RESUMO
BACKGROUND: Pedicle screw insertion at the level of the fractured vertebra has been shown to improve clinical and radiological outcomes in unstable thoracolumbar and lumbar fractures, albeit this requires further evidence. The study aims to evaluate the effect of pedicle screw placement on the fractured vertebra in such cases. METHODS: A prospective study included adult patients with thoracolumbar and lumbar fractures treated with short-segment posterior instrumentation with a pedicle screw into the fractured vertebra. Anterior vertebral body height loss, kyphotic angle and degree of spinal canal compromise were measured preoperatively and postoperatively in radiographs and CT scans. The neurological status was followed up for one year of the postoperative period. RESULTS: The study included a total of 30 patients. Five patients (16.7%) had grade C, three patients (10%) had grade D, and 22 patients (73.3%) had grade E neurological status. The mean (SD) preoperative kyphotic angle, vertebral body height and canal compromise were 5.54 (5.35), 39.67% (8.04), and 31.59% (10.62), respectively. Postoperatively there was a significant canal decompression, with a mean postoperative spinal canal compromise of 5.53% (SD=7.70; p-value <0.001). At the end of one year of follow-up, the radiological evaluation showed a correction of the kyphotic angle to 6.62 (SD=2.57; p-value <0.001), and the mean anterior vertebral body height was 70.38% (SD=11.25; p-value <0.001). At the end of one year, there was a significant overall neurological recovery with a final neurological status of grade D in 5 (16.7%) and grade E in 25 patients (83.3%). There was no significant association between canal decompression and neurology at the end of the one-year follow-up. CONCLUSION: Unstable thoracolumbar and lumbar fractures surgically treated with short-segment fixation with an additional intermediate screw can achieve significant restoration of vertebral body height and correction of kyphotic angle without any added complications.
RESUMO
Transolecranon fracture-dislocations are a result of high-energy trauma, caused due to axial loading of the flexed forearm, with associated anterior dislocation of the ulna with respect to the distal humerus. The usual management of these comminuted and unstable fractures is by using locking compression plates via the dorsal approach. However, plating in cases of poor soft tissue coverage and open wounds can be precarious. In this study, we aimed to evaluate outcomes of cerclage wiring in the management of comminuted trans-olecranon fracture-dislocations in such scenario. A total of seven patients diagnosed with trans-olecranon fracture-dislocation with poor soft tissue coverage who underwent cerclage wiring were included in the study. The aim was to realign the proximal portion of the olecranon to the trochlea and restore the normal ulnohumeral articular relationships accomplished by the anatomical reconstruction of the greater sigmoid notch. Reconstruction of the proximal ulna was started from the distal to the proximal direction so as to convert an unstable fracture into a stable one. After the reduction of the proximal fragment, two long 2 mm K wires were inserted from the tip of the olecranon into the intramedullary canal (with at least 1 wire passed subchondrally), and later cerclage was done. Postoperatively the patient was immobilized for a duration of two weeks and was later started on active assisted mobilization of the elbow. All patients showed fair-to-excellent outcome on the Mayo elbow performance score (MEPS) at the final follow-up (five patients had an excellent score, one had a good score, and one had a fair score). At the final follow-up, the mean extension, flexion, pronation and supination were -20, 117.14, 82.85 and 78.57 degrees respectively. The key components of such management are the restoration of articular congruity, including continuity of the sigmoid cavity, ulnar length, and early initiation of active elbow movements to avoid joint stiffness. Optimal functional results can be achieved with K wire and cerclage when a stable anatomic reconstruction is accomplished, as a feasible alternative to plating.
