Management of Lower Extremity Long-bone Fractures in Spinal Cord Injury Patients.

The AO classification system, used as a guide for modern fracture care and fixation, follows a basic philosophy of care that emphasizes early mobility and return to function. Lower extremity long-bone fractures in patients with spinal cord injury often are pathologic injuries that present unique challenges, to which the AO principles may not be entirely applicable. Optimal treatment achieves healing without affecting the functional level of the patient. These injuries often result from low-energy mechanisms in nonambulatory patients with osteopenic bone and a thin, insensate soft-tissue envelope. The complication rate can be high, and the outcomes can be catastrophic without proper care. Satisfactory results can be obtained through various methods of immobilization. Less frequently, internal fixation is applied. In certain cases, after discussion with the patient, amputation may be suitable. Prevention strategies aim to minimize bone loss and muscle atrophy.

Pitfalls associated with open reduction and internal fixation of fractured ribs.

Rib fracture is exceedingly common and remains a leading cause of death in patients with chest injury. Probability of death increases by 19% with each broken rib, and the probability of death increases further with age. Treatment is centered on pain control and early mobilization to provide adequate pulmonary hygiene. Multimodality interventions, such as incentive spirometry, postural changes, and coughing, are pivotal in minimizing the risk of pneumonia and death. Recently, many studies have found mortality benefit to operation fixation (ORIF) of ribs in select patients. However, this procedure remains underutilized partly due to lack of familiarity with its technique and pitfalls by trauma surgeons, in particular. Whereas there are publications on operative technique, there are no studies describing pitfalls associated with this procedure. The purpose of this paper is to describe pitfalls on the technical aspects of ORIF of the ribs based on the medical literature where possible and based on our experience in instances where peer reviewed evidence is lacking. The paper is not meant to serve as a protocol for managing rib fractures.

Management of adult diaphyseal both-bone forearm fractures.

Simultaneous diaphyseal fractures of the radius and ulna, often referred to as both-bone forearm fractures, are frequently encountered by orthopaedic surgeons. Adults with this injury are typically treated with open reduction and internal fixation because of the propensity for malunion of the radius and ulna and the resulting loss of forearm rotation. Large case series support the use of plate and screw fixation for simple fractures. More complex fractures are managed according to strain theory, with the intention of controlling rather than eliminating motion at the fracture site. This can be achieved with flexible plate and screw constructs or intramedullary nails. In general, results of surgical fixation have been good, with only modest losses of forearm strength and rotation. Notable complications include nonunion, malunion, and refracture after device removal.

Deep vein thrombosis and pulmonary embolism after spine surgery: incidence and patient risk factors.

Anticoagulation after spine surgery confers the unique risk of epidural hematoma. We sought to determine the incidence of and patient risk factors for deep vein thrombosis (DVT) and pulmonary embolism (PE) after spine surgery. We retrospectively reviewed the charts of 1485 patients who had spine surgery at a single tertiary-care center between 2002 and 2009. DVT and PE incidence were recorded along with pertinent patient history information. Univariate and multivariate analyses were performed on the data. VTE incidence was 1.1% (DVTs, 0.7%; PEs, 0.4%). Univariate analysis demonstrated that VTEs had 9 positive risk factors: active malignancy, prior DVT or PE, estrogen replacement therapy, discharge to a rehabilitation facility, hypertension, major depressive disorder, renal disease, congestive heart failure, and benign prostatic hyperplasia (P<.05). Multivariate analysis demonstrated 4 independent risk factors: prior DVT or PE, estrogen replacement therapy, discharge to a rehabilitation facility, and major depressive disorder (P>.05). Surgeons with an improved understanding of VTE after spine surgery can balance the risks and benefits of postoperative anticoagulation.

Change in sagittal balance with placement of an interspinous spacer.

STUDY DESIGN: A prospective case series. OBJECTIVE: To determine the effect of X-STOP implantation on sagittal spinal balance using 36-inch films. SUMMARY OF BACKGROUND DATA: Interspinous process spacers have been shown as an effective treatment of neurogenic claudication. The devices block the last few degrees of extension at the stenotic level, thus preventing compression of the nerve roots. These devices have been criticized because they may push the patient's spine into a kyphotic position. However, opening the stenotic level may allow a patient to stand more upright, thereby improving sagittal balance. METHODS: Institutional review board's approval was obtained. A prospective study of 20 patients who were undergoing an X-STOP insertion was utilized. Their spines were x-rayed preoperatively and postoperatively with 36-inch films. Preoperative and postoperative sagittal balance was measured with a C7 body plum line on both films and the difference was measured. Lumbar lordosis was also compared using Cobb angles. RESULTS: Measurements taken from lateral full-length spine radio-graphs showed an average improvement in sagittal balance of 2.0 cm (range -3.7 to 6.1 cm). The average change in lordosis was -1.1°. CONCLUSION: Although previous studies of interspinous process distraction have examined segmental lordosis, disc angles, and other parameters, this study is the first to examine overall spinal balance on full-length films. Interspinous distraction does not seem to be detrimental to sagittal balance, and may improve it.

Proximal periarticular locking plates in proximal humeral fractures: functional outcomes.

BACKGROUND: Some recent studies have asserted that locking plates do not provide adequate fixation of proximal humeral fractures. The purpose of this study is to review our experience with proximal humeral locking plates, including complications, functional outcomes, and predictors of successful treatment. MATERIALS AND METHODS: At our institution, 45 patients (46 shoulders) with displaced proximal humeral fractures were treated with a proximal humeral locking plate over a 6-year period. Patients underwent standard surgical and rehabilitation protocols and were evaluated clinically with Disabilities of the Arm, Shoulder and Hand and American Shoulder and Elbow Surgeons standardized outcome measurements and range of motion at last follow-up. Radiographs obtained preoperatively, immediately postoperatively, and at final follow-up were evaluated for fracture type, union, and change in alignment. RESULTS: There were 43 patients (44 shoulders) available for range-of-motion and functional outcome measures with an average follow-up of 34 months. Fracture types included 19 two-part, 21 three-part, 3 four-part, and 1 head-splitting fracture. The mean Disabilities of the Arm, Shoulder and Hand score was 11. The average American Shoulder and Elbow Surgeons score was 85. The average visual analog pain score was 0.8. The average range of motion was as follows: elevation, 140°; external rotation at side, 49°; external rotation in abduction, 77°; and internal rotation, T11. No patient had evidence of screw cutout, varus collapse, or avascular necrosis. One patient required hardware removal. CONCLUSIONS: Displaced proximal humeral fractures can be successfully fixed with locking plates when attention is paid to anatomic reduction, proper plate placement below to the greater tuberosity to allow abduction, screws in the head with subchondral bone purchase, calcar screws from inferior-lateral to superior-medial and delaying shoulder motion until at least 2 weeks.

Clinical and histologic results related to a low-modulus composite total hip replacement stem.

BACKGROUND: Osteolysis secondary to stress shielding in patients with a total hip arthroplasty has been attributed to greater stiffness of the prosthetic femoral stem compared with the stiffness of the femur. This concern led to the development of a composite femoral stem implant with a structural stiffness similar to that of the native femur. The stem consists of a cobalt-chromium-alloy core surrounded by polyaryletherketone and titanium mesh for bone ingrowth. The purpose of this study was to determine the intermediate-term clinical, radiographic, and histologic results of the use of this stem. METHODS: Twenty-eight patients (nineteen men and nine women) with an average age of 51.3 years underwent primary total hip arthroplasty with the Epoch stem and were followed for an average of 6.2 years. Harris hip scores were determined and radiographic studies were performed preoperatively, postoperatively, and at two-year intervals thereafter. In addition, dual x-ray absorptiometry scans were made up to two years postoperatively to evaluate osseous resorption. Two femora obtained at autopsy thirteen and forty-eight months after surgery were analyzed for bone ingrowth and ongrowth. RESULTS: The Harris hip scores averaged 56 points preoperatively and improved to 97 points at the time of the last follow-up. Dual x-ray absorptiometry scans demonstrated the greatest decrease in mean bone density (27.5%) in Gruen zone 7 at two years. Radiographs demonstrated no instances of migration, and only one hip had osteolysis. All stems had stable osseous fixation. Histologic evaluation of the two femora that had been retrieved at autopsy at thirteen and forty-eight months showed the mean bone ingrowth (and standard deviation) along the entire length of the stem to be 49.62% +/- 13.04% and 73.57% +/- 8.48%, respectively, and the mean bone ongrowth to be 54.18% +/- 7.68% and 80.92% +/- 6.06%, respectively. CONCLUSIONS: Intermediate-term follow-up of hips treated with the Epoch stem indicated excellent clinical success, radiographic evidence of osseous integration, and histologic findings of osseous ingrowth and ongrowth. Although the implant has been associated with excellent results in both the short and the intermediate term, longer follow-up will be necessary to assess the long-term function of the implant.

Nonmyeloablative bone marrow transplantation: Infectious complications in 65 recipients of HLA-identical and mismatched transplants.

Infections are a common complication of allogeneic bone marrow transplantation and the leading cause of transplantation-related mortality. It had been hypothesized that transplantation following nonmyeloablative preparative regimens would result in fewer infections by causing less mucosal injury, less graft-versus-host disease, and allowing earlier immune reconstitution. We have retrospectively reviewed the infectious complications of 65 consecutive patients with advanced hematologic malignancies who underwent bone marrow transplantation using a novel preparative regimen consisting of cyclophosphamide, thymic irradiation, and in vivo T-cell depletion. Cytomegalovirus (CMV) infection occurred in 52% of cases in which the donor or recipient had evidence of prior CMV exposure. Using a strategy of preemptive therapy and secondary prophylaxis with ganciclovir, no CMV disease occurred. Infections with gram-positive bacteria predominated over the first 100 days after bone marrow transplantation. Thereafter, the relative proportion of gram-negative infections increased without a significant increase in episodes of neutropenia. The rate of bacterial infections was not influenced by relapse of the underlying malignancy. Seven patients developed infections with Aspergillus species, which was the most common infectious cause of death in these patients. Infections with viruses other than CMV (n=10) and with protozoan organisms (n=2) also occurred. The use of HLA-mismatched donors, the occurrence of grade II-IV acute graft-versus-host disease, and treatment with corticosteroids did not influence the risk of CMV or bacterial or fungal infections in patients who underwent transplantation following this preparative regimen. Overall, the incidence and spectrum of infections in this series was similar to the reported incidence of infections following conventional myeloablative allogeneic stem cell transplantation. We conclude that a quantitative T-cell deficiency in these extensively T-cell depleted patients may be a risk factor for infection, even in the absence of graft-versus-host disease.

Requirement for the NF-kappaB family member RelA in the development of secondary lymphoid organs.

The transcription factor nuclear factor (NF)-kappaB has been suggested to be a key mediator of the development of lymph nodes and Peyer's patches. However, targeted deletion of NF-kappaB/ Rel family members has not yet corroborated such a function. Here we report that when mice lacking the RelA subunit of NF-kappaB are brought to term by breeding onto a tumor necrosis factor receptor (TNFR)1-deficient background, the mice that are born lack lymph nodes, Peyer's patches, and an organized splenic microarchitecture, and have a profound defect in T cell-dependent antigen responses. Analyses of TNFR1/RelA-deficient embryonic tissues and of radiation chimeras suggest that the dependence on RelA is manifest not in hematopoietic cells but rather in radioresistant stromal cells needed for the development of secondary lymphoid organs.