The 'Holy Grail' of shoulder dislocations: a systematic review on traumatic bilateral luxatio erecta; is it in reality a once-in-a-lifetime experience for an orthopaedic surgeon?

INTRODUCTION: Even though shoulder dislocation is thought to be the most common dislocation treated in the Emergency Department, inferior ones, known as Luxatio Erecta, comprise only 0.5% of them. Taking into consideration the rareness of unilateral Luxatio Erecta, bilateral cases should be even fewer. The purpose of this paper is to identify the reported number of cases of Traumatic Bilateral Luxatio Erecta in the literature over the last 100 years and to summarize the mechanism of injury, the initial management, and the complications of these patients. MATERIALS AND METHODS: We performed a systematic review of the literature regarding Traumatic Bilateral Luxatio Erecta. All articles published until 31st of December 2022 in PubMed and Google Scholar databases were searched using the terms "luxatio erecta", 'inferior dislocation", and "bilateral". RESULTS: Eighty-two articles were retrieved from PubMed and Google Scholar search. Forty-four of them were initially included in our review. Six additional articles meeting the inclusion criteria were found from cross-references. CONCLUSION: The presence of this injury is extremely rare with only 51 cases in the literature. The incidence of concomitant injuries and complications seems to be extremely high and neurological deficits were detected on 42.8% of patients with Bilateral Luxatio Erecta. To our knowledge, this is the first systematic review of the literature regarding Traumatic Bilateral Luxatio Erecta that includes articles not only in English, a fact that provides more reliability on the estimation of the real number of cases of this rare injury compared to any other review on this subject to date.

Static Baropodometry for Assessing Short-Term Functional Outcome after Unilateral Total Knee Arthroplasty: Exploring Correlation between Static Plantar Pressure Measurements and Self-Reported Outcomes.

This study aimed to investigate the association between objective baropodometric and radiological measurements and patient self-reported functional outcomes, assessed through the Knee Injury and Osteoarthritis Outcome Score (KOOS). Additionally, it sought to evaluate the effectiveness of static baropodometry in predicting short-term KOOS results following unilateral total knee arthroplasty (TKA). We conducted a prospective single-center study involving 32 patients who underwent unilateral TKA for knee osteoarthritis (KOA). Patients were evaluated both preoperatively and six months postoperatively, utilizing objective measurements derived from static baropodometric analysis in a normal, relaxed, bipedal standing position using a multi-platform Plantar Pressure Analysis System (PPAS) and radiographic measurements of the femorotibial angle (FTA) and subjective assessments through the national validated version of the KOOS. The study found an insignificant average correction of -0.69° ± 4.12° in the preoperative FTA at the sixth month after TKA. Moreover, there were no significant differences in the KOOS based on different types of knee alignment (KA) both pre- and postoperatively (p > 0.05). No significant correlations were observed between the KOOS, and total average affected and unaffected plantar pressures (TAAPP and TAUPP) pre- and postoperatively, as well as KA pre- and postoperatively. However, significant changes were observed in TAAPP and TAUPP measurements after unilateral TKA. TAAPP demonstrated a significant increase postoperatively (mean change (SD) = 18.60 (47.71); p = 0.035). In conclusion, this study found no significant correlation between KA, static baropodometric measurements, including pre- and postoperative differences, and KOOS outcomes. Therefore, static plantar pressure measurements alone might not serve as a reliable predictor of short-term clinical outcomes after unilateral TKA, as reported by patients.

Osteoporotic Vertebral Body Fractures: New Trends in Differential Diagnosis, Bracing and Surgery.

In the past, many researchers have investigated the effects of different conservative and operative treatments for Osteoporotic Vertebral Fractures (OVFs) [...].

New Concepts in Diagnosis, Risk Factors and Work Ability in Patients with Hematogenous Spinal Infection.

In the last decades, there is an increasing incidence of hematogenous septic spinal infection (HIS) [...].

An infected Andersson lesion presented with incomplete paraplegia in a patient with ankylosing spondylitis. A unique case report with literature review.

INTRODUCTION: A relatively rare and unknown entity in patients with ankylosing spondylitis is the Andersson lesion (AL). It was first described by Andersson in 1937 as destructive vertebral or disco-vertebral lesion of the spine without history of trauma. AL may result from inflammation or stress fracture of the rigid spine, while there is no evidence for an infectious origin. To our knowledge, only one case with an infected AL has been published many years ago; we hereby present the second case, but the first one with severe neurologic deterioration. CASE PRESENTATION: A 79-year-old male patient was presented to our emergency department and his neurological examination on admission revealed incomplete paraplegia below the Th10 level. Plain radiograms at the level of 10th thoracic vertebra revealed a lesion mimicking a severe vertebral fracture. The computed tomography confirmed the diagnosis of the AL and due to the significant local instability and the neurologic deficit, the patient underwent posterior decompression and stabilization. During decompression, we noticed purulence and extensive debridement was performed. The cultures of the Th10 pus revealed Enterococus sp, while the same pathogen was developed to urine cultures. The patient received intravenous antibiotics for 4 weeks, followed by per os antibiotic therapy. At the 18-month follow-up our patient had significant improvement of this functional status. DISCUSSION: Most studies support that inflammatory or traumatic/mechanical (pseudarthrosis) etiology are the most possible causes of Anderson lesions. Possible neurological deterioration should be investigated and demonstrates significant spinal instability. The integrity of the posterior column should be investigated, and exclusion of other concomitant lesions should be done. In cases with instability due to the fractured posterior elements, surgical intervention is mandatory. Spine surgeons should be competent to differentiate fracture from the Andersson lesion. In this rare case we highlight also that spine surgeons should obtain intraoperative cultures in cases with Andersson lesions, to exclude the minor possibility of the infectious origin of the entity and/or the possible secondary contamination of the affected area.

Predictive value of sagittal craniocervical roentgenographic parameters for HRQOL after craniocervical fusion.

PURPOSE: Loss of "physiological" sagittal alignment following craniocervical fusion (CCF) for degenerative disease may be associated with loss of horizontal gaze, dysphagia and poor HRQOL. This study reports on sagittal craniocervical roentgenographic predictors of HRQOL (SF-36) in patients following uncomplicated CCF for fresh upper cervical traumatic (UCT) injuries. METHODS: Twenty-two consecutive adult patients (group P) aged 50 ± 16 years, who had undergone CCF for fresh unstable C1 and C2AO/type UCT injuries, were evaluated 39 ± 12 months postoperatively with upright lateral cervical roentgenograms and SF-36as HRQOL measure. Physiological data for cervical sagittal alignment and SF-36 were taken from an age-matched control group (C) of 30 individuals aged 52 ± 12 years. Several commonly used sagittal cervical roentgenographic parameters were tested as potential predictors of the SF-36 domains in both groups. Roentgenographic predictors for each of the nine SF-domains were calculated using stepwise multilinear regression analysis (MLRA). RESULTS: The roentgenographic predictors in patients included (1) the angle created by McGregor's line and the inferior surface of the axis (OC2a) for physical function (PF, P = 0.049), role limitations due to physical health (RLPH, P = 0.004),role limitation due to emotional problems (RLEP, P = 0.004), emotional functioning (EF) (P = 0.012), social functioning (SF) (P = 0.028) and general health (GH, P = 0.041). (2) The angle formed between a horizontal line and the superior endplate of T1-vertebra (T1-slope) was predictor for SF (P = 0.017) and pain (P = 0.021), and (3) the angle between McGregor's line and the line that links the center of the C1 anterior arch and the apex of cervical sagittal curvature (PIA) was predictor for health change (HC, P = 0.002). CONCLUSIONS: This study showed that postoperative OC2a, PIA and T1-slope safely predict HRQOL outcomes (SF-36) following CCF for fresh trauma. It seems theoretically that the adequate restoration of the upper cervical alignment including C1-C2 upper cervical lordosis (OC2a) and PIA, in interaction with T1-slope, is important for postoperative HRQOL scores close to physiological values. The authors speculate that C0-C4 fusion restores horizontal gaze and allows for painful regain of pre-trauma quality of life. Spine surgeons should realign and stabilize the craniocervical junction taking in consideration these roentgenographic predictors.

Fatigue Acetabular Fracture after Lumbopelvic Instrumented Fusion in Elderly.

PURPOSE: Only several cases of acetabular "fatigue"/insufficiency fractures have been reported in elderly patients with osteoporosis. However, fatigue acetabular fracture below lumbopelvic fixation has not been published. This review reports on the frequency and mechanisms of acetabular fatigue fractures in elderly individuals, including postmenopausal osteoporosis, and presents a case of an acetabular "fatigue" fracture in association with lumbopelvic fusion. METHODS: We report on a 71-year-old postmenopausal woman who underwent in our department a L2-pelvis instrumented fusion for failed lumbar decompression and interbody fusion performed in another institution. For at least one year, the patient was receiving antiosteoporotic treatment (Alendronate plus Calcium and Vitamin D) and was fully ambulatory without limping. Eighteen months following our surgery, the patient sought again our department because of increasing pain in her right hip and limping without trauma. RESULTS: The physical examination disclosed painful passive motion in her right hip. The roentgenograms and CT-scans disclosed a transverse acetabular fracture with radiolucencies around both iliac screw tips, particularly the right. Additionally, a severe compression fracture of the 12th thoracic vertebral body and upper endplate of the L2 vertebra was disclosed. We recommended open stabilization of the acetabulum and T12 and L2 vertebrae. Immediately before the planned surgeries, the patient had a serious heart infarct, and thus, surgeries were canceled by the patient's cardiologist because of the high perioperative risk. The patient and relatives denied further surgeries because of the heart disease. In the final telephone call and CT and roentgenographic evaluation that went to us after request, there was an acetabular pseudarthrosis in the right hip without however associated complaints. Since surgery was not accepted, the patient was prescribed Denosumab injection therapy plus Vitamin and Calcium supplement. CONCLUSION: This case report emphasizes the significance of follow-up observation of elderly patients with postmenopausal osteoporosis following lumbopelvic fusions, for possible fatigue acetabular and vertebral fractures. The authors speculate that this extremely rare acetabular "fatigue"/insufficiency fracture should be the result of increased repetitive mechanical forces acting around the acetabulum in association with osteoporosis.

Quality of Life in Adult Patients Receiving Cervical Fusion for Fresh Subaxial Cervical Injury: The Role of Associated Spinal Cord Injury.

PURPOSE: To study postoperative Health-Related Quality of Life (HRQOL) after instrumented fusion for fresh subaxial cervical trauma and the effect of spinal cord injury (SCI). METHODS: From a total of 65 patients, 17 (26%) patients suffered on admission from SCI. Twenty-five patients underwent anterior, 25 posterior, and 15 circumferential cervical surgery for a single cervical injury. Sagittal roentgenographic parameters were measured in 65 age-matched asymptomatic controls and in patients on admission, eight months postoperatively and at final follow-up (lower C2-C7 curvature, cervical sagittal vertical axis (cSVA), spinocranial angle (SCA), T1-slope, neck tilt (NT), thorax inlet angle (TIA), cervical tilt (CT), cranial tilt (CrT), and occiput-C2 angle (C0-C2)). In the last evaluation, SCI patients were compared with their counterparts without SCI using national validated HRQOL instruments (SF-36 and neck disability index (NDI)). RESULTS: Fusion included an average of 3 vertebrae (range 2-4 vertebrae). All 65 patients were followed for an average of 5.5 years, (range 3-7 years) postoperatively. In the last evaluation, 10 (15.4%) patients with incomplete SCI improved postoperatively at 1-2 grades. At the last observation, patients with SCI showed poorer HRQOL scores than their counterparts without SCI. In particular, each SF-36 domain score was correlated with SCA, T1-slope, cSVA, and CT. At baseline, patients showed higher NT, CrT, and C0-C2 angle than controls. Eight months postoperatively, cSVA, NT, TIA, and cranial tilt (CrT) were increased in patients. In the last observation, there was difference in the sagittal roentgenographic parameters between patients with SCI compared to those without SCI. Patients aged ≥55 years had postoperatively increased cSVA, NT, and CrT compared to their younger counterparts. CONCLUSION: At the final observation, HRQOL scores were lower in patients with SCI than in their non-SCI counterparts, obviously because of the associated neurologic impairment. SF-36 scores correlated with several sagittal roentgenographic parameters. These correlations should be taken in consideration by spine surgeons when performing cervical spine surgery for fresh cervical spine injuries.

A Smart Technique to Remove Ruptured Inflatable Bone Tamp From the Vertebral Body in Balloon Kyphoplasty.

Accidental rupture of the inflatable bone tamp is a rare but possible complication during balloon kyphoplasty. We describe an easy and minimal invasive technique to remove this foreign body from fractured vertebra. A 62-year-old female patient with severe osteoporosis had a low energy trauma and sustained burst fracture of the 12th thoracic (Th12) vertebra. The inflated bone tamp was not possible to be fully deflated and during the maneuvers to withdraw the balloon, it was disassembled and trapped under the distal end of working cannula, remaining within the bone cavity formed by balloon. Since no standard recommendation for this complication exists in current literature, we faced the dilemma of either leaving ruptured bone tamp in situ or removing it with a more extensive approach. We decided to use an alternative minimal invasive technique and managed to remove it through the right pedicle using a small size straight pituitary rongeur forceps under biplane continuous image intensifier and neuromonitoring. Subsequently, balloon kyphoplasty (BK) was performed through the left cannula accompanied with pedicle screw fixation of the adjacent vertebrae. The patient was followed up to our outpatient department for one year without complications. This extremely rare complication during BK consists of a challenge for spine surgeons and interventional radiologists. The described technique is relatively easy, safe, minimal invasive, time-saving and avoids further complications related with trapping of foreign bodies within the vertebral body.

Sinonasal Extramedullary Plasmacytoma With Rare Osteolytic Lesions.

Plasmacytomas are malignant tumors characterized by abnormal monoclonal proliferation of plasma cells. They originate either from bone or soft tissue and could be primary or a part of a systemic process during the course of multiple myeloma. Extramedullary plasmacytomas (EPs) in the sinonasal tract or nasopharynx are rare and mostly presented as case reports. We describe a unique case of multiple myeloma involving the nasal cavity and the paranasal sinuses with osteolytic expansile lesions of the first cervical vertebrae (atlas), the clavicle, and the skull in a 51-year-old man. The diagnostic approach was challenging, and finally the biopsy of the extramedullary tumor settled the diagnosis of multiple myeloma. The patient underwent posterior occipitocervical fusion due to upper cervical spine instability due to atlas osteolysis. The patient had an uneventful recovery, and he was finally referred to the hematology department. EP of the nasal cavity is a rare entity and requires a high index of suspicion. EP should be included in the differential diagnoses of nasal cavity masses, especially in males in the age group of 50-60 years. A thorough clinical history, examination, and proper laboratory and radiological investigations are important to settle an accurate diagnosis to initiate treatment as soon as possible. Timely diagnosis ensures a better prognosis and deters the progression of the disease.

Late Onset Atraumatic Ceramic Head Fracture of a Hybrid Ceramic Bearings Total Hip Arthroplasty.

Ceramic head fracture is a major complication of ceramic-on-ceramic (CoC) total hip arthroplasty (THA) and though new generation ceramics have lowered the rates, although it is still a great concern. We report a case of late onset (more than 10 years after surgery) ceramic head fracture of a hybrid ceramic bearings to emphasize on its unusual clinical manifestation. Furthermore, we highlight the late onset presentation and also the rarity of this complication with this particular hybrid ceramic bearings. A relevant review of the literature revealed that hybrid ceramic bearings need to be more thoroughly studied to understand modes of their failure and to reach a consensus on how to reduce and prevent these disastrous complications.

Simultaneous Combined Major Arterial and Lumbar Plexus Injury During Primary Extra Lateral Interbody Fusion: Case Report and Review of the Literature.

Extra lateral interbody fusion (XLIF) has been established in recent years as an effective approach to address degenerative lumbar disc disease (DLDD). Although neurological and vascular complications during XLIF have been reported, to our knowledge, a combination of simultaneous vascular and neurovascular complication during XLIF has not been reported to date. A 72-year-old female patient was admitted to our orthopaedic department because of back pain associated with severe neuropathic radicular pain to her both lower extremities, incomplete paraplegia and low back fistula with serous secretion for several weeks. She had been wheel-chair bound since nine years before her admission in our department when she had her initial XLIF operation in another institution. Intraoperatively, an aorta lesion occurred, which was emergently addressed, along with lumbar plexus injury. Since then, she had an extensive history of subsequent operations that ended with a T10-S1 posterior lumbar fusion, with no improvement of her neurological condition, complicated by hardware-induced infection. She underwent her last operation in our department; removal of the posterior lumbar construct and extensive debridement of the posterior lumbar spine. We present this rare case and we perform an extensive literature review. Although XLIF has been established in recent years, the report of major vascular injuries, although rare, has questioned its safety profile. Spine surgeons should be aware of catastrophic major neurovascular complications associated with this procedure and be prepared to address them.

A unique cause of Gamma 3 cut-out: A case report and literature review.

Gamma 3 nail is a wide spread intramedullary device for fixation of per trochanteric fractures. Cut out of the lag screw is the most common complication of this implant. We present a 62-year-old female patient, who underwent a total hip arthroplasty following cut out of a Gamma 3 nail in the femoral neck. The cause of the cut out in our case is actually unique. Our intraoperative findings accompanied with the radiographic evaluation argue that the malposition of the set screw was the cause of failure, due to the rotational instability of femoral head-lag screw unit. We present this case with detailed description, highlighting the proper use of this specific nail and appose a brief literature review.

Traumatic Spondylolisthesis of the Fourth Lumbar Vertebra Without Neurologic Deficit or Fracture of the Posterior Elements.

Acute traumatic spondylolisthesis in the lumbosacral spine is an uncommon injury. Traumatic dislocation of the fourth lumbar vertebra over the fifth lumbar vertebra (L4/L5) is extremely rare since few studies have been reported in the current literature. We report on a 53-year-old man, who had a motor vehicle accident and sustained an injury of the lumbar spine without neurological impairment. The radiographic evaluation disclosed an L4/L5 traumatic spondylolisthesis, classified as Meyerding grade III without any fracture of the posterior vertebral elements. To the best of our knowledge, this is the sixth case of L4 traumatic spondylolisthesis without concomitant fracture of the posterior vertebral elements and the third case without any neurological deficit among them. The patient underwent open reduction and posterior instrumentation. Intraoperatively, the posterior ligamentous complex, the capsules of the facet joints and also the disc were found torn, although facets, neural arch, and pedicles were intact. Following decompression and reduction of the spondylolisthesis without any neurologic complications, we performed pedicle screws and rods fixation from the third to the fifth lumbar vertebra (L3-L5). The patient had an uneventful recovery and returned to his previous activity three months after surgery. The four-year follow-up evaluation showed normal spinal alignment, successful pain-free fusion without neurologic complications. Flexion/distraction injury without simultaneous rotation at the L4/L5 segment during traffic accidents or the fall of a heavy object on the bent back accompanied with posterior ligament weakness is thought to be the probable mechanism for this type of injury. Concomitant neurologic impairment is associated with the majority of L4/L5 spondylolisthesis cases. Posterior decompression, reduction, and posterior instrumentation enhances bony fusion, improves the patient's neurologic status and restores the sagittal alignment.

Femoral Bowing and Femoral Neck-Shaft Angle Evaluation Can Reduce Atypical Femoral Fractures in Osteoporotic Patients: A Scientific Report.

Bisphosphonates (BPs) are the mainstay of osteoporosis treatment due to their safety and efficacy. There is evidence that BPs medication may be complicated by atypical femoral fractures (AFFs). Prolonged administration of BPs is even more strongly associated with AFFs. AFF is a relatively rare complication of BPs when taking into account the huge population worldwide that benefits from this pharmacotherapy. AFF is, however, a serious complication of BPs treatment, which includes prolonged healing time and high revision rate when operative treatment is required. Less frequently, AFFs occur even without BPs administration, while these fractures have all the characteristics of "stress" or "insufficiency" fractures. The critical point of view in AFFs pathogenesis seems to be not only the biology of cortical bone, but also the mechanical issue. It has been proven that BPs, glucocorticoids and proton pump inhibitors (PPIs) can cause bone turnover suppression and affect the biological parameter of AFFs pathogenesis. Specific mechanical femoral bone properties predispose to AFFs pathogenesis. Several studies have already reported that increased femoral bowing > 5.250 degrees or decreased femoral neck-shaft angle <125 degrees, are associated with increased risk for diaphyseal and subtrochanteric AFFs respectively, regardless of BPs uptake. If these two parameters are simultaneously present, the probability for AFFs occurrence increases dramatically. Our scientific report, which is based on the current evidence about AFFs, is that if both femoral bowing angle and femoral neck-shaft angle are evaluated before BPs administration, this intervention may reduce the incidence of AFFs. Thus, in cases with excessive lateral femoral shaft bowing or very small femoral neck-shaft angle, the prescription of another anti-osteoporotic treatment than BPs should be recommended. If, however, BPs can't be avoided, clinicians should be aware of the fact that long-term administration may be implicated with AFFs occurrence. In these cases, short term BPs administration with timely drug holiday between three and five years may be reasonable. Finally, roentgenographic evaluation of both femurs every six months and medical reference in case of any emerging thigh pain are also logical interventions to prevent and reduce AFFs.

Hypovitaminosis D in the Greek Elderly Population Doesn't Concern Only Patients with Hip Fracture.

Introduction Vitamin D (VD) deficiency seems to be an underestimated public health issue, especially in countries with a significant duration of sunlight throughout the year, as in this sunny Mediterranean region where this cross-sectional observational study was held. This study was conducted to assess the hypothesis that a higher prevalence of hypovitaminosis D exists in the elderly population with a hip fracture as compared with patients with knee/hip osteoarthritis or lumbar spondylosis in a south-western Mediterranean region. Methods This study included 61 consecutive patients with a mean age of 83 years who sustained a hip fracture (Group A). Sixty patients, with an average age of 73 years, who suffered from degenerative hip/knee osteoarthritis or lumbar spondylosis were subsequently selected as the control group (Group B). Parathyroid hormone (PTH) and 25-hydroxy VD blood levels were measured. Results Ninety-six point seven percent (96.7%; 59/61) of the individuals with hip fracture and 81.7% (49/60) in the controls were found with abnormal VD values (<30 ng/ml). The comparison of vitamin D values between the total samples of group A and B revealed a statistically significant difference (unpaired t-test, p<0.0001) while both male (p=0.0049) and female (p<0.0001) individuals in group A also showed statistically significant lower VD levels than their counterparts did. In addition, increased levels of parathormone were observed in women of group A (p=0.0016) and, therefore, for group A in the total sample (p=0.0004) while no statistical significance was observed in males (p=0.7712). Age was found to be an independent risk factor for VD deficiency in both groups (Group A p=0.04, Group B p=0.043). It is noteworthy that only four patients from group B (6, 67%) and none from group A had undergone blood tests for VD and PTH evaluation before hospital admission. Conclusions Τhe results confirmed the initial hypothesis of the study. Although VD hypovitaminosis concerns the majority of elderly living in this south-western Mediterranean region, the authors suggest VD and PTH measurements regardless of annual insolation, to identify and counsel the elderly with an increased risk of hip fracture and to avoid perioperative complications in patients who undergo elective orthopedic surgeries.

Posterior Occipitocervical Fusion for Unstable Upper Cervical Trauma in Old and Elderly Population, Although Decreases Upper Cervical Rotation, Does Not Significantly Increase Neck Disability Index.

BACKGROUND: Despite the research progress in the thoraco-lumbo-pelvic balance, cervical spine balance has only recently gained increasing interest. To our knowledge, there is a lack of research regarding sagittal occipitocervical spine balance restoration following posterior occipitocervical fusion (POCF). PURPOSE: The primary outcome measure is the evaluation of sagittal cervical alignment roentgenographic parameters and the secondary is the functional outcome (NDI), following POCF for upper (C1 & C2) cervical trauma (UCT) in coexistence with upper cervical spine degeneration. Patients and Methods. Twenty old and elderly patients aged 62 ± 12 years with evident upper cervical degeneration, who received POCF for upper C1 & C2 unstable cervical spine injuries, were included. C2-C7 lordosis, C2-C7 SVA, spinocranial angle (SCA), T1-slope, neck tilt (NT), thorax inlet angle (TIA), cervical tilt (CT), cranial tilt (CrT), and C0-C1 angle were measured. The subfusion angle was used to study the behavior of the unfused cervical segments below fusion. The Neck Disability Index (NDI) was used for the functional outcome evaluation. 29 age-matched individuals were used as controls for radiographic analysis and self-reported functional status comparison. RESULTS: The roentgenographic data were measured 3 and 39 ± 12 months postoperatively. Twelve patients showed no disability, and eight showed mild disability. Postoperatively, the patients stood with less C2-C7 lordosis, SCA, and CT (P < 0.02) but with higher NT (P < 0.02) in comparison to the controls. The patient's neck disability (NDI) was increasing as TIA increases (P=0.023). Subfusion angle seems to adapt to C2-C7 lordosis (P < 0.0033) and C0-C2 angle (P < 0.003) without any changes till the last evaluation. CONCLUSIONS: POCF sufficiently restored occipitocervical sagittal balance along with functional outcome similar to controls in adult and elderly individuals with evident upper cervical degeneration. We do not recommend POCF for young active individuals without occipitocervical pathology, but in contrary, we recommend the removal of the spinocranial connection hardware after cervical fusion is completed.

Three-level lumbar Ponte osteotomies with less invasive pelvic fixation improve spinal balance, quality of life and decrease disability in adult and elderly women with moderate adult spinal deformity.

PURPOSE: To report on quality of life and radiological changes of Ponte osteotomies (POs) with long fixation for primary and revision surgery, in elderly women with adult spinal deformity (ASD). METHODS: Sixty-seven (67) women, aged 69 ± 7 years, received 3 POs, spinopelvic fixation plus TLIFs. Forty-nine (73%) patients received primary and 18 (27%) revision surgery. Survivorship analysis was made for unplanned revision surgery for broken rods (BR); proximal junction failure (PJF); and deep wound infection (DWI). ODI and SF-36 were used for disability (ODI) and quality of life (SF-36) evaluation. RESULTS: In total, 201 lumbar POs were made and 9.55 ± 3 levels fused. All patients were available 49 ± 11 months postoperatively. Postoperatively, SVA, CSVL, PI-LL, scoliosis, PT and T9-spinopelvic inclination were reduced, while LL and SS were increased significantly. At the final visit, PI-LL ≤ 10° was achieved in 26 (39.4%) patients; ≤ 15° in 51 (76%) patients, while all 67 patients showed a PI-LL ≤ 20°. Unplanned reoperation was performed in 11 (16.4%) patients: for BR in 5 (7.5%); for PJF in 3 (4.5%) and for DWI in 3 (4.5%) patients, respectively. With end point the reoperation for any reason the survival ± SE was 67.8% ± 0.1; for PJF 89.6 ± 0.065; and for BR 76% ± 0.1 in the final evaluation. There was no difference in survival between the primary and revision surgery groups (P = 0.568). ODI and SF-36 scores were improved postoperatively. CONCLUSIONS: Three-segment lumbar POs offered and maintained sufficient improvement of lumbar lordosis along with restoration of the sagittal and coronal spinal alignment, improvement of quality of life and disability of female adult and elderly population after primary and revision surgery for ASD.

Trifocal Femoral Fracture Treated With an Intramedullary Nail Accompanied With Compression Bolts and Lag Screws: Case Presentation and Literature Review.

Ipsilateral combined fractures of the proximal femur, femoral shaft, and distal femur occur rarely with few published cases in the literature. These injures are classified as type 4 combined femoral fractures according to the classification of Lambiris et al. We present a rare case of a combined injury including an ipsilateral intertrochanteric fracture, a mid-shaft transverse femoral fracture, and a Y-shaped intra-articular fracture of distal femur in a 36-year-old man following a traffic accident. There was also an un-displaced extra-articular fracture of the ipsilateral patella. This combined injury has been reported only once, while our treatment strategy has never been reported in the literature. We used a single long Gamma-nail to treat all three fractures, while we locked the nail distally with compression bolts. The intra-articular part of the distal femoral fracture was managed with two cannulated percutaneous 6.5 mm lag screws. This modification of the nail allowed us to lock the nail and also to compress the metaphyseal part of the distal femoral fracture and secure this fracture to the nail. Our patient had an uneventful recovery, while the union was observed to all fractures four months postoperatively. As these combined femoral injuries are rare, there is no consensus of the management of such fractures. Many authors suggest an individualized approach to these rare cases based on the configuration of all fractures, especially the proximal and the distal one. By this case presentation we cite an alternative treatment of type 4 combined femoral fractures. Trauma surgeons may benefit from this Gamma-nail modification for such complicated injuries.