The procedure of anterior lumbar interbody fusion (ALIF) is commonly performed on patients suffering from pain and/or neurological symptoms associated with disorders of the lumbar spine caused by disc degeneration and trauma. Surgery is indicated when prolonged conservative management proves ineffective. Because an important objective of the ALIF procedure is solid arthrodesis of the degenerative spinal segment, bone graft selection is critical. Iliac crest bone grafts (ICBG) remain the “gold standard” for achieving lumbar fusion. However, patient dissatisfaction stemming from donor site morbidity, lengthier operating times and finite supply of ICBG has prompted a search for better alternatives. Here presented is a literature review evaluating available bone graft options assessed within the clinical setting. These options include autografts, allograft-based, synthetic and cell-based technologies. The emphasis is on the contentious use of recombinant human bone morphogenetic proteins, which is in widespread use and has demonstrated both significant osteogenic potential and risk of complications.
]]>Charcot neuroarthropathy (CN) is a rare, progressive, deforming disease of bone and joints, especially affecting the foot and ankle and leading to considerable morbidity. It can also affect other joints such as the wrist, knee, spine and shoulder. This disease, described originally in reference to syphilis, is now one of the most common associates of diabetes mellitus. As the number of diabetics increase, the incidence of CN is bound to rise. Faster initial diagnosis and prompt institution of treatment may help to reduce its sequelae. There should be a low threshold for ordering investigations to assist coming to this diagnosis. No single investigation is the gold standard. Recent studies on pathogenesis and development of newer investigation modalities have helped to clarify the mystery of its pathogenesis and of its diagnosis in the acute phase. Various complementary investigations together allow the correct diagnosis to be made. Osteomyelitis continues to be confused with acute CN. Hybrid positron emission tomography has shown some promise in differentiating these conditions. A multispecialty approach involving diabetologists, orthopaedists and podiatrists should be used to tackle this difficult problem. The aim of this article is to describe current knowledge about CN with particular reference to the status of diagnostic indicators and management options.
]]>The Rule of Spence states that displacement of the C1 lateral masses by >6.9–8.1 mm suggests loss of transverse ligament integrity. The purpose of this study was to establish the thresholds of C1 displacement on CT scans that correspond to transverse ligament disruption.
Over four years, consecutive patients with acute C1 fractures with at least three fracture lines were analyzed. CT measurements and MRI were assessed by blinded observers for bony displacement in the axial (internal and external lateral mass separation), coronal and sagittal planes and transverse ligament integrity.
Eighteen patients were studied. Mean CT bony measurements were as follows: internal border lateral mass separation (ILM) 23.3 ± 3.4 mm, external border lateral mass separation (ELM) 50.3 ± 4.3 mm, total C1 lateral mass overhang over the C2 superior process (LMO) 5.4 ± 1.3 mm. Twelve patients were identified as having intact transverse ligament and six had transverse ligament disruption. There was no difference in mean normalized ILM, ELM, or LMO between patients with or without transverse ligament integrity (P > 0.05).
There was no correlation between bony displacement and transverse ligament integrity. CT scans post-injury may not show the position of maximal displacement. If there is clinical concern about a possible transverse ligament injury, MRI should be performed.
To investigate the characteristics of patients with traumatic vertebral fractures and concomitant fractures of the first rib and their management.
From January 2001 to December 2010, 17/3142 patients (0.5%) with traumatic vertebral fractures who presented to our hospitals had concomitant fractures of the first rib.
The study included 14 men (82.4%) and 3 women (17.6%) patients of age 32–57 years (mean, 46.6 years). The mechanisms of trauma were falls from heights in seven, motor vehicle accidents in five and direct collisions with blunt objects in five. Thirteen patients (76.5%) presented initially with pulmonary complications after sustaining trauma. Three patients sustained one rib fracture, two three rib fractures, three four rib fractures and 10 > five rib fractures. The injuries were right-sided in three cases, left-sided in three and bilateral in eleven. Four patients (23.5%) presented with craniocerebral injuries. According to the American Spinal Injury Association (ASIA) classification, 10 patients (58.8% of the total study group) had motor and sensory deficits (ASIA A–D). There were no vascular injuries or deaths.
Traumatic vertebral fractures with concomitant fractures of the first rib are associated with multisystem injuries, but not always with morbidity and mortality. A multidisciplinary approach, early diagnosis, appropriate treatment and observation in the intensive care unit may prevent morbidity and/or mortality.
To describe the clinical and imaging findings in young adults with single vertebra tuberculosis presenting with solitary osteolytic lesions.
Six patients with proven tuberculosis of a single vertebra of the lumbar spine presenting with solitary osteolytic lesion were retrospectively evaluated. There were four male and two female patients with a mean age of 27.6 years (range, 22–38 years). The clinical and imaging features (plain radiographs, CT and MRI) were studied in all six patients.
Involvement occurred from L1 to L5 vertebral levels. The patients presented with local back pain and tenderness but without any obvious deformity of spine or cold abscess. In each case, imaging demonstrated a well-defined, solitary, lytic lesion of average diameter 1.6 cm with thin sclerotic margins within a vertebral body. There were no fragments within the lesions and no paravertebral soft tissue extension around the affected vertebral bodies. The tuberculous eitology was confirmed by CT-guided biopsy in two patients and by curettage of the lesion in four.
Tuberculosis affecting a single vertebral body presenting with a localized solitary osteolytic lesion is an unusual form of single vertebra tuberculosis. MRI combined with CT scan of the vertebral body can be very helpful for precisely defining the location of the lesion and extent of osseous destruction. Such small, solitary, osteolytic lesions are often confused with other single vertebra diseases that can have similar appearances on imaging.
To retrospectively compare the functional performances of rotating platform and fixed-bearing total knee arthroplasties with or without patellar resurfacing.
One hundred and ninety-seven patients (205 knees) of mean age 66.4 years were randomly assigned to receive different prostheses. One hundred ninety-five patients, including 97 fixed-bearing prostheses with 37 patellae resurfaced and 106 rotating platform prostheses with 76 patellae resurfaced, were followed up for a mean duration of 32 months.
Outcomes in the rotating platform with patellar resurfacing and fixed-bearing with patellar resurfacing groups did not differ significantly according to Hospital for Special Surgery (HSS) scores and flexion and extension angles. For total knee arthroplasties without patellar resurfacing, there were no significant differences in HSS score and flexion angle between the rotating platform and fixed-bearing subgroups. Although the extension angle of rotating platform prostheses was slightly better than that of the fixed-bearing in the patellar non-resurfacing group, this difference was not clinically significant.
Rotating platform and fixed-bearing prostheses have similar overall postoperative outcomes with regard to postoperative HSS scores and extension and flexion angles. Rotating platform prostheses are not superior to fixed bearing prostheses.
Treatment of distal femoral fracture in post-polio patients is difficult because the bone is usually osteopenic, small and deformed. This retrospective study aimed to investigate the outcomes of distal femoral fracture in post-polio patients treated by locking compression plates (LCP).
The medical records of 19 post-polio patients (mean age 49 years at time of surgery) were reviewed and intraoperative data retrieved. Fracture union and callus formation were evaluated on radiographs taken at each postoperative visit. Functional outcome assessments included range of motion and Hospital for Special Surgery (HSS) score of the ipsilateral knee joint.
Sixteen femoral fractures occurred in the poliomyelitis-affected limbs. The mean duration of operation was 86 min and mean blood loss 120 mL. All fractures healed (mean, four months) but union was delayed in one. At the final follow-up 2 yrs after surgery, the mean range of knee flexion was 105° (range, 90°–130°), and mean HSS score 76 points (range, 60–93). There were no cases of nonunion, implant cutout, or other complications.
LCP provides stable fixation of distal femoral fractures in post-polio patients. Bony union and good functional outcomes are achieved, but delayed union and minimal callus may occur.
To study the outcome of basicervical intertrochanteric fractures of the proximal femur treated with cephalomeduallary hip nails.
The clinical outcomes of 32 cases of basicervical intertrochanteric fractures treated with cephalomeduallary hip nails from January 2008 to June 2010 were retrospectively reviewed and the progress of fracture healing and occurrence of complications recorded. The function of the hip joints was evaluated by the Harris social index 2 years postoperatively.
Thirty patients were followed up until fracture union for at least 24 months. Twenty-seven fractures had healed with no loss of position by 12 months postoperatively; the remaining three had mild varus deformity of the hip joint. No patient had evidence of avascular necrosis of the femoral head. No cut out of the helical blade was visible on radiographs. The mean Harris score was 86.5 (75–96) two years postoperatively, 11 patients having excellent scores, 15 good and 4 fair.
Closed reduction and proximal femur intramedullary nail fixation for basicervical intertrochanteric fractures provides stable fixation and allows early exercise. It appears to have excellent outcomes in the short and medium term.
To study the methods for constructing a digitized three-dimensional (3D) model of a virtual lumbar region and its adjacent structures in order to assist anatomical study and virtual surgery.
Images of DSCF5375-p1 to DSCF5745-p1 were taken from the database of the digitized Virtual Chinese human of Southern Medical University in Guangzhou. This region encompasses the superior facet joint of L4 to the inferior edge of the intervertebral body of L5. The regions of interest were interactively segmented from the images utilizing Adobe Photoshop software. The images were further processed using format conversion and segmentation. Finally, a 3D model of the L4–5 region and its neighboring structures was reconstructed with the assistance of Mimics 10.01 software.
A digitized 3D model of this part of the virtual lumbar spine and its adjacent structures was reconstructed. This model allows all constructed structures to be displayed individually or jointly, moved or rotated arbitrarily, setting of different transparencies and convenient measurement of the diameters and angles of the reconstructed structures. The 3D model precisely displays the anatomical relationships between all structures and provides a reliable 3D model for a spinal endoscopic surgery simulation system.
Visualization of the digitized 3D reconstruction of the virtual lower lumbar region displays this region and its adjacent structures stereoscopically and in actuality, thus providing morphological data concerning anatomy, image diagnosis and virtual operations in this region.
The authors describe a hybrid technique that involves a combination of open decompression and posterior lumbar interbody fusion (PLIF) and percutaneously inserted pedicle screws. This technique allows performance of PLIF and decompression via a midline incision and approach without compromising operative time and visualization. Furthermore, compared to standard open decompression, this approach reduces post-operative wound pain because the small midline incision significantly reduces muscle trauma by obviating the need to dissect the paraspinal muscles off the facet joint complex and by avoiding posterolateral fusion, thus requiring limited lateral muscle dissection off the transverse processes. A series of patients with Grade I-II spondylolisthesis at L4–5 and moderate–severe canal/foraminal stenosis underwent midline PLIF at L4–5, with closure of the midline incision. Percutaneous pedicle screws were inserted, thereby minimizing local muscle trauma, reduction of the spondylolisthesis being performed by using a pedicle screw construct. Rods were inserted percutaneously to link the L4 and L5 pedicle screws. Image intensification was used to confirmed satisfactory screw placement and reduction of spondylolisthesis. The results of a prospective study comparing a standard open decompression and fusion technique for spondylolisthesis versus the minimally invasive hybrid technique are discussed. The minimally invasive technique resulted in shorter hospital stay, earlier mobilization and reduced postoperative narcotic usage. The long-term clinical outcomes were equivalent in the two groups.
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