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PubMed2002

[Replacement of the vertebral body with an expansion implant (Synex)].

PURPOSE OF THE STUDY: This paper describes replacement of the vertebral body with the expansion implant Synex. Usually, autologous bone graft is used to replace the vertebral body. In patients with bone cancer or multiple injuries to the spine, cement filling is preferred whereas, in other indicated cases, implants are inserted, of which Harms' titanium cage has been the most common one. However, this needs filling with a large amount of bone tissue and it is often difficult to adjust its size into the space available. Telescopic devices, on the other hand, are easier to implant and their application requires only a minimum amount of autologous bone tissue. MATERIAL: In the period from January 2000 to June 2001, we used telescopic implants Synex to replace vertebral bodies in 34 patients. Indications for treatment were: vertebral fractures in 14, post-traumatic kyphosis in six, vertebral metastatic tumours in eight and a primary tumour in six patients. METHODS: In 25 cases, the vertebral body replacement was completed by posterior stabilization using internal fixation and, in nine cases, by anterior stabilization with a Ventrofix fixator. In 32 patients, the implant was inserted from the anterior approach and, in two, from the posterior approach following complete spondylectomy. RESULTS: The L1 vertebra was replaced most frequently (nine patients), then T 12 (seven patients) and L2 (six patients). For treatment of fresh fractures, the Synex implant was used in 14 cases. Of these one was inserted from the posterior approach in the L1 region where trauma had caused severe injury to the spinal cord. In spinal tumours. Synex was used in 14 patients, i.e., in six with diagnosed plasmacytoma, in two with metastatic dissemination from prostate carcinoma, in four with vertebral metastases from breast cancer and in two patients with non-differentiated metastases. The anterior approach was performed by conventional thoracotomy or combined thoracotomy and lumbotomy in 20 patients and a less invasive retroperitoneal approach was used in 12 patients. One patient died of multiple metastases at 7 months after surgery and one patient had relapse of a local tumour resulting in paraparesis that required a repeat decompression of the spinal canal. The operation took 1 h and 50 min when the anterior approach and anterior stabilization with a Ventrofix fixator were used; the operation lasted from 3 h 20 min to 6 h 10 min when complementary posterior stabilization was involved. The patients were followed up for 2 to 24 months. No failure of the implant in terms of migration, change in position or penetration into adjacent vertebral bodies occurred. DISCUSSION: The replacement of a vertebral body has conventionally been performed with the use of a massive bone graft. However, collection of an autologous bone graft large enough to suit this purpose is not always possible. Complications at the donor site have been described. A homologous bone graft carries a risk of disease transmission and the reconstruction ability of a massive graft has not been confirmed for certain. Cement filling augmented with Kirschner's wires is usually used in cancer patients. Titanium cages require application of a large amount of spongiose bone tissue into their interior. Consequently, bone in the centre fails to remodel. A sharp edge of the mesh may induce migration of the cage towards the vertebral body and failure of the implant. Mechanical failure and collapse of cages have also been described. Telescopic cylindrical implants, on the other hand, need only a small amount of spongiose bone tissue to fill. They can be adapted directly to the implantation site by means of a special distractor and, therefore, before adjusting its final length, the exact position and orientation of the implant can be achieved in the space prepared. This facilitates close contact with the endplates of adjacent vertebral bodies and the development of osteointegration. The use of telescopic implants enabled us to avoid the force that is often necessary to apply during insertion of Harms' cages in the patients whose spines had already been stabilized with posterior fixation or to avoid the need of a triple surgical procedure in order to achieve better stability of the implant. In two patients, Synex was inserted from a non-standard posterior approach. Indications for Synex implantation should be evaluated in view of disease prognosis in each patient. If only limited survival is expected, cement filling with K-wires should be preferred. CONCLUSIONS: Synex is a sophisticated implant to replace severely damaged vertebral bodies regardless of the nature of lesion. Its application required additional stabilization by either posterior or anterior fixation (internal transpedicular fixator and Ventrofix or Kaneda, respectively). Its use is indicated in post-traumatic defects of vertebrae in acute or poorly healed scervical.

Bone Transplantation↗
PubMed2005

Clinical outcomes of unstable pelvic fractures in skeletally immature patients.

BACKGROUND: The orthopaedic literature contains few studies evaluating the long-term outcomes of unstable pelvic fractures in skeletally immature patients. The purpose of this study was to determine the factors that may influence the clinical and functional outcomes of such fractures. METHODS: A retrospective review of all patients with open triradiate cartilages and an unstable pelvic (Tile type-B or C) fracture treated, from 1986 to 2000, at one of two level-I trauma centers was performed. Patients were evaluated with a review of their medical records, the Modified Injury Severity Score (MISS), standardized physical examination, standardized radiographic evaluation, and the Short Musculoskeletal Function Assessment Questionnaire (SMFA). The outcomes were then used to assess the difference between patients who had been treated operatively and those who had been treated nonoperatively. RESULTS: Of 230 pelvic fractures treated during the study period, twenty-three in twenty-three patients were unstable. Of the twenty-three patients, twenty, with a mean age of 9.5 years at the time of injury, were evaluated. The mean duration of follow-up was 6.5 years. There were four type-B and sixteen type-C fractures according to the Tile classification system. The four patients with a type-B fracture had a mean of 1.4 cm of pelvic asymmetry at the time of union and the last follow-up, whereas the sixteen patients with a type-C fracture had a mean of 1.5 cm of pelvic asymmetry at those times. Pelvic asymmetry did not remodel even in younger patients. Eighteen patients were treated operatively with external fixation, internal fixation, or a combination of both, and pelvic asymmetry of < or =1 cm was achieved in ten of them. Patients who had < or =1 cm of pelvic asymmetry had no lumbar or sacroiliac pain, no or mild sacroiliac tenderness, no Trendelenburg sign, no lumbar scoliosis, and lower (better) bother and dysfunction scores on the SMFA compared with patients with more pelvic asymmetry. All patients with > or =1.1 cm of pelvic asymmetry had three or more of the following: nonstructural scoliosis, lumbar pain, a Trendelenburg sign, or sacroiliac joint tenderness and pain. Patients with fewer associated injuries and pelvic asymmetry of < or =1 cm had better clinical results. CONCLUSIONS: Unstable pelvic fractures in children can result in long-term morbidity and functional problems. Fractures associated with > or =1.1 cm of pelvic asymmetry following closed reduction should be treated with open reduction and internal or external fixation in order to improve alignment and the long-term functional outcome.

Adolescent↗
PubMed2006

Knee arthrodesis.

Arthrodesis is one of the last options available to obtain a stable, painless knee in a patient with a damaged knee joint that is not amenable to reconstructive measures. Common indications for knee arthrodesis include failed total knee arthroplasty, periarticular tumor, posttraumatic arthritis, and chronic sepsis. The primary contraindications to knee fusion are bilateral involvement or an ipsilateral hip arthrodesis. A variety of techniques has been described, including external fixation, internal fixation by compression plates, intramedullary fixation through the knee with a modular nail, and antegrade nailing through the piriformis fossa. Allograft or autograft may be necessary to restore lost bone stock or to augment fusion. For the carefully selected patient with realistic expectations, knee arthrodesis may relieve pain and obviate the need for additional surgery or extensive postoperative rehabilitation.

Arthrodesis↗
PubMed1995

Arthrodesis after infected knee arthroplasty using long arthrodesis nail. A report of five cases.

Safe methods to perform secondary arthrodesis in the treatment of infected total knee arthroplasty (TKA) after revision arthroplasty has failed are increasingly needed as TKA becomes more common. Possible treatments include external fixation (with single- or double-framed fixators), internal fixation, or amputation. This article reports five cases of infected TKA treated with arthrodesis using a long intramedullary nail. Arthrodesis was performed in a two-stage manner, with surgical revision and insertion of a long intramedullary nail. All arthrodeses healed on an average of 4.8 months.

Adult↗
PubMed1988

Two-hole plate fixation for traumatic symphysis pubis diastasis.

Techniques for managing traumatic diastasis of the pubic symphysis include bed rest, hip spica casting, pelvic slings, external fixation, and internal fixation. We report herein our experience with 14 consecutively managed patients in whom we successfully stabilized traumatic pubic diastasis with a single two-hole plate fixation. The average age of the 13 men and one woman was 30 years; followup averaged 17 months. Most of the patients had associated injuries (Injury Severity Score average, 19). Nine patients had concomitant disruption of the sacroiliac joint requiring either delayed open reduction and internal fixation or prolonged skeletal traction; among the five remaining patients, time to mobilization (bed to chair) averaged 1 day. There were no complications attributable to the procedure; i.e., no infections, and no failures of fixation. In this small series of patients early two-hole plate fixation of the traumatic diastasis of the pubis satisfactorily restored the disrupted anterior pelvic ring, contributed to early mobilization of the patients, and made reduction of a concomitantly disrupted sacroiliac joint easier, whether accomplished by skeletal traction or open reduction and internal fixation during a second procedure.

Adolescent↗
PubMed2000

The treatment of unstable distal radius fractures with volar fixation.

Stable internal fixation and early motion has not been routinely available for distal radius fractures. Difficulties with the dorsal approach discourage surgeons from internally fixing the most common fracture types. The introduction of a new volar plate with subchondral support fixation allows the treatment of most distal radius fractures with stable internal fixation and early motion while avoiding the complications inherent in the dorsal approach.

Adult↗
PubMed2003

[Are the terms "biology" and "osteosynthesis" contradictory?].

Biology and Osteosynthesis may, at first glance, appear to be contradictory. The disadvantages of the surgical procedure are offset by improved recovery of blood supply across a fracture zone and by stimulation of callus formation due to (controlled and slight) instability (elastically flexible fixation). Biological internal fixation is a principle in its own right; its technique is to some extent incompatible with conventional compression fixation. Locked screws provide better anchorage of the implant in both biological and compression internal fixation techniques. This generally offers improved potential in the treating fractures in osteoporotic bone. Because locked screws offer improved anchorage, the use of unicortical screws is made possible with the effect that the medullary circulation is damaged less. Locked unicortical screws, especially if they are self-drilling and self-cutting, offer important surgical advantages in minimally invasive percutaneous osteosynthesis (MIPO) whereas bicortical screws are required for epi- and metaphyseal anchorage.

Adolescent↗
PubMed1986

Impending pathologic fractures from metastatic malignancy: evaluation and management.

Both lytic and blastic long bone metastases are at risk to develop pathologic fractures in instances where more than 50% of the circumferential cortical bone has been destroyed or where the pain with weight-bearing stresses persists, increases, or recurs despite adequate local irradiation. Moreover, those most commonly encountered lesions of the proximal femur are at high risk to fracture if they are in excess of 2.5 cm in any dimension or if they are associated with avulsion of the lesser trochanter. Such lesions should be treated aggressively by prophylactic internal fixation. This will avoid the development of a secondary fracture with its concomitantly high risk that true bony healing will not occur even with adequate fixation. When internal fixation is chosen for a large metastasis with extensive cortical destruction, that fixation should be augmented by debulking of the lesion and by packing it with methylmethacrylate polymerizing in situ. Such an expedient not only improves the efficacy of subsequent radiotherapy but also prevents shortening of the bone with weight bearing while enhancing the torque capacity and sheer resistance inherent in the metal fixation device.

Adult↗
PubMed1977

Treatment of mandibular fractures by means of stable internal wire fixation.

Treatment according to the principles of stable internal fixation offers great advantages for fractures of the mandibular body. Most authors believe that a stable internal fixation can be achieved only by means of bone plating or screw fixation. At Groningen a wire connection was designed by BRONS which could be considered to be stable. The application of this stable internal wire fixation and the results of treatment in 272 fractures of the mandibular body between 1967 and 1976 are discussed.

Fracture Fixation, Internal↗
PubMed2002

Salvage of infected total knee fusion: the last option.

Currently the most common indication for an arthrodesis of the knee is a failed infected total knee prosthesis. Other causes of a failed total knee replacement that might necessitate a knee fusion include aseptic loosening, deficient extensor mechanism, poor soft tissues, and Charcot joint. Techniques available for achieving a knee fusion are external fixation and internal fixation methods. The external fixation compression devices have been the most widely used for knee fusion and have been successful until the indications for fusion changed to mostly failed prosthetic knee replacement. With failed total knee replacement, the problem of severe bone loss became an issue, and the external fixation compression devices, even including the biplane external fixators, have been the least successful method reported for gaining fusion. The Ilizarov technique has been shown to achieve rigid fixation despite this bone loss, and a review of reports are showing high fusion rates using this method. Internal fixation methods including plate fixation and intramedullary nails have had the best success in gaining fusion in the face of this bone loss and have replaced external fixation methods as the technique of choice for knee fusion when severe bone loss is present. A review of the literature and a discussion of different fusion techniques are presented including a discussion of the influence that infection has on the success of fusion.

Arthrodesis↗
PubMed2000

The evolution of indirect reduction techniques for the treatment of fractures.

During the last decade, classic AO/ASIF techniques for internal fixation shifted from direct reduction and rigid fixation to biologic internal fixation using indirect reduction techniques. Biologic internal fixation is characterized by the preservation of bone and soft tissue vascularity and relative rather than absolute mechanical stability. Reduction is achieved by using soft tissue traction while obtaining axial and rotational alignment and the correct length. Stabilization is performed when possible by compression plating for load sharing or by bridge plating in comminuted fractures. Advancements of these techniques and the development of newer implants that minimize vascular damage have contributed to the development of biologic internal fixation. By using indirect reduction, by using longer plates to improve the mechanical leverage, and by applying fewer screws to avoid unnecessary damage to the bone, fracture union rates were high. There also was a decreased need for supplemental bone grafting. All of these factors provided stable fixation and allowed early motion.

Bone Transplantation↗
PubMedDate not supplied

Internal fracture fixation in patients with osteoporosis.

Because of the decreased holding power of plate-and-screw fixation in osteoporotic bone fractures, internal fixation can have a high failure rate, ranging from 10% to 25%. Screws placed into cortical bone have better resistance to pullout than do those placed into adjacent trabecular bone. Plates should not be used to bridge unstable regions of bony comminution in osteoporotic patients. Fixation stability is optimized by securing stable bone contact across the fracture site and by placing screws both as close to and as far from the fracture as possible. Intentional shortening can improve stability and load sharing of the fracture construct. Structural bone graft or other types of fillers can be used to fill voids when comminution prevents stable contact. Load-sharing fixation devices such as the sliding hip screw, intramedullary nail, antiglide plate, and tension band constructs are better alternatives for osteoporotic metaphyseal locations. Proper planning is essential for improved fracture fixation in this high-risk patient group.

Fracture Fixation, Internal↗
PubMed2001

Allograft fractures revisited.

A retrospective review of patients with allograft fractures was done at the authors' institution. Between 1974 and 1998, 185 of 1046 (17.7%) structural allografts fractured in 183 patients at a mean of 3.2 years after transplantation. Initial allograft fixation included internal fixation with plates and screws in 181 patients. Patients with grafts that were longer than the average length (15.5 cm) tended to have worse results. Adjuvant therapy had no effect on fracture rate. Seventy-three patients with fractures had other allograft complications. Infection and nonunion with allograft fracture significantly worsened the outcome. The incidence of fracture in the patients with osteoarticular and arthrodesis transplants was significantly higher than those patients who had intercalary and composite reconstructions. Treatment of the allograft fractures included open reduction and internal fixation in 41 patients, reconstruction with a new allograft in 38, allograft-prosthesis composite in five, oncologic prosthesis in 19, amputation in 15, arthroscopic removal of loose bodies in three, resurfacing of fractured osteoarticular allograft surfaces in 39, allograft removal and cement spacer placement in 15. Twenty patients did not receive treatment. Eight of the fractures in patients who were not treated healed spontaneously. Outcomes were judged as excellent in nine patients (4.9%), good in 72 patients (38.9%), fair in 17 patients (9.2%), and in 85 patients (45.9%) the allograft reconstruction failed.

Adult↗
PubMed1996

[External fixator in severe traumatic injuries of the pelvis: results apropos of 20 consecutive cases].

From August 91 to December 94, 20 external fixators were used for severely injured patients (avg. ISS 25.2). The fractures were essentially open book with or without lateral compression and vertical lesions. The indication for fixation was treatment of shock and stabilization in 8 cases, stabilization alone in 9 cases, and in 3 cases as complementary fixation after internal fixation of posterior lesions. The fixation of the pelvis was effective on the amount of blood loss. One acetabulum fracture required surgery, two patients had internal fixation for loss of reduction and two others for late pubic and posterior pain. The clinical results are good; they are more related to the severity of the initial lesion than to the mode of fixation or the quality of the reduction. No superficial sepsis or osteitis was observed in relation to the pins.

Adult↗