Surgical management of U-shaped sacral fractures: a systematic review of current treatment strategies.

PURPOSE: U-shaped sacral fractures usually result from axial loading of the spine with simultaneous sacral pivoting due to a horizontal fracture which leads to a highly unstable spino-pelvic dissociation. Due to the rarity of these fractures, there is lack of an agreed treatment strategy. METHODS: A thorough literature search was carried out to identify current treatment concepts. The studies were analysed for mechanism of injury, diagnostic imaging, associated injuries, type of surgery, follow-up times, complications, neurological, clinical and radiological outcome. RESULTS: Sixty-three cases were found in 12 articles. No Class I, II or III evidence was found in the literature. The most common mechanism of injury was a fall or jump from height. Pre-operative neurological deficit was noted in 50 (94.3%) out of 53 cases (not available in 10 patients). The most used surgical options were spino-pelvic fixation with or without decompression and ilio-sacral screws. Post-operative complications occurred in 24 (38.1%) patients. Average follow-up time was 18.6 months (range 2-34 months). Full neurological recovery was noted in 20 cases, partial recovery in 14 and 9 patients had no neurological recovery (5 patients were lost in follow-up). Fracture healing was mentioned in 7 articles with only 1 case of fracture reduction loss. CONCLUSION: From the current available data, an evidence based treatment strategy regarding outcome, neurological recovery or fracture healing could not be identified. Limited access and minimal-invasive surgery focussing on sacral reduction and restoration seems to offer comparable results to large spino-pelvic constructs with fewer complications and should be considered as the method of choice. If the fracture is highly unstable and displaced, spino-pelvic fixation might offer better stability.

An immunohistochemical study of the dorsal capsule of the lumbar and thoracic facet joints.

STUDY DESIGN: The molecular composition of the extracellular matrix in the dorsal capsules of lumbar and thoracic facet joints was analyzed immunohistochemically. OBJECTIVES: To determine whether the immunohistochemical profile of the lumbar joint capsule suggests a role of the capsule in limiting axial rotation of the lumbar motion segment. SUMMARY OF BACKGROUND DATA: During axial rotation of the lumbar vertebrae, the axis of rotation shifts toward the facet joints in the direction of rotation. Thus, the capsule of the opposing joint should become tensed and wrap around the inferior articular process. Previous studies suggest that wrap-around ligaments are fibrocartilaginous. However, thoracic joint capsules are largely shielded from such loading and should be purely fibrous. METHODS: Dorsal capsules were removed from lumbar and thoracic facet joints of six adult cadavers. Specimens were immunolabeled with monoclonal antibodies for collagens, chondroitin, dermatan and keratan sulfates, versican, tenascin, aggrecan and link protein. Antibody binding was detected using the Vectastain ABC 'Elite' peroxidase kit (Vector Laboratories, Inc., Burlingame, CA). RESULTS: Both lumbar and thoracic joint capsules immunolabelled for most glycosaminoglycans and for Type I, III and VI collagens. However, labeling for Type II collagen, chondroitin-6-sulfate, aggrecan, and link protein was restricted to lumbar capsules. Such labeling was constantly seen at entheses and occasionally in the midsubstance. CONCLUSIONS: The molecular composition of the lumbar joint capsule suggests that it acts as a fibrocartilaginous, 'wrap-around' ligament that withstands compression in addition to tension during torsional movements of the lumbar spine. It wraps around the inferior articular process as rotation occurs and limits further movement.

[The enthesis. Physiological morphology, molecular composition and pathoanatomical alterations]. / Die Enthesis. Physiologische Morphologie, molekulare Zusammensetzung und pathoanatomische Veränderungen.

The composition of the extracellular matrix in tendons and ligaments is directly related to the mechanical environment. Local compression triggers functional adaptation that leads to cartilage-specific transformation of the tissue. The molecular composition of the extracellular matrix at the enthesis is related to the amount of stress and to the geometry of the insertion. Comparison of physiologically and non-physiologically loaded entheses shows that only certain molecules occur under relatively high amounts of local compressive stress. The occurrence of certain cartilage specific molecules is clinically relevant, because some of these molecules have been identified as autoantigens during the autoimmune response in patients with rheumatoid arthritis. These molecules constitute potential targets for the manifestation of rheumatoid arthritis at fibrocartilaginous entheses.

Comparative and functional anatomy of the mammalian lumbar spine.

As an essential organ of both weight bearing and locomotion, the spine is subject to the conflict of providing maximal stability while maintaining crucial mobility, in addition to maintaining the integrity of the neural structures. Comparative morphological adaptation of the lumbar spine of mammals, especially in respect to locomotion, has however received only limited scientific attention. Specialised features of the human lumbar spine, have therefore not been adequately highlighted through comparative anatomy. Mathematical averages were determined of 14 measurements taken on each lumbar vertebrae of ten mammalian species (human, chimpanzee, orang-utan, kangaroo, dolphin, seal, Przewalski's horse, cheetah, lama, ibex). The revealed traits are analysed with respect to the differing spinal loading patterns. All examined mammalian lumbar spines suggest an exact accommodation to specific biomechanical demands. The lumbar spine has reacted to flexion in a predominant plane with narrowing of the vertebral bodies in quadrupeds. Torsion of the lumbar spine is withstood by an increase in the transverse distance between the inferior articular processes in the upper lumbar spine in primates, but lower lumbar spine in humans, quadrupeds and the seal. Sagittal zygapophyseal joint areas resist torsion in the seal and humans. Ventral shear is resisted by frontal zygapophyseal joint areas in humans and primates, and dorsal shear by encompassing joints in the ibex. The human fifth lumbar vertebra is remarkable in possessing the largest endplate surface area and the widest distance between the inferior articular processes, as an indicator of the high degree of axial load and torsion in bipedalism.

The skeletal attachment of tendons--tendon "entheses".

Tendon entheses can be classed as fibrous or fibrocartilaginous according to the tissue present at the skeletal attachment site. The former can be "bony" or "periosteal", depending on whether the tendon is directly attached to bone or indirectly to it via the periosteum. At fibrocartilaginous entheses, the uncalcified fibrocartilage dissipates collagen fibre bending and tendon narrowing away from the tidemark; calcified fibrocartilage anchors the tendon to the bone and creates a diffusion barrier between the two. Where there are additional fibrocartilaginous specialisations in the tendon and/or bone next to the enthesis, an "enthesis organ" is created that reduces wear and tear. Little attention has been paid to bone at entheses, despite the obvious bearing this has on the mechanical properties of the interface and the clinical importance of avulsion fractures. Disorders at entheses (enthesopathies) are common and occur in conditions such as diffuse idiopathic skeletal hyperostosis and the seronegative spondyloarthropathies. They are also commonly seen as sporting injuries such as tennis elbow and jumper's knee.