Time to Surgery for Unstable Thoracolumbar Fractures in Latin America-A Multicentric Study.

OBJECTIVE: We sought to identify delays for surgery to stabilize unstable thoracolumbar fractures and the main reasons for them across Latin America. METHODS: We reviewed the charts of 547 patients with type B or C thoracolumbar fractures from 21 spine centers across 9 Latin American countries. Data were collected on demographics, mechanism of trauma, time between hospital arrival and surgery, type of hospital (public vs. private), fracture classification, spinal level of injury, neurologic status (American Spinal Injury Association impairment scale), number of levels instrumented, and reason for delay between hospital arrival and surgical treatment. RESULTS: The sample included 403 men (73.6%) and 144 women (26.3%), with a mean age of 40.6 years. The main mechanism of trauma was falls (44.4%), followed by car accidents (24.5%). The most frequent pattern of injury was B2 injuries (46.6%), and the most affected level was T12-L1 (42.2%). Neurologic status at admission was 60.5% intact and 22.9% American Spinal Injury Association impairment scale A. The time from admission to surgery was >72 hours in over half the patients and over a week in >25% of them. The most commonly reported reasons for surgical delay were clinical instability (22.9%), lack of operating room availability (22.7%), and lack of hardware for spinal instrumentation (e.g., screws/rods) (18.8%). CONCLUSIONS: Timing for surgery in this sample of unstable fractures was over 72 hours in more than half of the sample and longer than a week in about a quarter. The main reasons for this delay were clinical instability and lack of economic resources. There is an apparent need for increased funding for the treatment of spinal trauma patients in Latin America.

Re-use of explanted osteosynthesis devices: a reliable and inexpensive reprocessing protocol.

INTRODUCTION: Orthopaedic surgical treatments emphasizing immobilization using open reduction and internal fixation with osteosynthesis devices are widely accepted for their efficacy in treating complex fractures and reducing permanent musculoskeletal deformity. However, such treatments are profoundly underutilized in low- and middle-income countries (LMIC), partially due to inadequate availability of the costly osteosynthesis devices. Orthopaedic surgeons in some LMIC regularly re-use osteosynthesis devices in an effort to meet treatment demands, even though such devices typically are regulated for single-use only. The purpose of this study is to report a reprocessing protocol applied to explanted osteosynthesis devices obtained at a leading trauma care hospital. METHODS: Explanted osteosynthesis devices were identified through a Register of Explanted Orthopaedic Prostheses. Guidelines to handle ethical issues were approved by the local Ethical Committee and informed patient consent was obtained at the time of explant surgery. Primary acceptance criteria were established and applied to osteosynthesis devices explanted between 2005 and 2008. A rigorous protocol for conducting decontamination and visual inspection based on specific screening criteria was implemented using simple equipment that is readily available in LMIC. RESULTS: A total of 2050 osteosynthesis devices, including a large variety of plates, screws and staples, were reprocessed using the decontamination and inspection protocols. The acceptance rate was 66%. Estimated labour time and implementation time of the protocol to reprocess a typical osteosynthesis unit (1 plate and 5 screws) was 25 min, with an estimated fixed cost (in Italy) of €10 per unit for implementing the protocol, plus an additional €5 for final sterilization at the end-user hospital site. DISCUSSION: This study was motivated by the treatment demands encountered by orthopaedic surgeons providing medical treatment in several different LMIC and their need for access to basic osteosynthesis devices. The rigorous decontamination protocol and generalized inspection criteria proved useful for efficiently screening a large volume of devices. Given that re-used osteosynthesis devices can yield satisfactory results, this study addresses potential complications of re-used devices and valid concerns that relate to patient safety. Implementing this defined reprocessing protocol into existing re-use practises in LMIC helps to limit the risks of inadequate sterilization and structural failure without adding additional risks to patients receiving re-used devices.

Coblation of spinal endplates in preparation for interbody spinal fusion.

Posterior lumbar interbody fusion (PLIF) and anterior lumbar interbody fusion (ALIF) have become routine alternatives to intertransverse process fusion. The use of Coblation (ArthroCare Corporation, Sunnyvale, CA) allows for routine and reproducible removal of cartilaginous endplate down to the bony endplate. Our experience with this new technology is reviewed. The authors used Coblation to prepare endplates of 10 consecutive patients undergoing interbody fusion. The results were compared to the following 10 consecutive patients undergoing interbody fusion with endplates prepared in the standard fashion with curettes and rongeurs. The same interbody grafts and instrumentation were used in all patients. Follow-up X-rays were done at 1 week, 6 weeks, 6 months, 1 year, and then each year thereafter. The 20 patients were reviewed along with their films. In each patient the disk spaces and the ALIF/PLIF cages appeared to be fused by 6 months. There was one superficial wound infection in each group. In each of the cases in which PLIF was performed, the cages were augmented by posterior lateral graft and pedicle screw fixation. All patients in both groups reported improvement in pain and/or neurologic symptoms by 6 months. The patients were followed for 4.6 years in the Coblation group and 4.1 years in the standard group. Disk space height was measured in all patients at 6 months. In the Coblation group, average disk space height was 9.0 mm compared to 8.2 mm in the standard group (p<0.1). We feel that the maintenance of normal structures within the lumbar spine with anterior/posterior lumbar interbody fusions and non-mechanical means of preparing the endplates are advantageous. Clearly, the number of patients involved and the length of follow-up limit this study, but it serves as an early indicator that endplate preparation may play a role in graft subsidence and fusion rates. Additional study is warranted.

[Comparison of primary trapezometacarpal cup fixation using mechanical tests]. / Comparaison de l'ancrage primaire de cupules trapézométacarpiennes par tests mécaniques.

INTRODUCTION: In order to optimise the primary fixation of the cup of the Arpe (Biomet Merck) trapeziometacarpal prosthesis, several geometries have been studied. The mechanical strengths of the primary fixations ensured by cup "with slots", "bladed" and "with crown", have been assessed and compared to the one obtained for the primary anchorage of the Arpe cup. METHOD: For each cup, the strength of the primary fixation has been assessed in torsion (torque along the cup axis) and bending (torque perpendicular to the cup axis). Tests have been performed on prototype cups set up in a vertebral body of lamb cancellous bone. Torque recording allowed the assessment of the maximum strength for each cup type. RESULTS: Arpe and cup "with slots" showed an effective bending strength, respectively due to the three anchorage picks and to the equatorial over-thickness. However, the cup "with crown" demonstrated a better bending strength with a mean torque of pulling out Cbending = 0.89 Nm. In torsion, the three anchorage picks of the Arpe cup did not allow a solid anchorage. For such a loading, the cup "with crown" also showed the best torsion strength with a mean unsealing torque Ctorsion = 0.83 Nm. DISCUSSION: The equatorial over-thickness seems to give good bending and torsion strengths to the "bladed" and "with crown" cups, with a press-fit effect. Replacing the fixation points of the Arpe cup by a crown also allowed the improvement of its torsion strength.