Anatomical considerations of C2 lamina for the placement of translaminar screw: a review of the literature.

PURPOSE: The thorough knowledge of C2 lamina anatomy is essential for the avoidance of complications during screw fixation. We performed a review of the literature, aiming to detect what was found about anatomical feasibility of C2 translaminar fixation in different populations, along with possible recommendations for the avoidance of complications, and to detect whether factors such as race or gender could influence axis lamina anatomy and fixation feasibility. METHODS: We performed a search in PubMed and Cochrane database of systematic reviews for studies which correlated axis lamina anatomy with fixation feasibility. We extracted data concerning measurements on C2 lamina, the methods and conclusions of the studies. RESULTS: Twenty-six studies met our inclusion criteria. The studies mainly focused on Asian populations. Male gender was generally related to larger anatomical parameters of C2 lamina. The use of a C2 translaminar screw with a diameter of 3.5 mm was generally feasible, even in children, but there was disagreement about risk of vertebral artery injury. Computed tomography was most frequently recommended preoperatively. Three-dimensional reconstruction was suggested by some authors. CONCLUSION: C2 lamina anatomy generally permitted screw fixation in most studies, but there was disagreement about risk of vertebral artery injury. Preoperative computed tomography was generally recommended, while, according to some authors, three-dimensional reconstruction could be essential. However, there is a relative lack of studies about non-Asian populations. More research could further illustrate the anatomy of C2 lamina, clarify the safety of axis fixation for more populations and perhaps modify preoperative imaging protocols.

Morphometric analysis of the odontoid process: using computed tomography--in the Greek population.

AIM: A morphometric analysis of the odontoid process of the A2 vertebra, in the Greek population, was conducted using CT scan. We aimed to determine the feasibility to use one or two screws when treating fractures of this anatomic element. PATIENTS AND METHODS: One hundred and fifteen patients (57 men) of a mean age of 48 years (16-95 years) underwent a cervical spine CT scan examination. The anterior-posterior and transverse diameters of the odontoid process were measured from the base, at 1-mm interval upward on axial CT images. The length from the tip of the odontoid process to the anterior-inferior angle of the body of the axis was calculated. Data concerning the height and weight of the examined patients were collected. RESULTS: The mean transverse and anterior-posterior distances were found to be 11.46 and 10.45 mm, respectively, for the upper end of the odontoid process. At the neck level of the odontoid process, the equivalent mean values were 11.12 and 8.73 mm, respectively, while at the base, these distances were found to be 13.84 and 12.3 mm, respectively. The mean distance from the tip of the odontoid to its base was 17.25 and 17.28 mm, respectively, while the mean distance from the tip of the dens to the anterior-inferior corner of the axis' body was 39.2 mm. Men showed greater values than women. CONCLUSIONS: In this study, it was shown that in the Greek population there is enough room for one 4.5-mm or one 3.5-mm cannulated screw to be used. The application of two 3.5-mm screws is feasible in 58.6 % of the male and 26.3 % of the female population. This confirms that the knowledge of the true dimensions of the odontoid process is of paramount importance before the proper management of fractured dens using the anterior screw technique.

Successful treatment of congenital pseudarthrosis of the tibia: still a challenge.

The congenital pseudarthrosis of the tibia (CPT) is one of the most challenging problems in pediatric orthopedics. The primary treatment goals are outlined as osteosynthesis, stabilization of the ankle mortise by fibular stabilization and lower-limb-length equalization. Despite the fact that each of the aforementioned goals is difficult to be achieved regardless the surgical option, the main biological consideration is the same: pseudarthrosis resection, biological bone bridging of the defect by stable fixation and the correction of any angular deformity. The external fixation method is suggested as valuable treatment of CPT because it can address not only pseudarthrosis but also all complex deformities associated with this condition. However, treatment of CPT is impaired with complications due to the complex nature of the disease thus failure is common. The most common of these are refracture, growth disturbance, poor foot and ankle function with stiffness. Of these, refracture is the most common and serious complication after primary healing and might result in the reestablishment of pseudarthrosis. Therefore, an effective, safe and practical treatment method that minimizes the residual challenges after healing and accomplishes the multiple goals of treatment is needed. In this article, we report a patient with CPT treated successfully with external fixation. Level of evidence IV retrospective.

Cementless versus cemented unicompartmental knee arthroplasty: a systematic review of comparative studies.

There are still some controversies regarding the clinical use of cementless UKAs. The aim of this systematic review was to determine whether cementless medial UKA leads to similar outcomes compared to cemented medial UKA. This search was conducted in accordance with the Preferred Reporting Items for Systematic Reviews guidelines (PRISMA). The random effects model with 95% confidence interval (CI) was applied to the analysis. The I2 statistic was used to assess study heterogeneity. Six studies were eligible for inclusion (4784 UKAs, 4776 patients): 2947 cemented UKAs (61.6%) and 1837 cementless UKAs (38.4%). The overall mean follow-up was 4.9 years. The all-cause reoperation rate was 11.3% (80 of 706) at mean 5.7-year follow-up for cemented UKA and 6.9% (57 of 824) at mean 4.1-year follow-up for the cementless. The overall revision rate was 10.2% (303 of 2947) for the cemented and 5.8% (108 of 1837) for the cementless. Aseptic loosening was the most frequent reason of revision (2.3% cemented vs 0.5% cementless). The overall rate of radiolucent lines (RLL) was 28.3% (63 of 223) in the cemented cohort and 11.1% in the cementless (26 of 234). All the studies reported improved functional outcomes. Cementless UKA provides at least equivalent if not better results compared to cemented UKA. Despite the use of cemented UKA outnumber cementless fixation, available data shows that cementless UKA had a reduced midterm revision rate, while providing similar functional outcomes.

Kinematic and Kinetic Waveform Changes of the Knee Joint Following a Mobile Bearing Total Knee Arthroplasty-Gait Analysis and Single Step Ascent.

The objective of this study is to analyze the kinetic and kinematic changes of the osteoarthritic knee after a mobile bearing total knee arthroplasty. Kinematic and kinetic gait analysis of level walking was performed in 15 patients (eight female and seven male) with knee ostoarthritis. All patients were free of any neurological diseases that could affect their normal gait. Mean age was 68.6 ± 5.2 years, mean height 159.8 ± 6.9 cm, and mean weight was 78.5 ± 10.1 kg. Full body gait analysis was performed using the BioKin three-dimensional (3D) motion analysis system preoperatively and 9 months after total knee arthroplasty. A single-step ascending kinetic analysis and a plantar pressure distribution analysis were also performed in all patients. An increased average cadence (mean 99.39 step/min preoperatively and 104.64 step/min postoperatively; p = 0.152), step length (0.44 m preoperatively and 0.52 m postoperatively; p < 0.001), stride length (0.89 m preoperatively and 1.0 m postoperatively; p < 0.007), and walking velocity (0.73 m/sec preoperatively and 0.90 m/sec postoperatively; p = 0.005) were noted postoperatively and postoperatively. A decrease in the stance duration percentage and the knee adduction moment was also reported postoperatively. All patients showed a significant improvement of knee kinetics and kinematics after a mobile bearing total knee arthroplasty. Statistically significant differences were found in the step length, stride length, and walk velocity postoperatively. The knee adduction moment was also significantly reduced. Further research is warranted to determine the clinical relevance of these findings. This study is a prospective comparative one and reflects level II evidence.

A cost analysis of treatment of tibial fracture nonunion by bone grafting or bone morphogenetic protein-7.

The parameter of health economics in the use of any contemporary medical module plays a dominant role in decision making. A prospective nonrandomised comparative study of the direct medical costs on the first attempt of treating aseptic nonunions of tibial fractures, with either autologous-iliac-crest-bone-graft (ICBG) or bone morphogenetic protein-7 (BMP-7), is presented. Twenty-seven consecutive patients, who were successfully treated for fracture nonunions, were divided into two groups. Group 1 (n = 12) received ICBG and group 2 (n = 15) received BMP-7. All patients healed their nonunions, and the financial analysis presented represents a best-case scenario. Three out of 12 of the ICBG group required revision surgery while just one out of 15 required it in the BMP-7 group. Average hospital stay was 10.66 vs. 8.66 days, time-to-union 6.9 vs. 5.5 months, hospitals costs pound2,133.6 vs. pound1,733.33, and theatre costs were pound2,413.3 vs. pound906.67 for the ICBG and BMP-7 groups, respectively. The BMP-7 cost was pound3002.2. Fixation-implant was pound696.4 vs. pound592.3, radiology pound570 vs. pound270, outpatient pound495.8 vs. pound223.33, and other costs were pound451.6 vs. pound566.27 for the ICBG and BMP-7 groups, respectively. The average cost of treatment with BMP-7 was 6.78% higher (P = 0.1) than with ICBG, and most of this (41.1%) was related to the actual price of the BMP-7. In addition to the satisfactory efficacy and safety of BMP-7 in comparison to the gold standard of ICBG, as documented in multiple studies, its cost effectiveness is advocated favourably in this analysis.

History of osteochondral allograft transplantation.

Osteochondral defects or injuries represent the most challenging entities to treat, especially when occur to young and active patients. For centuries, it has been recognized that such defects are almost impossible to treat. However, surgeons have never stopped the effort to develop reliable methods to restore articular cartilage and salvage the endangered joint function. Osteochondral allograft transplantation in human was first introduced by Eric Lexer in 1908. Since that era, several pioneers have been worked in the field of osteochondral allotransplantation, presenting and developing the basic research, the methodology and the surgical techniques. Herein we present in brief, the history and the early clinical results of osteochondral allograft transplantation in human.

Patient radiation doses in various fluoroscopically guided orthopaedic procedures.

All orthopaedic fluoroscopic procedures performed using C-arm guidance were monitored for 1 y. The type of procedure, fluoroscopy time (T), kerma-area product (KAP) values and number of radiographs (F) were recorded. The two most often performed techniques were as follows: intramedullary nailing (IMN) of intertrochanteric/peritrochanteric (IP) fractures (101 cases, 49.3 %) and antergrade IMN of femur or tibia shaft (TS) fractures (28 cases, 13.7 %). For the remaining procedures, none accounted for >5 %, categorised as 'various' (76 cases, 37 %). Large variations in T, KAP and F were observed. For IMN of IP fractures, antergrade IMN of femur and TS fractures and for various procedures, respectively, median values were T--2.1, 2.2 and 0.6 min, KAP--6.3, 6.3 and 0.6 Gy cm(-2) and F--21, 2.2 and 6.7. The patient doses during fluoroscopically guided procedures are relatively low compared with other interventional procedures.

A prospective randomised controlled trial comparing three alternative bearing surfaces in primary total hip replacement.

The ideal bearing surface for young patients undergoing total hip replacement (THR) remains controversial. We report the five-year results of a randomised controlled trial comparing the clinical and radiological outcomes of 102 THRs in 91 patients who were < 65 years of age. These patients were randomised to receive a cobalt-chrome on ultra-high-molecular-weight polyethylene, cobalt-chrome on highly cross-linked polyethylene, or a ceramic-on-ceramic bearing. In all, 97 hip replacements in 87 patients were available for review at five years. Two hips had been revised, one for infection and one for peri-prosthetic fracture. At the final follow-up there were no significant differences between the groups for the mean Western Ontario and McMaster Universities osteoarthritis index (pain, p = 0.543; function, p = 0.10; stiffness, p = 0.99), Short Form-12 (physical component, p = 0.878; mental component, p = 0.818) or Harris hip scores (p = 0.22). Radiological outcomes revealed no significant wear in the ceramic group. Comparison of standard and highly cross-linked polyethylene, however, revealed an almost threefold difference in the mean annual linear wear rates (0.151 mm/year versus 0.059 mm/year, respectively) (p < 0.001).

Early palsy of the sciatic nerve due to heterotopic ossification after surgery for fracture of the posterior wall of the acetabulum.

We describe a patient in whom an initially intact sciatic nerve became rapidly encased in heterotopic bone formed in the abductor compartment after reconstruction of the posterior wall of the acetabulum following fracture. Prompt excision and neural release followed by irradiation and administration of indometacin resulted in a full neurological recovery and no recurrence 27 months later.

Factors determining quality of life and level of sporting activity after internal fixation of an isolated acetabular fracture.

We investigated whether patients who underwent internal fixation for an isolated acetabular fracture were able to return to their previous sporting activities. We studied 52 consecutive patients with an isolated acetabular fracture who were operated on between January 2001 and December 2002. Their demographic details, fracture type, rehabilitation regime, outcome and complications were documented prospectively as was their level and frequency of participation in sport both before and after surgery. Quality of life was measured using the EuroQol-5D health outcome tool (EQ-5D). There was a significant reduction in level of activity, frequency of participation in sport (both p < 0.001) and EQ-5D scores in patients of all age groups compared to a normal English population (p = 0.001). A total of 22 (42%) were able to return to their previous level of activities: 35 (67%) were able to take part in sport at some level. Of all the parameters analysed, the Matta radiological follow-up criteria were the single best predictor for resumption of sporting activity and frequency of participation.

Surgical techniques-How do I do it? Open reduction and internal fixation of posterior wall fractures of the acetabulum.

Posterior wall fractures are the commonest type of acetabular fracture. Nonoperative management is associated with significant complications and poor outcome. Consequently, open reduction and internal fixation has become increasingly common. In this article, inaugurating the new section of "how do I do it", we present our current approach to the treatment of posterior wall fractures of the acetabulum, including the preoperative planning, the details of the operative procedure in terms of patient's positioning and draping, surgical approach, osteosynthesis and wound closure.

What's new in the management of proximal femoral fractures?

The incidence of proximal femoral fractures has increased significantly in recent years, and is expected to continue to rise with increasing life expectancy. However, the optimal method of treatment of these fractures is still debated. This article summarises current evidence concerning the most controversial issues in the treatment of intracapsular and extracapsular proximal femoral fractures. Despite initial enthusiasm, many new treatment options have been proved inferior to older, traditional methods, and physicians should be cautious when it comes to managing these fractures. It seems that meticulous surgical technique and implant selection according to fracture pattern and the characteristics of the individual patient offer the best route to optimal final outcome.

Fracture vascularity and bone healing: a systematic review of the role of VEGF.

SUMMARY: Fracture healing constitutes a complex and delicate physiological process. Local vascularity at the site of the fracture has been identified as one of the most significant parameters influencing the healing procedure. VEGF is the most important component of the regeneration of the vascular system at the fracture site. The aim of this review is to determine the evidence supporting the direct role of VEGF in the enhancement of fracture healing and the possible clinical use of VEGF for non-unions. The literature search was performed via the internet using the Medline. The key words which were searched in the abstracts were the terms "VEGF", "angiogenesis", "fracture", "bone" and "healing". Twenty-five articles were relevant to the topic of interest. A total of 11 articles were excluded from our research due to non conformity of their content to the inclusion criteria. Evidence retrieved suggests that VEGF could be extremely valuable for the treatment of critical size bone defects and that VEGF could have a direct effect on osteoprogenitor cells, mainly by promoting the differentiation of osteoblasts and by increasing the mineralisation of the regenerated bone. The former observation could have very interesting repercussions for the field of non-unions and the latter for the field of osteoporosis.