Surgical Management of Hangman's Fracture: A Systematic Review.

BACKGROUND: Hangman's fractures are bilateral fractures of the C2 pars interarticularis produced during hyperextension injuries. The Levine-Edwards classification divides these fractures into 4 categories determined by injury stability. While stable fracture patterns are typically managed conservatively, prolonged traction required in unstable fractures may be superseded by surgery in its practicality. Surgical approaches can be divided into anterior and posterior: the anterior approach allows access to the disc and is used for anterior cervical discectomy and fusion (ACDF); the posterior approach includes C2 direct pedicle screw (DPS), which preserves motion segments and may be done with a minimally invasive surgery (MIS) approach. Multilevel rod and screw fusion provide the strongest biomechanical fixation. This systematic review compares indications, complications, and functional outcomes of different approaches. METHODS: A search of multiple databases with keywords "hangman fracture," "hangman's fracture," "axis fracture," and "C2 fracture" was conducted; articles were included if they described the surgical technique and included at least one of the primary outcomes: functional outcomes, complication rates, operation time, and blood loss. RESULTS: A total of 1889 abstracts were screened, 137 full text articles were analyzed, and 36 articles were included, yielding a combined total of 627 patients. ACDF was preferred in unstable fracture patterns. Pre- and postoperative visual analog scale (VAS) scores fell in all groups, with MIS DPS producing the lowest VAS scores. Approaches had excellent neurological improvement and fusion rates. Reported complication rates were generally low; self-limiting dysphagia was most common in the anterior approach and higher volumes of blood loss occured with the posterior approach (255.9 mL in open posterior approach, 75.8 mL in MIS, and 64.3 mL in ACDF). CONCLUSION: All surgical methods of hangman's fracture fixation have their indications and advantages; surgeons should be equipped to perform all options. Anterior approaches may be preferred for their lower blood loss and access to the disc; however, MIS may improve outcomes in posterior approach. CLINICAL RELEVANCE: This systematic review can assist spinal surgeons in the selection of the most appropriate surgical option for hangman's fracture and allow surgeons to inform patients of the risks and benefits.

Bullying in trauma and orthopaedics: a survey of staff in orthopaedic departments in the UK.

BACKGROUND/AIMS: An orthopaedic department requires good teamwork and communication to function. This is undermined by bullying and harassment, which may affect the victim's health and career. METHODS: A 26-item questionnaire was sent to all delegates who registered for a free orthopaedic webinar teaching series via email and social media. This study includes the responses from all those who had worked in a UK orthopaedic department. RESULTS: There were 168 respondents from varying backgrounds; 17.9% had experienced bullying or harassment in their orthopaedic department, while 36.3% had witnessed it. Women and people from ethnic minority backgrounds suffered 10.2% and 6.9% higher rates of bullying than their male or white counterparts respectively. CONCLUSIONS: The results demonstrate that despite attempts to reduce bullying in orthopaedics, it remains prevalent, and particularly affects women and those from ethnic minority backgrounds. Orthopaedic departments must adapt to reflect changes in society.

The successful use of collagenase for Ledderhose disease (plantar fibromatosis) in a paediatric patient: a case report.

Ledderhose disease is a connective tissue disorder involving proliferation of fibrous tissue in the plantar fascia of the foot. Histologically identical manifestations exist in the hand (Dupuytren's contracture) and penis (Peyronie's disease), and collagenase injections are approved as a treatment in both, however not in Ledderhose, where the treatment of choice remains surgical resection. Surgery is associated with high rates of recurrence and need for further surgery, so alternative therapies should be sought. Due to their histological and physiological similarities, it is likely that therapies useful in Dupuytren's and Peyronie's would be useful in Ledderhose. Two previous case reports investigating collagenase injections for Ledderhose disease in adults have shown conflicting results; this study demonstrates the efficacy of collagenase injections in a paediatric patient at 1-year follow-up.

Cervical Spine Pedicle Screw Accuracy in Fluoroscopic, Navigated and Template Guided Systems-A Systematic Review.

Background: Pedicle screws provide excellent fixation for a wide range of indications. However, their adoption in the cervical spine has been slower than in the thoracic and lumbar spine, which is largely due to the smaller pedicle sizes and the proximity to the neurovascular structures in the neck. In recent years, technology has been developed to improve the accuracy and thereby the safety of cervical pedicle screw placement over traditional fluoroscopic techniques, including intraoperative 3D navigation, computer-assisted Systems and 3D template moulds. We have performed a systematic review into the accuracy rates of the various systems. Methods: The PubMed and Cochrane Library databases were searched for eligible papers; 9 valid papers involving 1427 screws were found. Results: fluoroscopic methods achieved an 80.6% accuracy and navigation methods produced 91.4% and 96.7% accuracy for templates. Conclusion: Navigation methods are significantly more accurate than fluoroscopy, they reduce radiation exposure to the surgical team, and improvements in technology are speeding up operating times. Significantly superior results for templates over fluoroscopy and navigation are complemented by reduced radiation exposure to patient and surgeon; however, the technology requires a more invasive approach, prolonged pre-operative planning and the development of an infrastructure to allow for their rapid production and delivery. We affirm the superiority of navigation over other methods for providing the most accurate and the safest cervical pedicle screw instrumentation, as it is more accurate than fluoroscopy and lacks the limitations of templates.