facilitating the intraoperative decision-making process for cases in which chronic PJI is suspected and diagnosis cannot be established preoperatively.

Dislocation of Total Hip Arthroplasty of Femoral Neck Fracture in the Elderly: A Narrative Review.

Femoral neck fracture (FNF) is a common and devastating injury in the elderly population. The incidence of FNF is expected to increase in the future, particularly in the aging population. The displaced intracapsular FNF is replaced with a reconstruction prosthesis. These treatment options typically include hemiarthroplasty (HA) or total hip arthroplasty (THA). Dislocation after THA can be a significant complication, leading to increased hospital costs and patient dissatisfaction. This narrative review aims to investigate the potential risk factors for dislocation following THA after FNF. A systematic literature search was conducted, and 21 studies met the inclusion criteria. The studies included a total of 1703 patients who underwent THA after FNF. The majority of the patients were women, and the average age of participants was 76.2 years. The studies were primarily conducted by the orthopedic and traumatology departments. The surgical approach used for THA varied, with the anterior approach being associated with lower dislocation rates compared to the posterior approach. The analysis of surgical volume revealed that high-volume hospitals had lower dislocation rates compared to low-volume hospitals. Eight studies reported postoperative Harris Hip Scores (HHS), with higher HHS scores correlating with lower dislocation rates. Body mass index (BMI) was mentioned in 11 studies, and a normal BMI range was associated with lower dislocation rates compared to the overweight group. Rehabilitation protocols, particularly early initiation of physiotherapy, showed promising results in reducing dislocation rates. Additionally, the type of prosthesis used in the acetabulum was found to influence dislocation rates, with dual mobility cups demonstrating lower rates compared to single cups. In conclusion, several factors may contribute to the risk of dislocation following THA after FNF. These include the surgical approach, surgical volume, postoperative HHS scores, BMI, rehabilitation protocols, and the type of acetabular cup used. Further research is needed to better understand these risk factors and develop strategies to minimize dislocation rates and improve patient outcomes.

Acetabular erosion after bipolar hip hemiarthroplasty for femoral neck fracture in elderly patients: a retrospective study.

BACKGROUND: The choice between total hip arthroplasty (THA) and hemiarthroplasty (HA) to treat displaced femoral neck fractures, particularly among the elderly, is still controversial. Acetabular erosion consists of a late multifactorial process that may happen after hip HA resulting in significant postoperative burden. This study aims to investigate the impact of acetabular erosion progress after hip HA in patients over 70 years old. MATERIALS AND METHODS: This is a 5-year (2013-2018) retrospective study including consecutive series of patients >70 years who were treated with bipolar hip HA for femoral neck fractures. Patients were categorised into 3 groups for analysis (A = 70-75 years, B = 75-80 years, C = >80 years). The study enrolled a total number of 813 patients who met the inclusion criteria. We assessed acetabular erosion through radiological examinations and measured functional deterioration using the modified Harris Hip Score (mHHS) at 6 and 12 months follow-up. Our comprehensive investigation extended over a maximum period of 5 years. The correlation of patients' characteristics and HA features on erosion progress was assessed. RESULTS: There were no significant differences in sex distribution, injury side, BMI, ASA score, bipolar head diameter, mHHS and leg-length discrepancy among the groups (p > 0.05). During the follow-up period, acetabular erosion with consequential conversion to THA was observed in 6.13%, 4.22% and 1.96% for Groups A, B and C respectively (p = 0.009). A statistically significant difference of acetabular erosion was observed in Group A compared to patients of Group C. CONCLUSIONS: Age constitutes a significant factor of acetabular wear after HA in the elderly. The higher rate of acetabular wear in patients <75 years suggests that THA is a more viable option, as HA is for patients >80 years old.

Pneumothorax After Shoulder Arthroscopy: A Rare Complication of Rotator Cuff Repair Surgery.

Shoulder arthroscopy is considered a very safe surgical procedure; however, there are possible complications that are prevalent or devastating. This article presents a 52-year-old woman scheduled for elective arthroscopic rotator cuff repair under general anesthesia in the lateral decubitus position. Postoperatively, the patient experienced dyspnea, chest pain, and oxygen desaturation, and a diagnosis of pneumothorax was made. A chest tube was inserted promptly and the patient was discharged in a good condition, experiencing an uneventful follow-up for the next four months. Knowledge of this uncommon complication may enable both surgeons and anesthesiologists to set up preventive and early therapeutic management.

Total hip arthroplasty through the direct anterior approach in morbidly obese patients.

AIMS: There is evidence that morbidly obese patients have more intra- and postoperative complications and poorer outcomes when undergoing total hip arthroplasty (THA) with the direct anterior approach (DAA). The aim of this study was to determine the efficacy of DAA for THA, and compare the complications and outcomes of morbidly obese patients with nonobese patients. METHODS: Morbidly obese patients (n = 86), with BMI ≥ 40 kg/m2 who underwent DAA THA at our institution between September 2010 and December 2017, were matched to 172 patients with BMI < 30 kg/m2. Data regarding demographics, set-up and operating time, blood loss, radiological assessment, Harris Hip Score (HHS), International Hip Outcome Tool (12-items), reoperation rate, and complications at two years postoperatively were retrospectively analyzed. RESULTS: No significant differences in blood loss, intra- and postoperative complications, or implant position were observed between the two groups. Superficial wound infection rate was higher in the obese group (8.1%) compared to the nonobese group (1.2%) (p = 0.007) and relative risk of reoperation was 2.59 (95% confidence interval 0.68 to 9.91). One periprosthetic joint infection was reported in the obese group. Set-up time in the operating table and mean operating time were higher in morbidly obese patients. Functional outcomes and patient-related outcome measurements were superior in the obese group (mean increase of HHS was 52.19 (SD 5.95) vs 45.1 (SD 4.42); p < 0.001), and mean increase of International Hip Outcome Tool (12-items) was 56.8 (SD 8.88) versus 55.2 (SD 5.85); p = 0.041). CONCLUSION: Our results suggest that THA in morbidly obese patients can be safely and effectively performed via the DAA by experienced surgeons. Cite this article: Bone Jt Open 2022;3(1):4-11.

Treatment of Schatzker Type II-VI Tibial Plateau Fractures by Means of Syndesmotaxis Using an Ilizarov External Fixator and Postoperative CT Evaluation.

Introduction Tibial plateau fractures are more common in young patients following high-energy trauma. In this study, we aim to evaluate the articular surface reduction quality by means of postoperative computer tomography (CT) in Schatzker type II-VI tibial plateau fractures treated with an Ilizarov frame. Materials and methods This case series study included 45 patients with a mean age of 39.5 years (range: 18 to 65 years) with a Schatzker type II-VI tibial plateau fracture. The surgical technique was a mini-open reduction of the articular surface impaction followed by application of an Ilizarov circular frame with knee bridging. Pre- and postoperative CT scan evaluation was performed in all of the patients. Outcomes were measured using the American Knee Society Score (AKSS). Mean outpatient follow-up was of at least 12 months (range: 12 to 21 months). Mean time for fracture consolidation was 15.5 weeks (range: 13 to 19 weeks). According to the degree of postoperative articular surface impaction, patients were grouped as follows: 11 had less than 2 mm of depression, 27 had 2 to 4 mm of depression, and 7 over 4 mm of depression. Results Patients with articular surface impaction of more than 4 mm presented statistically significant lower values of AKSS compared to those with impaction of lower than 2 mm (p<0.001 ) and 2-4 mm (p<0.001). Patients with joint alignment equal to or more than 5° presented statistically significant lower values of AKSS compared to those with lower than 5°. Conclusions Schatzker type II-VI tibial plateau fractures may be treated successfully with mini-open reduction and the application of an Ilizarov frame. The increase of articular surface impaction by 1 mm causes reduction of AKSS by 15 units. Patients with joint alignment equal to or more than 5° present lower values of AKSS. The preoperative CT scan is important and useful in planning the surgical intervention no matter the classification system is used.

Anterior Cruciate Ligament Reconstruction With the All-Inside Technique: Equivalent Outcomes and Failure Rate at Three-Year Follow-Up Compared to a Doubled Semitendinosus-Gracilis Graft.

PURPOSE: To compare in terms of failure rates, clinical and functional outcomes the all-inside anterior cruciate ligament (ACL) reconstruction with double suspensory fixation and quadrupled semitendinosus autograft with anteromedial portal doubled semitendinosus-gracilis autograft with suspensory femoral and tibial interference screw fixation. METHODS: Forty-four patients were sequentially allocated into two groups and followed up prospectively for a 3-year period. The first group was the all-inside group and the second was the "classic" AM portal with S-G graft. Each group comprised 22 patients. All patients underwent KT-1000 testing preoperatively and at a minimum of six months postoperatively. Visual pain analog was recorded preoperatively and during both the immediate postoperative period and throughout the follow-up. The Lysholm knee score was used comparing the preoperative and 24-month timepoints. RESULTS: The visual analog scale (VAS) pain scores showed a significant difference at two weeks (2.4 vs 1.8, p < 0.01 ) in favor of the all-inside group, but that difference disappeared in the later follow-up visits. Similarly, there was no significant difference with Lysholm knee scores at two years and the side-to-side anterior translation measured with the KT-1000. At the three-year mark, there were no failures in either of the groups. CONCLUSION: The all-inside technique appears to be equivalent in terms of outcomes to the classic S-G technique, and given the less-invasive nature and versatility in graft choices is a safe and effective technique for primary ACL reconstruction.

A rare case of closed degloving injury of the fifth toe.

Empty toe injury is a rare type of closed degloving injury; limited cases have been reported previously, with controversial outcomes. Our case is a 22 year old male who was injured by a trolley bus. The patient presented at our emergency department with extensive swelling of the right foot, deformity of the fifth toe, bruising and intact skin. On clinical examination the phalangeal bone could not be palpated in the fifth toe and there was no capillary refill. The patient underwent open reduction combined with fasciotomies. The toe regained perfusion after the reduction and was under close observation to ensure its viability. Finally the distal and part of the middle phalanx of the toe was amputated. The purpose of this report is to inform health providers about this unique type of injury and contribute to a more sufficient treatment plan. Level of evidence: IV.

Falls from height due to accident and suicide attempt in Greece. A comparison of the injury patterns.

BACKGROUND: Falls from height are a common cause of death and disability. Falls from height can be divided between accidental and suicide attempts. The aim of this study is to ascertain the demographic characteristics of these patients, and to identify the fracture patterns. METHODS: In this retrospective cross sectional comparative study we present 244 patients who sustained injuries as a result of a fall from height. They were divided into those with accidental falls (n = 180, group I) and those with suicide attempts (n = 64, group II). Data collected included age, gender, associated trauma, injury severity score (ISS), Glasgow Coma Scale (GCS), haemodynamic status, length of intensive care unit (ICU) and hospital stay. The diagnosis of mental disorder was ascertained by psychiatric specialists using the criteria of the International Classification of Disease Ninth Version Clinical Modification (ICD - 9CM). Postoperative follow-up ranged from 12 months to 10 years. RESULTS: The injuries sustained were as follows: Abdominal trauma in 9 cases (5 in group I, 4 in II), thoracic trauma in 81 cases (49 in group I, 32 in II), head injury in 23 cases (7 in group I, 16 in II), 383 extremities fractures (184 in group I, 199 in II) and 133 spinal fractures (101 in group I, 32 in II). Twenty-one patients died in hospital while 223 patients survived to hospital discharge. The mean height from which the fall occurred was 5.4 m (range, 3 - 25 m). The mean Injury Severity Score was 19 (range, 6 to 58) for all fall victims. CONCLUSIONS: Patients following an accidental high fall mostly had upper limb fractures. Patients following a suicidal high fall mostly had lower limb fractures, pelvis, spinal fractures and head injuries. Spinal fractures are common either when the fall is accidental or following suicide attempt.

Transfusion rate, hospital stay and cost-effectiveness of intravenous or local administration of tranexamic acid in total hip and knee arthroplasty: A single-center randomized controlled clinical study.

We have conducted a prospective randomized study to determine the effect of intravenous or local administration of tranexamic acid (TXA) in perioperative transfusion rates, hospital stay and overall hospitalization costs in patients underwent total knee (TKA) or total hip (THA) arthroplasty. During 2015-2016, 125 THA and 124 TKA consecutive patients were randomly allocated to receive low dose TXA either intravenously (ivTXA groups) or local administration (locTXA groups) or to serve as controls. Power analysis showed that 41 patients in each group were required in order to have an 80% probability of demonstrating a between surgeries difference of more than 35%. Full blood counts obtained on the first and third postoperative day and the maximum hemoglobin difference was documented in all patients. The costs of hospitalization, transfusions and TXA were retrieved by the hospital financial administration. All groups were homogenic in regards to age and preoperative Hgb levels. In both THA and TKA patients, a statistically significant reduction in the maximum hemoglobin difference was found for both the intravenous (ivTXA) and local application (locTXA) groups compared to controls (P<0.001). The average hospitalization was reduced by 2.2 and 2.9 days in THA and TKA patients in respect. The hospitalization costs for the control groups were higher both in THA (286 € more) and TKA (374 € more) patients. We were able to demonstrate that both intravenous and local administration of TXA can significantly reduce transfusion rate, hospital stay and overall cost in TKA or THA patients.

Complex Tibial Plateau Fractures Treated by Hybrid External Fixation System: A correlation of followup computed tomography derived quality of reduction with clinical results.

BACKGROUND: Tibial plateau fractures are common due to high energy injuries. The principles of treatment include respect for the soft tissues, restoring the congruity of the articular surface and reduction of the anatomic alignment of the lower limb to enable early movement of the knee joint. There are various surgical fixation methods that can achieve these principles of treatment. Recognition of the particular fracture pattern is important, as this guides the surgical approach required in order to adequately stabilize the fracture. This study evaluates the results of the combined treatment of external fixator and limited internal fixation along with the advantages using postoperative computed tomography (CT) scan after implant removal. Materials and. METHODS: 55 patients with a mean age of 42 years (range 17-65 years) with tibial plateau fracture, were managed in our institution between October 2010 and September 2013., Twenty fractures were classified as Schatzker VI and 35 as Schatzker V. There were 8 open fractures (2 Gustilo Anderson 3A and 6 Gustilo Anderson 2). All fractures were treated with closed reduction and hybrid external fixation (n = 21/38.2%) or with minimal open reduction internal fixation and a hybrid system (n = 34/61.8%). After the removal of the fixators, CT-scan was programmed for all the cases, for correlation with the results. At final followup, the American Knee Society Score (AKSS) was administered. RESULTS: All patients were evaluated with a minimum of 12 months (range 12-21 months) followup. Average time to union was 15.5 weeks (range 13-19 weeks). The postoperative joint congruity as evaluated in the postoperative CT-scan was <2 mm of articular step-off in 8 patients (14.5%), between 2 and 4 mm in 18 patients (32.7%) and over 4 mm in 29 (52.7%). The injured limb mechanical axis was restored within 5° compared to the contralateral limb in 36 cases (65%) and with an angulation >5° in 19 cases (35%). Patients with residual joint depression <3.5 mm had a 95% chance of having excellent AKSS knee score results and 80% chance of having excellent AKSS function scores. On the other hand, residual joint depression of >4.5 mm displayed a 100% chance of getting poor-fair scores both in AKSS knee and AKSS function score. The association of a postoperative mechanical axis within 5° of the contralateral limb and improved knee scores was statistically significant for the AKSS function and total scores but not for the AKSS knee score. The AKSS was negatively correlated with postoperative joint depression magnitude which was statistically significant. Only the amount of joint collapse was verified as a prognostic factor in a multivariate logistic regression analysis. CONCLUSIONS: The postoperative CT-scan shows important information about bone healing, and an exact image of the reduction and the shaft alignment. Postoperative radiographs may have led to an underestimation of the degree of residual displacement. On the contrary, CT-scan demonstrates the exact grade of articular displacement and depending on CT-scan results one can better manage the postoperative rehabilitation.

Flap reconstruction of the knee: A review of current concepts and a proposed algorithm.

A literature search focusing on flap knee reconstruction revealed much controversy regarding the optimal management of around the knee defects. Muscle flaps are the preferred option, mainly in infected wounds. Perforator flaps have recently been introduced in knee coverage with significant advantages due to low donor morbidity and long pedicles with wide arc of rotation. In the case of free flap the choice of recipient vessels is the key point to the reconstruction. Taking the published experience into account, a reconstructive algorithm is proposed according to the size and location of the wound, the presence of infection and/or 3-dimensional defect.

Surveillance of Arc2f polyethylene after 15 years of implantation.

BACKGROUND: To investigate the behavior of Arc2f polyethylene (PE) component after a minimum of 15 years post implantation and its possible reasons for failure. METHODS: Between January 1988 and March 1995, 557 cementless total hip arthroplasties were performed in 578 patients. A total of 435 patients (450 hips) were followed up for 18.6 years (range 15-22). RESULTS: At 10 years follow-up no cup needed revision surgery. After 15 years of implantation, we observed massive PE wear in 140 cups (31%) with large osteolytic lesions. A revision procedure was performed in all cases. Exchange only of the PE liner was sufficient in 78 cases, whilst in 59 the cup was also revised. PE insert thickness and the type of prosthetic head were found to be related to PE wear. CONCLUSIONS: We postulate that the massive failure seen is attributed to the manufacturing of the PE insert. We advocate following all patients that have an implant lasting a decade after implantation for routine monitoring to identify those at risk for accelerated PE wear.

Which patients are at risk for kidney dysfunction after hip fracture surgery?

BACKGROUND: Kidney dysfunction (KD) after hip fracture surgery is a major complication. However, the incidence and risk factors of KD in this population are unclear. QUESTIONS/PURPOSES: We therefore (1) determined the incidence of KD in a large cohort of fracture patients, (2) identified preoperative risk factors predisposing to KD, and (3) determined the effect of KD on length of stay and subsequent function. METHODS: Between April 2011 and June 2012, 450 patients (263 women) with a mean age of 73 years (range, 67-96 years) underwent surgery for hip fracture in our institution. We calculated incidence and retrospectively reviewed suspected predisposing risk factors. We report followup at 6 months. RESULTS: The overall incidence of KD was 11% (n = 52). Forty-five patients (86%) developed acute KD and seven patients developed acute-on-chronic KD. Three of the 52 patients died during the followup time. Thirty-eight of the 52 patients (73%) regained their prior kidney function after treatment. An increased risk of KD was found in those with diabetes, shock during or after surgery, age, and preexisting KD. Mean length of stay was higher for patients with KD compared to those without: 9.6 versus 7.4, respectively. At 6 months, 39 of the 49 surviving patients (80%) were fully weightbearing. CONCLUSIONS: Many patients at risk for postoperative KD can be identified and treated. Most patients recover from their KD and the majority return to full weightbearing.

Analysis of kidney dysfunction in orthopaedic patients.

BACKGROUND: This retrospective study was undertaken to determine the incidence of kidney dysfunction (KD) and to identify potential risk factors contributing to development of KD in orthopaedic population following an elective or emergency surgery. METHODS: A total of 1025 patients were admitted in our institution over a period of one year with various indications. Eight hundred and ninety-three patients (87.1%) had a surgical procedure. There were 42 (52.5%) male and 38 (47.5%) female with a mean age of 72 years (range: 47 to 87 years). We evaluated the following potential risk factors: age, comorbidities, shock, hypotension, heart failure, medications (antibiotics, NSAIDs, opiates), rhabdomyolysis, imaging contrast agents and pre-existing KD. RESULTS: The overall incidence of KD was 8.9%. Sixty-eight patients developed acute renal injury (AKI) and 12 patients developed acute on chronic kidney disease (CKD). In sixty-six (82.5%) patients renal function was reversed to initial preoperative status. Perioperative dehydration (p = 0.002), history of diabetes mellitus (p = 0.003), pre-existing KD (p = 0.004), perioperative shock (p = 0.021) and administration of non-steroid anti-inflammatory drugs (NSAIDs) (p = 0.028) or nephrotoxic antibiotics (p = 0.037) were statistically significantly correlated with the development of postoperative KD and failure to gain the preoperative renal function. CONCLUSION: We conclude that every patient with risk factor for postoperative KD should be under closed evaluation and monitoring.

A two stage re-implantation protocol for the treatment of deep periprosthetic hip infection. Mid to long-term results.

Deep periprosthetic hip infection is a devastating complication. Goal of treatment is infection eradication and durable functional reconstruction. Two-stage re-implantation is the standard of treatment. From January 1998 to December 2004 we treated 38 patients with an infected THA. There were 24 females and 14 males, with a mean age of 67 years (61-75). The infection occurred 13 months to 15 years (mean: 7.2 years) after the index operation. The mean follow-up was 11.6 years (7 to 14). 35 patients were available for review. Almost one third of the patients had been treated before with antibiotics. In 5 cases more than one pathogen were present. In 3 cases, it was not possible to isolate a causative organism. In 15 cases (43%), a resistant pathogen was isolated. We used a two stage re- implantation protocol. Spacer was not used in any of the cases. Femoral revision was performed with uncemented implants, 21 of distal (wagner type) fixation and 14 of modular type with proximal fixation. 24 press fit shells (17 oTMT cups) and 11 Muller rings were used. In 33 cases (94%) eradication of infection was achieved. The mean HHS improved from a mean of 38.2 preoperatively to a mean of 88.6 at final follow-up (p<0.001). There was no case of implant loosening or migration. Chronic late infection can be managed successfully with a two stage re-implantation protocol, without interim spacer, including neglected cases, previous long term antibiotics and cases with resistant pathogens.

Does PFNA II avoid lateral cortex impingement for unstable peritrochanteric fractures?

BACKGROUND: Proximal femoral nail antirotation devices (PFNAs) are considered biomechanically superior to dynamic hip screws for treating unstable peritrochanteric fractures and reportedly have a lower complication rate. The PFNA II was introduced to eliminate lateral cortex impingement encountered with the PFNA. However, it is unclear whether the new design in fact avoids lateral cortex impingement without compromising stability of fixation and fracture healing. QUESTIONS/PURPOSES: We therefore asked whether the PFNA II: (1) eliminates the lateral cortex impingement and fracture displacement experienced with PFNA; and (2) provides stable fracture fixation with a low major complication rate for unstable fractures in European patients. METHODS: We retrospectively reviewed 108 patients with an unstable peritrochanteric fracture, 58 treated with PFNA and 50 with PFNA II. We compared nail positioning, major and minor complication rates, operative and fluoroscopy time, blood transfused, time to mobilization, hospital stay, fracture union, and Harris hip score. The minimum followup was 12 months (mean, 13 months; range, 12-18 months). RESULTS: In the PFNA II group we encountered no impingement on the lateral cortex and no patients with lateral fragment or loss of reduction at insertion, whereas with the PFNA group, we had 10 and five cases, respectively. Fracture union occurred in all patients treated with PFNA II without mechanical failures. PFNA II cases were associated with a slightly shorter surgical time than PFNA cases (23 minutes versus 27 minutes, respectively). CONCLUSION: PFNA II avoided lateral cortex impingement experienced with PFNA, providing fast and stable fixation of the unstable peritrochanteric fractures. LEVEL OF EVIDENCE: Level III, retrospective comparative study. See Guidelines for Authors for a complete description of levels of evidence.

Posterior instrumentation for occipitocervical fusion.

Since 1995, 29 consecutive patients with craniocervical spine instability due to several pathologies were managed with posterior occipitocervical instrumentation and fusion. Laminectomy was additionally performed in nineteen patients. The patients were divided in two groups: Group A which included patients managed with screw-rod instrumentation, and Group B which included patients managed with hook-and-screw-rod instrumentation. The patients were evaluated clinically and radiographically using the following parameters: spine anatomy and reconstruction, sagittal profile, neurologic status, functional level, pain relief, complications and status of arthrodesis. The follow-up was performed immediately postoperatively and at 2, 6, 12 months after surgery, and thereafter once a year. Fusion was achieved in all but one patient. One case of infection was the only surgery related complication. Neurological improvement and considerable pain relief occurred in the majority of patients postoperatively. There were neither intraoperative complications nor surgery related deaths. However, the overall death rate was 37.5% in group A, and 7.7% in group B. There were no instrument related failures. The reduction level was acceptable and was maintained until the latest follow-up in all of the patients. No statistical difference between the outcomes of screw-rod and hook-and-screw-rod instrumentation was detected. Laminectomy did not influence the outcome in either group. Screw-rod and hook-and-screw-rod occipitocervical fusion instrumentations are both considered as safe and effective methods of treatment of craniocervical instability.

Treatment of unstable thoracolumbar burst fractures by indirect reduction and posterior stabilization: short-segment versus long-segment stabilization.

In order to compare short-segment stabilization with long-segment stabilization for treating unstable thoracolumbar fractures, we studied fifty patients suffered from unstable thoracolumbar burst fractures. Thirty of them were managed with long-segment posterior transpedicular instrumentation and twenty patients with short-segment stabilization. The mean follow up period was 5.2 years. Pre-operative and post-operative radiological parameters, like the Cobb angle, the kyphotic deformation and the Beck index were evaluated. A statistically significant difference between the two under study groups was noted for the Cobb angle and the kyphotic deformation, while, as far as the Beck index is concerned, no significant difference was noted. In conclusion, either the long-segment or the short-segment stabilization is able for reducing the segmental kyphosis and the vertebral body deformation postoperatively. However, as time goes by, the long-segment stabilization is associated with better results as far as the radiological parameters, the indexes and the patient's satisfaction are concerned.