Percutaneous balloon kyphoplasty of malignant lesions of the spine: a prospective consecutive study in 115 patients.

PURPOSE: To evaluate the benefits of minimally invasive balloon kyphoplasty (BKP) in patients with cancer and painful pathologic vertebral lesions. METHODS: In this longitudinal, prospective, consecutive study, patients received BKP at one or more vertebral levels. The BKP procedure was guided by computed tomographic fluoroscopy. Orthopaedic bone tamps were inflated to create a cavity and the fracture was stabilised using viscous polymethylmethacrylate bone cement. After the procedure, early mobilisation was encouraged. RESULTS: Overall, 115 patients (52.2% with vertebral fractures) received BKP. The majority (82.6%) of patients received BKP as a stand-alone procedure. BKP treatment provided significant (P<0.0001) improvements in Visual Analogue Scale (VAS)-pain (median change: -4), Oswestry Disability Index (ODI; mean change: -53.2), and Karnofsky Performance Status (KPS; median change: 15) scores at 6 and 12 months. In total, 23% of patients achieved increased vertebral height (7.4% mean improvement in angle index). The presence of height restoration and the number of levels treated did not affect VAS or ODI scores; improvements in KPS scores were numerically higher in patients who received BKP plus additional surgery (15-20) compared with stand-alone BKP (10-15). Mean hospital times were 7.2±6.5 days. The majority (97.4%) of patients showed no complications related to the procedure; three patients (2.6%) had a temporary radiculopathy. Incidences of cement leakage were observed in 40 patients (34.8%). CONCLUSIONS: Minimally invasive BKP provided excellent long-term palliation of pain and improved mobility in patients with cancer and painful osteolytic spinal lesions or vertebral fractures.

Partial weightbearing is not necessary after cementless total hip arthroplasty: a two-year prospective randomized study on 100 patients.

The purpose of this study was to evaluate the effects of partial and full weightbearing after cementless total hip arthroplasty over a two year follow-up period. Fifty-nine women and 41 men (average age 61 years) received an uncemented Spotorno stem and were randomised into a full and a partial weightbearing group. No significant difference was found between the groups with regard to the Merle d' Aubigne hip score, VAS pain level, shaft migration or radiographic signs of bony ingrowth. All femoral components seemed radiologically well-fixed and showed bone ingrowth at 24 months. Provided that solid initial fixation is obtained full weightbearing immediately after cementless total hip arthroplasty using a hydroxyapatite-coated Spotorno-type femoral shaft component can be recommended.

Decreasing glenoid inclination improves function in shoulders with simulated massive rotator cuff tears.

BACKGROUND: A massive rotator cuff tear leads to poor shoulder function as evidenced by diminished glenohumeral abduction and superior translation of the humeral head compared to its normal position. The inclination angle of the glenoid has been associated with rotator cuff tears. The objective of this study was to quantify the effect of a decreased glenoid inclination angle on glenohumeral kinematics during active abduction in shoulders with a simulated, massive rotator cuff tear. METHODS: Eight fresh-frozen full upper extremities were tested using a dynamic shoulder testing apparatus. After recording the kinematics of the intact shoulder, a massive rotator cuff tear was surgically simulated. An osteotomy of the glenoid was then performed and the inclination angle was decreased by 30 degrees . The translation of the humeral head during abduction and the maximum abduction angle were recorded. FINDINGS: With an intact rotator cuff minimal humeral head translation on the glenoid occurred and the maximum abduction angle was mean 85.5 degrees (SD 7.4 degrees ). A massive rotator cuff tear resulted in superior translation of the humeral head with impingement on the acromion. The maximum abduction angle was mean 15.5 degrees (SD 9.4 degrees ). Decreasing the inclination angle of the glenoid resulted in a significant reduction of superior humeral head translation during abduction and there was no impingement on the acromion. The maximum abduction achieved was mean 28.5 degrees (SD 17.0 degrees ). INTERPRETATION: From a clinical perspective the reduced superior translation may decrease shoulder pain since the humeral head no longer impinges on the acromion. Further investigations are necessary to assess if the improvement in abduction is clinically significant.

Epidemiology and outcome of complex pelvic injury.

Soft tissue injuries associated with pelvic fractures are often responsible for compromised haemodynamics. The objective of this study was to clarify what parameters determine patient outcome. In a cohort study, all patients with a pelvic fracture treated between 1991 and 2001 at a Level I trauma center were analysed for associated intrapelvic injuries, classification, severity of trauma, type of intervention and outcome. Of 552 patients with a pelvic fracture who entered the study, 15.5% presented with associated intrapelvic injuries secondary to the fracture (group I). A subgroup of patients with lacerations of branches of the iliac artery was identified as being at high risk for lethal outcome; they represented 4.3% of all patients with pelvic fracture (group II). The overall mortality reached 4.4%; it increased in group I to 15.5%, and in group II to 33.3%. In the subgroup with pelvic arterial haemorrhage (group II), the severity of injury, the proportion of multiple injured patients, the prevalence of unstable fractures and the incidence of sepsis were significantly increased. The only predictive factor for outcome was the amount of blood transfused, suggesting that fast elimination of the bleeding source decides about patient survival.

MRI and discography in traumatic intervertebral disc lesions.

In this study we evaluated magnetic resonance imaging (MRI) in trauma patients for assessing traumatised adjacent discs of fractured vertebrae before dorsoventral stabilisation. In a prospective study, MRI of 54 discs was performed with a 1.5-T MRI unit. The preoperative MRI with sagittal T1-W-SE and T2-W-TSE was compared to intraoperative discography, which was carried out on both intervertebral discs adjacent to the fractured vertebrae. Signal alterations, morphological changes in the adjacent discs, fractured vertebrae and associated ligament injuries were evaluated. In 47/54 (87%) of the intervertebral discs, the results of both imaging findings were concordant. The discs adjoining vertebral fractures were normal in 18 cases. Regarding the positive concordant imaging findings, MRI and discography revealed traumatised adjacent cranial and caudal discs in 22 discs. In 7 cases, only the cranial adjacent disc was affected. Moreover, 17 cases of intradiscal bleeding, 13 intraosseous herniations into the fractured vertebrae and 20 anuluar tears were visualised in MRI. Associated ligament injuries were detected in 18 cases. Findings were discordant in eight discs. In six discs, MRI was abnormal, demonstrating signal alterations suggestive of positive imaging findings, whereas discography demonstrated no disc injury. MRI failed to detect disc injury in two discs, whereas discography was positive, showing an irregular intradiscal contrast media distribution. MRI, as a non-invasive method for assessing fractures of the thoraco-lumbar spine, may detect traumatised adjacent intervertebral discs. MRI is superior to intraoperative discography. The performance of MRI of the thoraco-lumbar spine is recommended before dorsoventral stabilisation in trauma patients, as it can reveal additional preoperative information such as fractures, disc and associated ligament injuries.

Tourniquets may increase postoperative swelling and pain after internal fixation of ankle fractures.

UNLABELLED: Tourniquets frequently are used in orthopaedic surgery to provide a bloodless field. There is still controversy among authors regarding the benefits and potential risks of using a tourniquet. The objective of this prospective randomized study was to quantify the effect of tourniquet use on postoperative swelling, pain, and range of motion after open reduction and internal fixation of ankle fractures. Fifty-four patients with closed ankle fractures were treated surgically; 26 patients were operated on using a thigh tourniquet (Group A), and 28 patients had surgery without the use of a tourniquet (Group B). The groups of patients were similar for age, gender, fracture types, and operative procedures. There was no difference in operation time. Using a tourniquet during open reduction and internal fixation of ankle fractures did increase postoperative swelling and postoperative pain at Day 5 and at Week 6 after surgery. We found a trend for a better range of motion in the ankle until the 6-week followup in the nontourniquet group compared with the group in which the tourniquet was inflated. According to these results we do not recommend using a tourniquet for osteosynthesis of ankle fractures. LEVEL OF EVIDENCE: Therapeutic study, Level I-1 (randomized controlled trial). See the Guidelines for Authors for a complete description of levels of evidence.

Femur-LISS and distal femoral nail for fixation of distal femoral fractures: are there differences in outcome and complications?

We evaluated the functional and radiologic outcomes after stabilization of distal femoral fractures using the distal femoral nail and a less invasive stabilization system to determine if the new implants are superior to other implants (especially the condylar blade plate) regarding the rates of axial deviation, nonunion, and infection and if one of these new implants (Less Invasive Stabilization System, or distal femoral nail) is superior to the other. Two groups, each with 16 patients, were documented prospectively and the results were compared. To record the findings objectively, the Lysholm-Gillquist score was used. A conversion procedure was done in two patients in the plate group and one patient of the nail group. At the 1-year followup mobility of the knee was on average 110 degrees in the plate group and 103 degrees in the nail group. The Lysholm-Gillquist score did not show any significant differences between the groups. There were clinically relevant varus or outer rotation deviations in three patients in the plate group and two patients in the nail group. The two minimally invasive implants used were good in terms of technique and outcome for treatment of distal femoral fractures and did not differ significantly for epidemiology, fracture type, conversion procedures, infection rate, malalignments, and subjective and objective findings at the 1-year followup. They were also superior to the condylar plate in terms of infection and axial malalignments.