Efficiency of a novel vertebral body augmentation system (Tektona™) in non-osteoporotic spinal fractures.

BACKGROUND: The restauration of the local kyphosis is crucial to thoracolumbar fractures outcomes. Recently, the Tektona™ (Spine Art) system, constituted by a flexible lamella for corporeal reduction has emerged as a promising solution for osteoporotic fractures. However, no study has yet focused on its results on traumatic fractures. METHODS: A retrospective longitudinal study on prospectively collected data was conducted on 53 patients that had a kyphoplasty by Tektona™, associated or not to percutaneous fixation. The data collected were clinical, surgical and scannographic (measurement of AVH, MVH and PVH (anterior/medium/posterior vertebral height), and RTA (regional traumatic angle) in°), preoperatively, post-operatively and at last follow-up. RESULTS: Fractures were mainly located at the upper lumbar spine and were AOSpine A3 type for 74%. The mean RTA was 12° in pre-operative, 4° in post-operative (p = 2e- 9), and 8° at the last follow-up (p = 0,01). The mean correction of RTA for the fixation group was - 10 ± 6° versus - 7 ± 4° for the kyphobroplasty alone group (p = 0,006). The mean correction for fractures located at T10-T12 was - 9 ± 3°, - 9 ± 5° for L1, - 8 ± 3° for L2 and - 5 ± 3° for L3-L5 (p = 0,045). CONCLUSIONS: The Tektona® system appears to be efficient for acute thoraco-lumbar fractures, comparable to other available systems, allowing a real intracorporeal reduction work. Its relevance, especially in the long term needs further investigation. The association of a percutaneous fixation allow to obtain a better correction of the RTA but did not seem to prevent the loss of correction at follow-up.

Management of thoracolumbar fracture in France. Analysis of practices and radiologic results of a cohort of 407 thoracolumbar fractures.

BACKGROUND: Thoracolumbar fractures are a public health issue due to their severity and frequency. Management varies according to demographic, clinical and radiologic features, from non-operative treatment to extensive fusion. In the two last decades, improvements and new techniques have emerged, such as kyphoplasty and percutaneous approaches. The main goal of this study was to describe the management of thoracolumbar fractures in France in 2018. HYPOTHESIS: The study hypothesis was that management of thoracolumbar fractures in France has progressed in recent decades. MATERIAL AND METHODS: The files of 407 adult patients operated on between January 1, 2015 and December 31, 2016 for T4-L5 thoracolumbar fracture in 6 French teaching hospitals were retrospectively reviewed, at a mean follow-up at 10.2±8.2 [1; 42] months. Demographic, surgical and postoperative radiological data were collected. p-values<0.05 on Student test were considered significant. RESULTS: Five hundred and thirty-one fractures were analyzed (27% of patients presented more than one fracture). Surgery consisted in internal fixation for 56% of patients, including 17% with associated kyphoplasty; 29% had fusion, and 15% stand-alone kyphoplasty. Surgery used an open posterior approach in 54% of cases, and a percutaneous approach in 46%. Initial sagittal angulation was not a significant decision criterion for screwing (p=0.8) or for a secondary anterior approach in case of fusion (p=0.6). Immediate postoperative sagittal correction was significantly better with an open than a percutaneous approach (p=0.004), but without significant difference at last follow-up (p=0.8). Correction at last follow-up was significantly better with anterior associated to posterior fusion (p=0.003). DISCUSSION: Management of the thoracolumbar fractures has progressed in France in recent years: 46% of surgeries used a percutaneous approach, compared to 28% in 2013; 90% used a posterior approach only, compared to 83% in 2013; rates of combined approach were unchanged, at 6%. Twenty-five percent of burst fractures were treated by fusion, possibly due to lack of preoperative MRI in 79% of cases. LEVEL OF EVIDENCE: IV, retrospective cohort study.

Evaluation of disc degeneration adjacent to AOspine A fractures: pre- and post-operative MRI analysis.

INTRODUCTION: The management of type A thoracolumbar fractures varies from conservative treatment to multiple level fusion. Indeed, although Magerl defined the type A fracture as a strictly bone injury, several authors suggested associated disc lesions or degeneration after trauma. However, the preservation of mobility of the adjacent discs should be a major issue. This study was conducted to analyze the presence of immediate post-traumatic disc injuries and to know if discs degenerate after receiving treatment. METHODS: We retrospectively reviewed the files of 27 patients with an AOspine A fracture, corresponding to 34 fractures (64 discs) with pre and post-operative MRI (mean follow-up: 32.4 months). Based on Pfirrmann's and Oner's classifications of disc injuries, two observers analyzed independently the type of lesion in the discs adjacent to the fractured vertebra in immediate post-trauma and at the last follow-up. RESULTS: The immediate post-traumatic analysis according to Pfirrmann's classification found 97% of the cranial adjacent discs and 100% of the caudal discs classified Pfirrmann 3 or less. The analysis on the secondary MRI revealed that 78% of cranial adjacent discs and 88% of caudal adjacent discs still were classified Pfirrmann 3 or less. CONCLUSIONS: Since, the great majority of type A fractures does not cause immediate disc injuries, these fractures are, as described by Magerl, strictly bony injuries. The quality of the body reduction seems to prevent secondary degeneration. These results may encourage surgeons not to perform arthrodesis on type A fractures even for A3 and A4.

Immediate and late discal lesions on MRI in Magerl A thoracolumbar fracture: Analysis of 76 cases.

INTRODUCTION: Magerl type A thoracolumbar fracture is frequent, but consensus is lacking on management, which ranges from non-operative treatment to corpectomy. It is, however, essential to spare adjacent discs in young patients. Historically, Magerl defined type A fracture in terms of isolated bone involvement. Subsequently, several authors suggested that discal lesions are associated, but results were inconsistent. The present study assessed the presence of immediate post-trauma discal lesions and late degeneration. HYPOTHESIS: Type A fracture does not entail discal lesion. MATERIAL AND METHOD: Fifty-four patients with type A fracture and immediate post-trauma MRI (76 fractures, 138 discs) were retrospectively reviewed. Twenty-seven also had follow-up MRI at a mean 32 months. Two observers analyzed adjacent discs on Oner's classification, on the immediate post-trauma MRI, and on follow-up MRI to assess disc degeneration. RESULTS: Immediate post-trauma analysis of the cranial discs of the fractured vertebrae found 81% normal (type 1), none type 2, 7% type 3, 4% type 4, 7% type 5 and 1% type 6. Caudal discs were 97% type 1. Analysis at follow-up found degeneration in only 15% of cranial and 9% of caudal discs. DISCUSSION: A large majority of type A fractures lead to no immediate discal lesions, and only 15% of cranial discs subsequently degenerate. MRI analyzing disc signal and morphology is essential before removing material. LEVEL OF EVIDENCE: IV, retrospective study.

Peri-prosthetic fractures around tumor endoprostheses: a retrospective analysis of eighteen cases.

PURPOSE: Tumour hip and knee endoprostheses have become the mainstay for reconstruction of patients with bone tumours. Fixation into host bone has improved over time. However, some patients present with a peri-prosthetic fracture over follow-up. The objective of this study was to analyse the mode of presentation and survival of implant after a peri-prosthetic fracture around a tumour endoprosthesis. METHODS: Eighteen peri-prosthetic fractures (17 patients) were included. All patients were treated at a tertiary care center. There were 11 (65%) women; the median age at the time of fracture was 38 years old. All implants were cemented and all knee endoprostheses were fixed-hinge. Twelve (67%) fractures occurred after femoral resection and six (33%) fractures after proximal tibial resection. RESULTS: There were three femoral neck fractures (UCS C), three femoral shaft type C fractures, two femoral shaft type B1, one tibial shaft type B2, three tibial shaft type C, three ankle fractures (UCS C) and three patella fractures (UCS F). Two fractures were treated conservatively and 16 were operated on. Only one patient had the implant revised. There were eight (44%) failures over follow-up; none of the conservative treatment failed. The cumulative probability of failure for any reason was 27% (8-52) and 55% (22-79) at five and ten years, respectively. CONCLUSIONS: Peri-prosthetic fractures around massive endoprostheses are different from that of standard implants. There are more type C fractures; internal fixation is an attractive option at the time of presentation but the risk of revision over follow-up is high and patients should be informed accordingly.

Ninety-day morbidity in patients undergoing primary TKA with discontinuation of warfarin and bridging with LMWH.

We asked whether patients under long-term warfarin and managed with current guidelines regarding bridging therapy have a higher complications rate within ninety days following total knee arthroplasty. We retrospectively identified 38 patients under long-term warfarin. They were match-paired with 76 control patients. Our results showed a significant increased rate of complications (42.1% vs. 6.9%, P < 0.001) and re-operation (21.1% vs. 5.2%, P < 0.001) in the warfarin group. The difference was related to the number of hematomas requiring surgical evacuation. The warfarin group had a significantly higher rate of blood loss, blood transfusion, and length of hospital stay. Our data suggest that current guidelines for preoperative warfarin management are associated with a high rate of bleeding complications and reoperations following TKA.