Complications of anterior surgery in cervical spine trauma: an overview.

OBJECTIVE: Although anterior surgery for cervical spine injuries is a widespread procedure, articles regarding its overall complications are infrequently published in the literature. In the current study we focus on the complications encountered after anterior instrumented stabilization of cervical spine injuries and we discuss ways to minimize them. PATIENTS AND METHODS: Patients with unstable lower cervical spine injuries who underwent anterior surgery over a 15-year period were identified and 74 patients with adequate follow-up were included in the study. Indication for surgery was set by the instability criteria of White and Panjabi. Demographic information, initial neurological examination, surgical reports, imaging findings and follow-up records were evaluated. RESULTS: Complications were classified as intraoperative (technique-related) and postoperative. Although radiological "complications" were noted, they had no or minor clinical consequences for the patient. We identified 9 patients with clinically significant complications: no purchase of the screws, late angulation deformity, screw breakage, backout of the screws and postoperative hematoma. Overall, 3 out of 74 patients (4%) were reoperated due to significant screw backout causing dysphagia, no purchase of the screws being completely in the adjacent disc and screw breakage, respectively. CONCLUSION: Anterior surgery for cervical spine injuries can present several complications, yet the technique is in a way permissive, even during the learning curve. Considering the significant morbidity of these patients, the reported rate of clinically significant complications is considered acceptable, and it could be further minimized by good preoperative planning, careful surgical technique and the use of modern implants and instrumentation.

Gamma nail breakage: a report of four cases.

Gamma nails have been used extensively for the treatment of proximal femoral fractures. Nail breakage at the level of the aperture of the lag screw is rare. We report 4 such cases mainly associated with a large posteromedial cortex gap and nonunion. The need for adequate reduction to avoid such a complication is emphasised.

Intramedullary knee arthrodesis as a salvage procedure after failed total knee replacement.

Septic and aseptic loosening with or without extensive bone loss after total knee replacement are the most common indications for knee fusion. Both external fixation and intramedullary nailing can be used for the treatment, though the latter appears to be the method of choice for most patients. Nine patients were treated after a total knee replacement failure using intramedullary nailing. A long intramedullary nail with a proximal interlocking screw was used in five cases, and a customised nail was used in four cases. Successful fusion occurred in eight of nine patients (89%). Average time for the joint union was 6.5 months, and average operative blood loss was 860 ml. In two patients, iliac crest and patellar bone graft were also used. In conclusion, intramedullary nailing can give excellent results in achieving knee fusion after a failed knee replacement as it allows early weight bearing and at the same time offers stability, pain relief, and a high rate of union, even though the surgical technique is demanding.

Mortality rates of patients with a hip fracture in a southwestern district of Greece: ten-year follow-up with reference to the type of fracture.

Increased mortality after a hip fracture has been associated with age, sex, and comorbidity. In order to estimate the long-term mortality with reference to hip fracture type, we followed 499 patients older than 60 years who had been treated surgically for a unilateral hip fracture for 10 years. At admission, patients with femoral neck fractures (n = 172) were 2 years younger than intertrochanteric patients (77.6 +/- 7.7 [SD] vs. 79.9 +/- 7.4 [SD], P = 0.001) and had a greater prevalence of heart failure (57% vs. 40.3%, P = 0.03). Similar mortality rates were observed at 1 year in both types of fracture (17.9% vs. 11.3%, log rank test P = 0.112). Mortality rates were significantly higher for intertrochanteric fractures at 5 years (48.8% vs. 34.7%, P = 0.01) and 10 years (76% vs. 58%, P = 0.001). Patients 60-69 years old with intertrochanteric fractures had significantly higher 10-year mortality than patients of similar age with femoral neck fractures (P = 0.008), while there was no difference between the groups aged 70-79 (P > 0.3) and 80-89 (P = 0.07). Women were less likely to die in 5 years (relative risk [RR] = 0.57, 95% confidence interval [CI] 0.41-0.79, P = 0.0007) and 10 years (RR = 0.65, 95% CI 0.49-0.85, P = 0.002). Age, sex, the type of fracture, and the presence of heart failure were independent predictors of 10-year mortality (Cox regression model P < 0.0001). The intertrochanteric type was independently associated with 1.37 (95% CI 1.03-1.83) times higher probability of death at 10 years (P = 0.002). In conclusion, the type of fracture is an independent predictor of long-term mortality in patients with hip fractures, and the intertrochanteric type yields worse prognosis.

The use of the Ilizarov method as a salvage procedure in infected nonunion of the distal femur with bone loss.

We reviewed 13 patients with infected nonunion of the distal femur and bone loss, who had been treated by radical surgical debridement and the application of an Ilizarov external fixator. All had severely restricted movement of the knee and a mean of 3.1 previous operations. The mean length of the bony defect was 8.3 cm and no patient was able to bear weight. The mean external fixation time was 309.8 days. According to Paley's grading system, eight patients had an excellent clinical and radiological result and seven excellent and good functional results. Bony union, the ability to bear weight fully, and resolution of the infection were achieved in all the patients. The external fixation time was increased when the definitive treatment started six months or more after the initial trauma, the patient had been subjected to more than four previous operations and the initial operation had been open reduction and internal fixation.

Arthroscopically assisted retrodrade intramedullary fixation for fractures of the distal femur: technique, indications and results.

The purpose of this study is to present our experience with the technique, the problems and the potential pitfalls of arthroscopically assisted retrograde femoral nailing for supracondylar femoral fractures. In a 2-year period, nine patients (seven women, two men, average age 72 years) with supracondylar femoral fractures were treated in our department with a retrograde nailing under arthroscopic control. The mean operative time was 63.8 min (42-84 min) and the mean follow up period was 34.5 months (ranged 12-52). Solid union of the fracture was achieved in all patients without additional intervention, in 14 weeks (range 12-18). There was no malalignment (more than 5 degrees in any plane) or implant failure. In conclusion we believe that the arthroscopically assisted technique is a very good method to treat supracondylar fractures of the femur. It has very low morbidity since the knee is not opened through the operation, and the surgeon has the ability to inspect the joint for any additional damage. It is very helpful in multitrauma patients and in young patients, where the precision of the entry point is critical. However, we do not recommend the technique in intraarticular fractures because the reduction is difficult and the fixation is performed with safety only under direct vision.

Correlation between radiological parameters and patient-rated wrist dysfunction following fractures of the distal radius.

The present study investigates the correlation between radiological parameters of wrist fractures and the clinical outcome expressed by objective clinical parameters and the level of patient-rated wrist dysfunction. Thirty consecutive cases of unstable distal radial fractures treated with closed reduction and percutaneous fixation were prospectively studied for a period of one year. The outcome parameters included objective clinical and radiological parameters and the previously described and validated patient-rated wrist evaluation (PRWE) score. Analysis showed that for unstable (AO classification types 23-A2, -A3, -C1 and -C2) fractures the fracture type affects the range of wrist palmarflexion (p=0.04) and that the presence of postoperative articular 'step-off' affects the range of wrist dorsiflexion and the patient-rated wrist function at the final time of the study (p<0.01 and p=0.02, respectively). It is also shown that permanent radial shortening and loss of the palmar angle were associated with prolonged wrist pain (p<0.01 and p=0.03, respectively). Our finding that residual articular incongruity correlates with persisting loss of wrist dorsiflexion and wrist dysfunction contradicts the view that loss of articular congruity is associated with late development of articular degeneration but not with early wrist dysfunction. Additionally, this study failed to show any association between the fracture type and the functional outcome as rated by the patients.

A randomised comparison of AMBI, TGN and PFN for treatment of unstable trochanteric fractures.

INTRODUCTION: In this study, we initiated a prospective, randomised, clinical trial comparing the AMBI, TGN and PFN operations used for treatment of unstable fractures, for differences in intra-operative use, consolidation, complications and functional outcome. MATERIALS AND METHODS: We have compared the pre-, intra- and post-operating variables of AMBI, TGN and PFN operations that were used for treatment of unstable trochanteric fractures, of 120 patients all above 60 years old diagnosed with extracapsular hip fractures classified as AO Type 31-A2 or Type 31-A3. RESULTS: According to our results the three methods are comparable in the treatment of unstable trochanteric fractures of patients above 60 years old. CONCLUSION: The AMBI remains the gold standard for the fractures of trochanteric region. TGN has an easier and faster procedure, facilitates early weight bearing and had minor late complications. An improper use of the PFN system was the reason for the most complications and the longer operation time of the device. PFN is also an accepted minimally invasive implant for unstable proximal femoral fractures but future modification of the implant to avoid Z-effect phenomenon, careful surgical technique and selection of the patients should reduce its high complication rate.

Chondral injury due to migration of a Mitek RapidLoc meniscal repair implant after successful meniscal repair: a case report.

A case of chondral lesion of the medial femoral condyle caused by a bioabsorbable Mitek RapidLoc meniscal repair implant is presented. Meniscal repair was quite successful, but migration of one of the implanted fixation devices resulted in chondral damage, 12 months postoperatively. All orthopaedic surgeons using these new devices should be aware of the possibility of chondral damage of the adjacent femoral condyles.

[Comparative study of the treatment of pertrochanteric fractures--trochanteric gamma nail vs. proximal femoral nail]. / Vergleichsstudie der Versorgung pertrochantärer Femurfrakturen -- trochanteric Gamma-Nagel vs. PFN.

AIM: We have performed a retrospective comparative study between the trochanteric gamma nail (TGN) and the proximal femoral nail (PFN). METHOD: During the period 1998-2003, 97 TGN and 83 PFN were used for the treatment of pertrochanteric fractures. Most of the fractures were of the A3 type according to the AO/ASIF classification. Clinical and radiological follow-ups were available for 87 TGN and 65 PFN. RESULTS: The mean operative time for the TGN was shorter than that for the PFN. Intraoperative complications were noted in 17.5 % and 28.8 % for the TGN and PFN groups, respectively. Late complications occurred in 18.4 % for TGN compared to 27.6 % of the PFN. Union was achieved in 94.2 % and 89.3 % of the patients treated with the TGN and PFN, respectively. The reoperation rates were 10.3 % and 24.6 % for the TGN and the PFN, respectively. Clinical outcomes were good for both groups (65 % in the TGN, 62 % in the PFN group). CONCLUSION: Treatment of pertrochanteric fractures using the TGN and PFN implants is quite reliable. The major complication was cut-out and occurred mostly in the PFN group, while varus deformity was more frequent in the TGN group. The PFN was associated with a higher rate of reoperation and longer operative time, probably due to a more demanding technique.

[Diagnosis of septic loosening of hip prosthesis with LeukoScan. SPECT scan with 99mTc-labeled monoclonal antibodies]. / Diagnose septischer Hüftprothesenlockerung via LeukoScan. SPECT-Scan mit 99mTc-markierten monoklonalen Antikörpern.

Diagnosis of septic loosening of hip endoprosthesis with antigranulocyte scintigraphy (AGS) was analysed. Twenty-one hip prostheses were studied using laboratory tests and, in cases of elevated values, three-phase bone scan (BS) and AGS. Elective SPECT/CT scans were performed. Histologic and microbiologic exams verified the diagnosis. The AGS analysis revealed sensitivity, specificity and accuracy of value 1, while positive and negative predictive values were also 1. BS showed sensitivity of 1 and specificity of 0.33. In three cases, SPECT/CT scans corroborated the AGS interpretation. This diagnostic algorithm proved effective in the detection of septic loosening of hip prostheses. AGS can be avoided without risk of infection being overlooked.

Valgus impacted proximal humeral fractures and their blood supply after transosseous suturing.

We treated 16 patients (11 women and five men, average age 45 years), all having four-part valgus impacted fractures of the proximal humerus, with transosseous suturing. All had preoperative angiography performed 6-12 h after admission. The average impaction angle was 43 degrees , and the mean lateral displacement of the humeral head was 1.4 mm. Postoperative angiography was performed 8-10 weeks after the operation followed by digital image processing using the segmentation technique. No statistically important reduction in the length and area of large (>0.5 mm) vessels was seen. Union was confirmed by the reduction in the length and area of small vessels (<0.5 mm). At a mean follow-up of 40 months, avascular necrosis was only found in one patient. The average Constant-Murley score was 87 (67-100) points, whereas the functional score in comparison with the unaffected shoulder was 94% (89-100%). Despite the small number of patients, transosseous fixation seems to preserve the remaining blood supply of the humeral head.

Distal tibial fractures and non-unions treated with shortened intramedullary nail.

We reviewed 18 patients, 14 with acute fractures and four with non-union of the distal tibia, treated between 1990 and 2001 with a shortened, reamed intramedullary nail. The mean follow-up was 38 (8-144) months. The fractures united at an average of 16 (12-18) weeks and the non-unions at 20 (12-30) weeks. Two patients required nail dynamization. No limb shortening nor material failures were seen. All patients returned to normal daily activities. Although technically demanding, intramedullary nailing for distal tibial fractures and non-unions with a shortened nail represents a safe and reliable method.

Intramedullary nailing in the treatment of aseptic tibial nonunion.

Fifty patients suffering from aseptic tibial nonunion underwent reamed intramedullary nailing (I.N.) and were retrospectively reviewed. Thirty-six patients were initially treated with external fixation, six with plate and screws, one with a static I.N., and seven with plaster of Paris. Eighteen of the fractures were initially open (A: 5, B: 6, and C: 7 according to the Gustilo classification). In 34 cases a closed procedure was performed, whereas in sixteen, an opening at the nonunion site was unavoidable either to remove metalwork or realign the fragments. Following failed external fixation, secondary I.N. was performed at least 10 days after removal of the device. Bone grafts from the iliac crest were used in three cases, and a fibular osteotomy was performed in 33. Patients were followed up for an average of 2.5 years after nailing, ranging from 10 months to 7 years. A solid union was achieved in all patients within a period of 6 months. One patient developed late infection, which settled after nail removal and one patient developed impending compartment syndrome which was detected on the first post-operative day and was treated with a fasciotomy. Transient peroneal nerve palsy occurred in one patient and this recovered in 3 months, whereas in nine patients a clinically acceptable deformity was noticed. In conclusion, we believe that reamed intramedullary nailing is a highly effective treatment for aseptic tibial nonunions. Early and late complications are rare and bone graft is rarely needed. The method allows early weight bearing even before solid union occurs, short hospitalisation time and early return to work without external support.

Interlocking intramedullary nailing in distal tibial fractures.

This retrospective study examined the results of non-pilon fractures of the distal part of the tibia treated with interlocking intramedullary nailing. Seventy-three patients with equal numbers of fractures treated surgically between 1990 and 1998 were reviewed. Mean patient age was 39.8 years, and follow-up averaged 34.2 months. The AO fracture classification system was used. Concomitant fractures of the lateral malleolus were fixed. All but three fractures achieved union within 4.2 months on average. Satisfactory or excellent results were obtained in 86.3% of patients. These results indicate interlocking intramedullary nailing is a reliable method of treatment for these fractures and is characterized by high rates of union and a low incidence of complications.

Rigid or sliding plate. A mechanical evaluation of osteotomy fixation in sheep.

Fracture fixation using rigid plates leads to direct bone union, but it also may lead to complications because of stress protection osteopenia. This study aims to compare the mechanical characteristics restored during the callus formation after an osteotomy is fixed with two types of internal plate fixation. Twenty-four adult female sheep were divided randomly into three groups of eight each, which were euthanized at 2, 4, and 6 months after operation. Half of them had their osteotomized radius fixed with a seven hole dynamic compression plate, whereas in the remainder a sliding plate was used. The sliding plate consists of two halves connected together in such a way as to permit axial sliding of the one within the other, thus allowing cyclic axial load transfer at the fracture site. Bone strips obtained from the healthy (control) and the surgically treated side were subjected to four-point bending tests. The effective modulus of elasticity, ultimate bending strength, and energy absorption to fracture (toughness) were calculated. All parameters were restored more quickly in the sliding plate group, but there was no statistically significant difference observed at 6 months when all the osteotomies were united completely. Thus, the sliding plate, by allowing axial loading at the fracture site, led to a faster callus maturation and hence bony union, which, hopefully, will permit earlier full weightbearing and functional recovery of the injured limb.

Estimation of artifacts induced by the Ilizarov device in quantitative computed tomographic analysis of tibiae.

This study concerns the estimation of the artifacts introduced by the metallic frame of an Ilizarov apparatus during quantitative computed tomography for the assessment of neoosteogenesis. Ten cadaver tibiae were tomographed before and after the mounting of an Ilizarov device. The increase in mean density and in the relative number of pixels were used as indicators of the artifacts induced by the apparatus. No significant influence by the device was recorded in regions corresponding to a corticotomy site. In regions close to the metallic rings of the Ilizarov apparatus, measurements are distorted significantly, but with no influence on the assessment of neoosteogenesis.

Hemiarthroplasty in the treatment of comminuted intraarticular fractures of the proximal humerus.

Thirty-eight patients with four-part proximal humerus fractures and fracture dislocations were treated with humeral head replacement between 1989 and 1995. At followup (mean, 37 months; range, 12-48 months) the patients were evaluated for postoperative pain, active range of motion, muscular strength, overall function in every day activities, and patient satisfaction. Complications developed in five patients and consisted of humeral component malposition (one shoulder), rotator cuff insufficiency (two shoulders), and heterotopic ossification (two shoulders). According to the Neer criteria, the overall results were: 32 (84%) patients had no pain and improved motion (active forward elevation averaged 130 degrees, external rotation 45 degrees, and average internal rotation to the first lumbar vertebra); in this group strength and function 6 months postoperatively was 80% of the normal side and reached 90% of the normal side at 1 year postoperatively under continuous stretching and strengthening exercises; and 34 patients (90%) were satisfied with their treatment. The results of the study indicate that humeral head replacement is a dependable method to restore comfort and function to patients with acute or old four-part fractures of the proximal humerus. However, recovery of function and range of motion are much less predictable in patients with an old injury.

Intramedullary nailing: experience in 427 patients.

In the Orthopaedic Department in Patras University 427 intramedullary nailings in the lower limbs were performed between 1989 and 1994 and retrospectively reviewed to evaluate the range of complications. One hundred and seventy-two were nailings of the femur; 80 gamma nails mainly for subtrochanteric and intertrochanteric with subtrochanteric extension fractures were included, (total 252/59%); 175 (41%) were nailings of the tibia. Union was achieved in all case. Overall the complication rate in this series was 3.3% (14 cases) and included infection (4 cases), neuropraxia (2 cases), implant failure (5 cases), limb length deficiency (2 cases) and malrotation (1 case).