The Use of Intraoperative Traction in Pediatric Scoliosis Surgery: A Systematic Review.

STUDY DESIGN: Systematic review. OBJECTIVE: To study the morbidity and the potential benefits of using intraoperative skeletal traction as an adjunct method for correcting scoliosis. SUMMARY OF BACKGROUND DATA: Cotrel et al., used intraoperative skeletal traction in all patients in their original series of segmental spinal instrumentation for scoliosis correction (Cotrel et al., Clin Orthop Relat Res 1988;227:10-23). However, the use of intraoperative traction may introduce other forms of surgical morbidity, which has not been systematically studied. METHODS: Two independent reviewers searched MEDLINE (1948-current) and EMBASE (1980-current) using the keywords scoliosis, intraoperative, and traction in all fields, combined with AND. Studies were subject to full-text assessment against specific inclusion and exclusion criteria; discrepancies between the reviewers were resolved by a third independent reviewer. Data were extracted into standardized extraction tables and papers were critically appraised papers with regards to their relative strengths and weaknesses, with particular attention to the study objective. RESULTS: Nine papers were included: case report (n = 1), retrospective case series (n = 2), retrospective case-control (n = 6), and studies included both adolescent idiopathic scoliosis (AIS) and neuromuscular scoliosis. Seven studies reported positive effects of intraoperative skeletal traction on diverse outcome measures, such as correction of pelvic obliquity, Cobb angle, and axial plane deformity, as well as precluding the need for an anterior release preceding posterior instrumentation for large curves. Overall, there was only one reported postoperative traction-related complication (anterosuperior iliac spine pressure sore). One paper reported that intraoperative traction may evoke neuromonitoring signal changes in a large proportion of patients undergoing AIS surgery. These changes were responded to intraoperatively by decreasing or removing weight and none of the patients had postoperative neurologic deficits. CONCLUSION: Isolated intraoperative skeletal traction may be a low-morbidity adjunct to facilitate scoliosis surgery. Further studies are needed to compare outcomes of scoliosis surgery with or without intraoperative skeletal traction.

Talus fractures: a current concepts review of diagnoses, treatments, and outcomes.

The talus is the key articular segment linking the leg and foot, and as such, is subject to complex loads and may occasionally fracture. Fracture patterns provide clues to the underlying pathomechanics and energy of the injury, both of which can help guide treatment and suggest prognosis. Talus fractures have a wide variety of presentation from low-energy avulsion fractures of the lateral or posterior processes, to high-energy comminuted talar body fractures. Appropriate, expedient treatment provides the patient the best chance of obtaining a good functional outcome. Treatment relies on appropriate diagnosis, which hinges on clinical suspicion provided by the patient's account of pathomechanics, clinical examination, and radiological workup. This current concepts review discusses the pathomechanics, presentation, workup, treatment, and prognosis of fractures of the talar head, neck, body, lateral process, posterior process, and talar extrusions. Key words: talus, fracture, talar neck, talar head, talar body, lateral process, posterior process, talar extrusion, orthopaedic surgery, review.

Bisphosphonates reduce bone mineral loss at ligament entheses after joint injury.

OBJECTIVE: To examine the effects of anterior cruciate ligament (ACL) insufficiency, and subsequent bisphosphonate (BP) antiresorptive therapy, on the bone mineral interface at the enthesis of remaining ligamentous restraints. METHODS: We measured bone mineral geometry (and subsequent adaptation) at the medial collateral ligament (MCL) origin, using micro-computed tomography (muCT). Groups of normal control, 6 and 14 wk anterior cruciate ligament transected (ACLX), and 6 wk ACLX-BP (risedronate) dosed rabbits were evaluated. Samples were then processed histologically, and the results of mineral adaptation and progression of osteoarthritis (OA) compared to joint laxity values obtained from previous biomechanical testing of the MCL-complex. RESULTS: muCT defined the MCL origin as a symmetrical, metaphyseal depression that contained soft-tissue elements, including fibrocartilage and ligament--as seen in subsequent histological sections. In contrast, the insertions from ACLX animals lost significant bone mineral, with an MCL-insertion volume 1.2 times that of normal controls at 6 wk ACLX, which further increased to 2.3 times that of normal controls at 14 wk ACLX. Significant differences were also measured between 6 and 14 wk ACLX and age-matched normal controls in volume of cortical bone containing the MCL insertion. However, there were no significant differences in the percentage of cortical bone to underlying trabecular bone at the MCL insertion. When comparing muCT mineral adaptation at the MCL-enthesis with historical MCL-complex laxity data, the values for laxity after ACLX increased proportionately as bone mineral at the insertion was lost, and subsequent use of the BP risedronate reduced both mineral loss and MCL-complex laxity. CONCLUSION: Compared to the untreated ACLX condition, administering bisphosphonate immediately after loss of the ACL conserved bone mineral at the MCL enthesis, suggesting the potential to therapeutically influence joint-complex laxity and OA progression.