The axial transsacral approach to interbody fusion at L5-S1.

Lumbosacral interbody fusion may be indicated to treat degenerative disc disease at L5-S1, instability or spondylolisthesis at that level, and severe neural foraminal stenosis resulting from loss of disc space height. In addition, L5-S1 interbody fusion may provide anterior support to a long posterior fusion construct and help offset the stresses experienced by the distal-most screws. There are 3 well-established techniques for L5-S1 interbody fusion: anterior lumbar interbody fusion, posterior lumbar interbody fusion, and transforaminal lumbar interbody fusion. Each of these has advantages and pitfalls. A more recently described axial transsacral technique, utilizing the presacral corridor, may represent a minimally invasive approach to obtaining lumbosacral interbody arthrodesis. Biomechanical studies demonstrate that the stiffness of the axial rod is comparable to existing fixation devices, suggesting that, biomechanically, it may be a good implant for obtaining lumbosacral interbody fusion. Clinical studies have demonstrated good early results with the use of the axial transsacral approach in obtaining lumbosacral interbody fusion for degenerative disc disease, spondylolisthesis, and below long posterior fusion constructs. The technique is exacting and complications can be major, including rectal perforation and fistula, loss of correction, and pseudarthrosis.

Comparative analysis of acute blood loss anemia in robotic assisted vs. manual instrumented total knee arthroplasty.

Introduction: Robotic assisted total knee arthroplasty has become an increasingly popular technique over the past several years. Manual total knee arthroplasty can be associated with acute blood loss anemia. Instrumentation of the femoral canal with the alignment guide may in part contribute to this blood loss. Because the femoral canal is not entered during robotic assisted total knee arthroplasty, the blood loss may be lower compared to that seen in manual total knee arthroplasty. The purpose of this study was to determine if acute blood loss is greater in manually instrumented total knee arthroplasty versus robotic assisted total knee arthroplasty. Materials and methods: This retrospective cohort study was performed in a large tertiary academic hospital network by two fellowship trained surgeons. Patients underwent either robotic assisted or manually instrumented total knee arthroplasty and were assessed for postoperative acute blood loss anemia, defined as hemoglobin <13 g/dL for males or <12 g/dL for females plus a 2 g/dL drop from preoperative levels, as well as postoperative drop in hemoglobin. Results: A total of 75 patients were included in each study arm. There was no significant difference (p > 0.05) in postoperative hemoglobin in robotic assisted (2.1 g/dL) compared to manually instrumented total knee arthroplasty (2.1 g/dL). There was no significant difference in the incidence of postoperative acute blood loss anemia between robotic assisted (45 %) and manually instrumented total knee arthroplasty (39 %). Higher BMI and increased age were protective against postoperative drop in hemoglobin. These protective effects were not significant when controlling for confounding variables. Surgical time was significantly longer for robotic assisted (99 min) versus manually instrumented total knee arthroplasty (86 min) (p < 0.001). Conclusions: There is no significant difference in acute blood loss when comparing patients undergoing robotic assisted and manually instrumented total knee arthroplasty.

Management of metastatic bone disease of the acetabulum.

Metastatic acetabular disease can be severely painful and may result in loss of mobility. Initial management may consist of diphosphonates, narcotic analgesics, radiation therapy, protected weight bearing, cementoplasty, and radiofrequency ablation. Patients with disease affecting large weight-bearing regions of the acetabulum and with impending failure of the hip joint are unlikely to gain much relief from nonsurgical treatment and interventional procedures. The profound osteopenia of the acetabulum, limited healing potential of the fracture, and projected patient life span and function necessitate surgical techniques that provide immediate stable fixation to reduce pain and restore ambulatory function. Current reconstructive procedures, including cemented total hip arthroplasty, the saddle or periacetabular endoprosthesis, and porous tantalum implants, are based on the quality of remaining acetabular bone as well as the patient's level of function and general health. Well-executed acetabular reconstructions can provide durable hip joints with good pain relief and function.

ORIF of an intertrochanteric fracture proximal to an above-knee amputation using two AO femoral distractors.

We present the case of a patient who sustained a displaced intertrochanteric fracture proximal to an above-the-knee amputation. Reduction was obtained using 2 AO femoral distractors placed anteriorly and laterally, spanning the hip joint. Fracture fixation was achieved using a sliding hip screw and side plate. Intertrochanteric fractures proximal to an above-the-knee amputation are challenging to manage because of the difficulty in obtaining sufficient skin traction on the stump to effect reduction. Using two femoral distractors anteriorly and laterally can help obtain length and alignment in these difficult cases.

Degenerative lumbar spinal stenosis: evaluation and management.

Degenerative lumbar spinal stenosis is caused by mechanical factors and/or biochemical alterations within the intervertebral disk that lead to disk space collapse, facet joint hypertrophy, soft-tissue infolding, and osteophyte formation, which narrows the space available for the thecal sac and exiting nerve roots. The clinical consequence of this compression is neurogenic claudication and varying degrees of leg and back pain. Degenerative lumbar spinal stenosis is a major cause of pain and impaired quality of life in the elderly. The natural history of this condition varies; however, it has not been shown to worsen progressively. Nonsurgical management consists of nonsteroidal anti-inflammatory drugs, physical therapy, and epidural steroid injections. If nonsurgical management is unsuccessful and neurologic decline persists or progresses, surgical treatment, most commonly laminectomy, is indicated. Recent prospective randomized studies have demonstrated that surgery is superior to nonsurgical management in terms of controlling pain and improving function in patients with lumbar spinal stenosis.

Surgical correction of kyphotic deformity in spinal tuberculosis.

PURPOSE: Approximately 5% of patients with spinal tuberculosis will develop a severe kyphotic deformity resulting in increased potential for pain, spinal cord compression, cardiopulmonary dysfunction, costopelvic impingement and cosmetic concerns. This manuscript reviews the evaluation and surgical management of tuberculous kyphosis. METHODS: This is a review article. RESULTS: Risk factors for the development of severe kyphosis include those who develop spinal tuberculosis as children, multiple vertebral body involvement and thoracic spine involvement. These complications can be prevented by early diagnosis and treatment of spinal tubercular lesions at stages with little to no deformity. When tubercular lesions result in progression of kyphosis to more than 50 degrees, the deformity should be surgically corrected to avoid problems associated with sagittal imbalance. There are several operations described for the treatment of kyphosis secondary to tuberculous spondylitis. The type of the operation depends on the magnitude of correction required. CONCLUSIONS: Anterior, posterior and combined techniques as well as osteotomies and vertebral column resection have been described to correct spinal alignment and restore sagittal balance.

Simultaneous Displaced Anterior and Posterior Cruciate Ligament Avulsion Fractures After Fall From a Bicycle: A Case Report.

CASE: We present the case of a 31-year-old man who sustained simultaneous displaced anterior and posterior cruciate ligament (PCL) tibial avulsion fractures after falling from a bicycle. CONCLUSION: Combined avulsion fractures of the anterior and PCLs is an extremely unusual event and has rarely been reported. The displaced fragments pulled proximally by their respective cruciate ligaments required open reduction and internal fixation to prevent impingement and instability. The patient had excellent clinical and radiographic results after open reduction internal fixation of both fractures.

Current Methods for the Evaluation and Surgical Treatment of Periprosthetic Femur Fractures Complicating Hip Arthroplasty.

Over the next decade, orthopedic surgeons will encounter an increasing number of periprosthetic fractures of the femur after hip arthroplasty. This rise is directly related to the increasing numbers of primary and revision hip arthroplasties being performed and the aging of the population. The Vancouver classification is the most widely used classification system for periprosthetic fractures of the femur occurring after hip arthroplasty. This classification considers the location of the fracture in relation to the femoral stem, the stability of the femoral stem, and the availability of femoral bone stock for revision. Most Vancouver AG and AL fractures can be treated nonsurgically, the exceptions being fractures associated with osteolysis and clamshell fractures of the lesser trochanter. B and C type fractures usually require operative intervention. Both Vancouver B1 and C types can be treated with fracture fixation alone, as the femoral implant is stable. Vancouver types B2 and B3 require femoral revision as the implant is loose. Distinguishing between types B1 and B2 can be difficult from radiographs alone and may require computed tomography and intraoperative testing.

Pectoralis Major Muscle Belly Repair in a Young Male Adult: A Case Report.

CASE: A 29-year-old man sustained a near-complete laceration to the left pectoralis major muscle belly. The muscle and epimysium were repaired using the Kragh technique-a combination of running interlocked and Mason-Allen stitches. At the 6-year follow-up, the patient had an excellent outcome as measured by clinical scores (Short Form Survey-36, Disabilities of the Arm, Shoulder, and Hand, and American Shoulder and Elbow Surgeons Score), bench press, cosmesis, and magnetic resonance imaging. CONCLUSIONS: Acute traumatic open pectoralis muscle belly tears may be successfully repaired in select patients using the Kragh technique with excellent postoperative function and cosmesis.

Hemiarthroplasty for Femoral Neck Fractures in the Elderly: A Comparison of Cemented and Uncemented Femoral Stems.

The incidence of displaced femoral neck fractures among elderly patients is increasing as the population ages.Historically, the preferred treatment for displaced femoral neck fractures in elderly patients has been hemiarthroplasty with use of cemented fixation of the implant. However, there is evidence that this technique may be associated with fat embolization and subsequent cardiopulmonary arrest in the early postoperative period. Cementing techniques are also associated with increased operative time when compared with cementless techniques.There is increasing evidence that, among elderly patients, the use of uncemented hemiarthroplasty has equivalent functional outcomes and overall mortality rates when compared with the use of hemiarthroplasty with cemented fixation. The main complication associated with uncemented hemiarthroplasty is intraoperative periprosthetic fracture.

Risk of malnutrition in orthopedic trauma patients with surgical site infections is associated with increased morbidity and mortality - a 3-year follow-up study.

BACKGROUND: Malnutrition is a worldwide problem which can result in prolonged hospitalization from complications such as poor wound healing and increased morbidity. There is increasing evidence of the effect of risk of malnutrition (ROM) on outcomes in orthopedic surgical patients. However, there is little data on the effect of nutritional status on clinical outcomes in orthopedic trauma patients with surgical site infections (SSI). Therefore, our aim was to investigate how malnutrition risk affects clinical outcomes in a prospective cohort of orthopedic trauma patients with SSI. METHODS: The study included 345 patients who underwent surgery due to SSI at a level 1 trauma center. All patients were evaluated on their nutritional status as assessed by the Nutritional Risk Screening in 2014/15 and 2017/18. 238 (69.0%) datasets were available for the follow-up analysis. Twenty patients (8.4%) had died, resulting in 218 patients. Outcomes investigated included comorbidities, medication intake, destination of discharge, degree of mobility, support for procuring food, mortality risk and quality of life. RESULTS: 32.8% were at risk of malnutrition (ROM) at EXAM1. Female patients had a higher ROM than males (p < 0.05). Patients with ROM had more comorbidities (p < 0.001), an increased need for medication intake (p < 0.001), a decreased level of mobility (p < 0.001) and increased need of support in procuring food (p < 0.001). The destination of discharge was independent of the nutritional status (p = 0.641). Twenty (8.4%) of the available 238 patients had died during follow-up time period, resulting in a 6.2-times higher risk of mortality in patients with ROM. EQ-5D revealed that mobility, self-supply and usual activities of daily living were increased in well-nourished patients (p < 0.001). CONCLUSION: ROM in orthopedic trauma patients with SSI is associated with an increased number of comorbidities and need for medication intake, a decrease in mobility and a higher dependency for food acquisition. Patients at ROM exhibited a 6.2-times higher mortality rate than well-nourished patients. EQ-5D evaluation showed better mobility, self-supply, and activity of daily living in well-nourished patients. We therefore strongly recommend supplementing patients with ROM with a specific diet during and after discharge from the hospital in order to reduce postoperative complications and long-term mortality.

Acetabular Fracture Resulting from a Basketball Cutting Movement in a Young Adult Male: A Case Report.

CASE: We present the case of a 26-year-old man who sustained a right transverse-posterior wall acetabular fracture while performing a cutting movement playing basketball. CONCLUSIONS: Acetabular fracture after a relatively low-energy injury in a healthy young adult male is an extremely unusual event. The cutting movement to the right likely forcefully placed the right hip in flexion, adduction, and internal rotation directing the femoral head into the posterior wall. The patient had excellent clinical and radiographic results after acetabular open reduction and internal fixation.

Gastrointestinal stromal tumors: a comprehensive review.

Gastrointestinal stromal tumors (GISTs) are rare neoplasms of the gastrointestinal tract associated with high rates of malignant transformation. Most GISTs present asymptomatically. They are best identified by computed tomography (CT) scan and most stain positive for CD117 (C-Kit), CD34, and/or DOG-1. There have been many risk stratification classifications systems which are calculated based on tumor size, mitotic rate, location, and perforation. The approaches to treating GISTs are to resect primary low-risk tumors, resect high-risk primary or metastatic tumors with imatinib 400 mg daily for 12 months, or if the tumor is unresectable, neoadjuvant imatinib 400 mg daily followed by surgical resection is recommended. Sunitinib is required for KIT exon 9, 13, and 14 mutations, while ponatinib is used for exon 17 mutations and regorafenib for highly refractory tumors. High-risk tumors should be monitored for recurrence with serial abdominal CT scans. Radiofrequency ablation has shown to be effective when surgery is not suitable. Newer therapies of ipilimumab, nivolumab, and endoscopic ultrasound alcohol ablation have shown promising results. This report addresses the epidemiology, clinical presentation, diagnostic imaging, histologic diagnosis, classification and risk stratification, staging and grading, surgical treatment, adjuvant treatment, and metastasis of GISTs.

Use of the Pelvic C-Clamp to Mitigate Acute Respiratory Distress Syndrome in a Patient with an Unstable Sacral Fracture.

CASE: We present the case of a 21-year-old man who fell from a roof, sustaining a displaced sacral fracture with pelvic instability. He developed acute respiratory distress syndrome (ARDS) within 24 hours of injury. Placement of the pelvic C-clamp resulted in rapid resolution of pulmonary dysfunction, allowing for definitive internal fixation. CONCLUSION: The C-clamp is most commonly used to control hemorrhage in unstable posterior pelvic ring injuries. Our case demonstrates a rare use of the C-clamp to stabilize the posterior pelvis in a patient with an unstable sacral fracture and ARDS, to rapidly improve pulmonary function prior to definitive surgery.

Combined Ipsilateral Humeral Shaft and Galeazzi Fractures Creating a Floating Elbow Variant.

"Floating elbow" injuries of the arm traditionally represent a combination of humeral shaft and forearm fractures which require anatomic rigid open reduction and internal fixation of all fractures to allow for early range of motion exercises of the elbow. There are published variants of the floating elbow injury which include ipsilateral diaphyseal humeral fracture, proximal ulna fracture with proximal radioulnar joint disruption, and ipsilateral diaphyseal humeral fracture with elbow dislocation and both bones forearm fracture. We present the case of a 21-year-old woman whose left arm became caught between the side of a waterslide and adjacent rocks at a park. She sustained a torsional and axial loading injury to her left upper extremity resulting in ipsilateral humeral shaft and Galeazzi fractures. The combination of ipsilateral humeral shaft and Galeazzi fractures resulted in a rare floating elbow variant. Prompt open reduction and internal fixation of both fractures and early range of motion of the elbow and wrist resulted in an excellent clinical and radiographic result. Floating elbow injuries and their variants should be promptly recognized as early anatomic reduction, and rigid internal fixation can allow for good elbow function with minimization of stiffness.

Fracture of the Neck of a Lateral Flare Femoral Implant in Total Hip Arthroplasty.

We present the case of a 38-year-old man who presented 7 years after primary total hip replacement with a fracture of the neck of a lateral flare femoral stem and catastrophic polyethylene wear. The unique design of the lateral flare hip stem has been shown previously to be associated with accelerated polyethylene wear, whereas the stem remains well fixed. The resultant polyethylene wear results in the harder cobalt chrome head abrading the titanium shell generating metallic debris. This may have resulted in proximal migration of the implant neck into the cup with subsequent neck-cup impingement and implant fracture.

Knee Osteoarthritis with Chronic Quadriceps Tendon Rupture Treated with Total Knee Arthroplasty and Extensor Mechanism Allograft Reconstruction: A Case Report.

CASE: A 51-year-old male construction worker with a history of chronic quadriceps tendon rupture presented with no active knee extension and tricompartmental knee osteoarthritis. He underwent simultaneous total knee arthroplasty and extensor mechanism allograft reconstruction. At 4 years postoperatively, the patient had pain-free knee function and active extension. CONCLUSION: The combination of a chronic quadriceps tendon rupture with lack of active knee extension and knee osteoarthritis is a rare and challenging problem. To our knowledge, this combined diagnosis and the treatment described in this case report have not been reported previously in the literature.

Sciatic nerve release following fracture or reconstructive surgery of the acetabulum.

BACKGROUND: Sciatic neuropathy associated with acetabular fractures can result in disabling long-term symptoms. The purpose of this retrospective study was to evaluate the effect of sciatic nerve release on sciatic neuropathy associated with acetabular fractures and reconstructive acetabular surgery. METHODS: Between 2000 and 2004, ten patients with sciatic neuropathy associated with an acetabular fracture were treated with release of the sciatic nerve from scar tissue and heterotopic bone. Additional surgical procedures included open reduction and internal fixation of the acetabulum (five patients), removal of hardware and total hip arthroplasty (three patients), and removal of hardware alone (one patient). The average age of the patients was forty-three years. All patients were followed with serial examinations and assessments for a minimum of one year (average, twenty-six months). RESULTS: All patients had partial to complete relief of radicular pain, of diminished sensation, and of paresthesias after the nerve release. Four of seven patients with motor loss and two of five patients with a footdrop demonstrated improvement in function after the nerve release. No patient had evidence of worsening on neurologic examination after the release. CONCLUSIONS: Sciatic nerve release during reconstructive acetabular surgery can decrease the sensory symptoms of preoperative sciatic neuropathy associated with a previous acetabular fracture. Motor symptoms, however, are less likely to resolve following nerve release.

Posttraumatic contracture of the elbow: current management issues.

Posttraumatic elbow stiffness can impose severe functional limitations on the performance of activities of daily living. Prevention is key to avoiding a motion-limiting condition. Fractures should be anatomically reduced and stabilized with active and active-assisted range of motion exercises instituted as early as possible to minimize the development of stiffness. Established contractures should be treated initially with physical therapy and static-progressive splinting. Patients who have failed a minimum of six months of nonsurgical management and who are motivated to comply with postoperative rehabilitation are candidates for surgical release. There are several effective surgical approaches and techniques available. The choice of surgical approach and technique is dictated by the location of the pathology, condition of the skin, and degree of arthritic changes. A major challenge to care is the management of the young patient with posttraumatic elbow contracture and advanced degenerative changes for which there is currently no reliable long-term surgical treatment.

A silencer element in the cartilage oligomeric matrix protein gene regulates chondrocyte-specific expression.

The molecular mechanisms by which mesenchymal cells differentiate into chondrocytes are poorly understood. The cartilage oligomeric matrix protein gene (COMP) encodes a noncollagenous extracellular matrix protein whose expression pattern correlates with chondrocyte differentiation and arthritis. We have used the COMP promoter as a model to identify regulatory sequences necessary for chondrocyte-specific expression and to identify cell type-specific proteins that bind these sequences. We have previously cloned 1.9 kilobases of the 5(') flanking promoter sequence of the murine COMP gene and by deletion analysis have identified two spatially distant chondrocyte-specific regulatory regions. One element is situated proximally (-125 to -75), and a second region is located distally (-1925 to -592) relative to the transcription start site. In the present study, we performed a finer deletion analysis of the region of the COMP promoter from -1925 to -592 and identified a silencer region situated between -1775 and -1725. This silencer binds sequence-specific protein complexes; the intensity of these complexes is greater in two different fibroblast cell lines (NIH3T3 and 10T1/2) than in chondrocytic RCS cells. Competition experiments localized the binding site of these protein complexes from -1775 to -1746; deletion of this 30-bp site results in a selective increase in COMP promoter activity in fibroblasts. Four tandem repeats of this 30-bp site are sufficient to confer negative transcriptional regulation on a heterologous promoter (SV40) in NIH3T3 fibroblasts. These results suggest that negative regulation of transcription is an important mechanism for chondrocyte-specific expression of the COMP gene.