Long-term investigation of nonsurgical treatment for thoracolumbar and lumbar burst fractures: an outcome analysis in sight of spinopelvic balance.

The nonsurgical treatment of thoracolumbar (TLB) and lumbar burst (LB) fractures remains to be of interest, though it is not costly and avoids surgical risks. However, a subset of distinct burst fracture patterns tend to go with a suboptimal radiographic and clinical long-term outcome. Detailed fracture pattern and treatment-related results in terms of validated outcome measures are still lacking. In addition, there are controversial data on the impact of local posttraumatic kyphosis that is associated, in particular, with nonsurgical treatment. The assessment of global spinal balance following burst fractures has not been assesed, yet. Therefore, the current study intended to investigate the radiographical and clinical long-term outcome in neurologically intact patients with special focus on the impact of regional posttraumatic kyphosis, adjacent-level compensatoric mechanisms, and global spine balance on the clinical outcome. For the purpose of a homogenous sample, strong in- and exclusion criteria were applied that resulted in a final study sample of 21 patients with a mean follow-up of 9.5 years. Overall, clinical outcome evaluated by validated measures was diminished, with 62% showing a good or excellent outcome and 38% a moderate or poor outcome in terms of the Greenough Low Back Outcome Scale. Notably, vertebral comminution in terms of the load-sharing classification, posttraumatic kyphosis, and an overall decreased lumbopelvic lordosis showed a significant effect on clinical outcome. A global and segmental curve analysis of the spine T9 to S1 revealed significant alterations as compared to normals. But, the interdependence of spinopelvic parameters was not disrupted. The patients' spinal adaptability to compensate for the posttraumatic kyphotic deformity varied in the ranges dictated by pelvic geometry, in particular the pelvic incidence. The study substantiates the concept that surgical reconstruction and maintenance of a physiologically shaped spinal curve might be the appropriate treatment in the more severely crushed TLB and LB fractures.

Arthroscopic treatment of a large lateral femoral notch in acute anterior cruciate ligament tear.

A 24-year-old professional soccer player suffered an acute anterior cruciate ligament tear associated with a radiologically evident impression fracture of the lateral femoral condyle, the so-called "lateral femoral notch sign". Following MRI validation of the injury with detection of an additional lateral meniscus tear, arthroscopy was carried out 3 days after the injury. Due to the extended impression of about 5 mm, arthroscopically assisted closed reduction of the depression fracture was performed. A 3.2 mm tunnel was drilled at the lateral femoral condyle in a supero-inferior direction using an ACL tibial guide and the depressed area could be restored using an elevator. The resulting subchondral bone defect in the femoral condyle was filled with freeze-dried human cancellous bone allograft. As a one-stage procedure ACL reconstruction was carried out using a hamstring tendon technique. At 1-year follow up the patient has returned to full sporting function, including playing soccer with a radiographically reduced lateral femoral notch sign.