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Overall symptomatic pseudathrosis after pelvic ring fracture is rare. A pseudarthrosis of the dorsal pelvic ring often leads to persisting pain due to instability and needs a consequent treatment strategy. Often a bacterial infection can be found in persisting pseudarthrosis notably in the anterior pelvic ring region. It is assumed that the peculiar anatomical site of the surgical approach - pubic region and abdominal skinfold - in particular accompanied with adipositas is predestined. Often patients with pseudathrosis and proof of bacterial infection show no symptoms. In these cases treatment is not mandatory. Patients however who complain about persisting pain limited treatment options exist.The following case report demonstrates a treatment strategy to achieve pelvic ring stability and infection eradication using a silver ionised plate and screws as well as a tantalum cage.
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Fracturas Óseas , Seudoartrosis , Humanos , Seudoartrosis/cirugía , Plata , Tantalio/uso terapéutico , Tornillos Óseos , Fijación Interna de Fracturas , Fracturas Óseas/cirugía , Complicaciones PosoperatoriasRESUMEN
OBJECTIVE: The treatment of thoracic spine (TS) fractures with additional sternal fractures compared to TS fractures without sternal fractures is discussed controversionally, because in some studies it was stated that sternal fractures decrease the thoracic stability. We hypothesized that both types of fractures can be treated the same way by posterior stabilization alone. METHODS: A total number of 69 patients with thoracic fractures, with or without additional sternal fractures, were examined, regarding the angle of kyphosis after fracture, postoperatively and after 6 and 12 months. We also recorded the outcome using the Odom's score and the time until patients returned to work and the activity level. RESULTS: It was found that the angle of kyphosis was nearly physiological after stabilization in both groups and a loss of reduction after 1 year was also comparable, either in the patients suffering from the additional sternal fracture or not. In addition, the Odom's score and the time until return to work and the activity level were comparable in both groups. CONCLUSION: We did not find any arguments to preserve additional anterior stabilization or reasons for different treatment strategies either additional sternal fractures occur in thoracic spine fractures or not.
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Cifosis , Fracturas de la Columna Vertebral , Traumatismos Torácicos , Humanos , Cifosis/diagnóstico por imagen , Cifosis/cirugía , Vértebras Lumbares/lesiones , Fracturas de la Columna Vertebral/diagnóstico por imagen , Fracturas de la Columna Vertebral/cirugía , Vértebras Torácicas/diagnóstico por imagen , Vértebras Torácicas/lesiones , Vértebras Torácicas/cirugíaRESUMEN
BACKGROUND: Minimally invasive, thoracoscopic anterior spondylodesis (MIAS) is an established treatment for burst fractures of the thoracolumbar spine. Good restoration of the local sagittal alignment and good functional results have been reported. The aim of this study was to evaluate long-term results of MIAS in patients with incomplete burst fractures and to analyze the influence on global sagittal alignment, clinical outcomes, and adjacent segment degeneration. METHODS: From 2002 to 2003, 18 patients were treated with MIAS for incomplete thoracolumbar burst fractures. Mono-segmental spondylodesis was performed with an iliac crest bone graft and bisegmental spondylodesis with a titanium cage. In this single-center prospective cohort study, 15 patients were available for follow-up (FU) after an average of 12.9 years (12.1-14.4). Seven patients were treated with a combined anterior and posterior instrumentation and eight patients with anterior spondylodesis only. The primary clinical outcome parameter was the Oswestry Disability Index (ODI); secondary parameters were the Short Form 36 (SF36) and the visual analog scale (VAS spine). Full spine radiographs were assessed for bisegmental Cobb angle, alignment parameters, and signs of adjacent segment degeneration (ASD). RESULTS: ODI evaluation showed a mean impairment of 11.7% with minimal limitations in 13 patients. Neither a significant deterioration over time nor significant differences between both therapy strategies were found in the clinical scores at the latest follow-up. The mean bisegmental increase of regional malalignment of reduction was 8.8° (± 7.3°) with no significant correlation to any clinical outcome scores. The majority of patients had no signs of adjacent segment degeneration. Two patients showed minor radiologic changes. All patients had a balanced sagittal spine profile. CONCLUSIONS: In conclusion, MIAS leads to good clinical results with-in majority-minimal spine-related impairment at the latest follow-up. No significant deterioration at 12-year FU was detectable compared to the 6-year results for the SF36 and VAS spine scores. There was no association between sagittal alignment, clinical outcome scores, and ASD. TRIAL REGISTRATION: The study was retrospectively registered in the German Clinical Trials Register ( Nr.00015656 ).
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Fracturas Conminutas/cirugía , Fracturas por Compresión/cirugía , Vértebras Lumbares/cirugía , Fracturas de la Columna Vertebral/cirugía , Fusión Vertebral/métodos , Vértebras Torácicas/cirugía , Toracoscopía/métodos , Adulto , Desviación Ósea/prevención & control , Trasplante Óseo/métodos , Femenino , Estudios de Seguimiento , Humanos , Ilion/trasplante , Vértebras Lumbares/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/prevención & control , Estudios Prospectivos , Vértebras Torácicas/diagnóstico por imagen , Factores de Tiempo , Resultado del Tratamiento , Escala Visual Analógica , Adulto JovenRESUMEN
OBJECTIVE: Early decompression after acute spinal cord injury (SCI) is recommended. Acute care is crucial, but optimal management is unclear. The aim of this study was to investigate the role of preoperative magnetic resonance imaging (MRI) in addition to computed tomography (CT) in surgical decision making for acute cervical SCI. METHODS: All patients with cervical SCI between 2008 and 2016 who had preoperative CT and MRI (n = 63) at the Trauma Center Murnau, Germany, were included. We administered a survey to 10 experienced spine surgeons (5 neurosurgeons, 5 trauma surgeons) regarding the surgical management. First, the surgeons were shown clinical information and CT scans. Two months later, the survey was repeated with additional MRI. Corresponding percentages of change and agreement were obtained for each rater and survey item. Finally, results from both parts of the survey were compared with the definitive treatment option (i.e., real-world decision). RESULTS: MRI modified surgical timing in a median of 41% of patients (interquartile range 38%-56%). In almost every fifth patient (17%), no surgery would have been indicated with CT alone. The advocated surgical approach was changed in almost half of patients (median 48%, interquartile range 33%-49%). Surgically addressed levels were changed in a median of 57% of patients (interquartile range 56%-60%). MRI led to higher agreement with the real-world decision concerning addressed levels (median 35% vs. 73%), timing (median 51% vs. 57%), and approach (median 44% vs. 65%). CONCLUSIONS: Preoperative MRI influenced surgical decision making substantially in our cohort and has become a new standard for patients with cervical SCI in our institution if medically possible.
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Toma de Decisiones Clínicas , Descompresión Quirúrgica/métodos , Imagen por Resonancia Magnética , Neurocirujanos , Procedimientos Neuroquirúrgicos/métodos , Traumatismos de la Médula Espinal/diagnóstico por imagen , Traumatología , Vértebras Cervicales , Humanos , Periodo Preoperatorio , Traumatismos de la Médula Espinal/cirugía , Fusión Vertebral/métodos , Cirujanos , Encuestas y Cuestionarios , Tomografía Computarizada por Rayos XRESUMEN
STUDY DESIGN: consensus paper with systematic literature review. OBJECTIVE: The aim of this study was to establish recommendations for treatment of thoracolumbar spine fractures based on systematic review of current literature and consensus of several spine surgery experts. METHODS: The project was initiated in September 2008 and published in Germany in 2011. It was redone in 2017 based on systematic literature review, including new AOSpine classification. Members of the expert group were recruited from all over Germany working in hospitals of all levels of care. In total, the consensus process included 9 meetings and 20 hours of video conferences. RESULTS: As regards existing studies with highest level of evidence, a clear recommendation regarding treatment (operative vs conservative) or regarding type of surgery (posterior vs anterior vs combined anterior-posterior) cannot be given. Treatment has to be indicated individually based on clinical presentation, general condition of the patient, and radiological parameters. The following specific parameters have to be regarded and are proposed as morphological modifiers in addition to AOSpine classification: sagittal and coronal alignment of spine, degree of vertebral body destruction, stenosis of spinal canal, and intervertebral disc lesion. Meanwhile, the recommendations are used as standard algorithm in many German spine clinics and trauma centers. CONCLUSION: Clinical presentation and general condition of the patient are basic requirements for decision making. Additionally, treatment recommendations offer the physician a standardized, reproducible, and in Germany commonly accepted algorithm based on AOSpine classification and 4 morphological modifiers.
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PURPOSE: The purpose of this study is to determine the long term-results after thoracoscopic spondylodesis particularly with respect to a ventral versus dorso-ventral treatment strategy. METHODS: In this prospective cohort study, a follow-up examination was performed in 19 patients (seven men, 12 women, average age: 37.7 years, follow-up rate: 79 %), six years after ventral thoracoscopic spondylodesis of unstable, incomplete burst fractures. Nine patients received a ventral monosegmental spondylodesis with iliac crest bone graft. The other ten cases were treated dorso-ventrally, five undergoing a ventral monosegmental treatment with iliac crest bone graft; the other five a ventral bisegmental treatment with expandable titanium cage. RESULTS: The complication rate was 15.7 %, the rate of revision of 10.5 %. No complication was related to the ventral thoracoscopic approach, whereas all of them were related to the iliac crest bone graft. The operative bisegmental kyphotic reduction was higher in the dorso-ventrally treated group. Afterwards, the loss of reduction was similar in both study groups. The mean VAS spine score summed up to more than 80 in both groups. The mean PCS scores were comparable to a normal healthy collective of the same age. CONCLUSIONS: The ventral thoracoscopic approach to the spine seems to be a safe therapeutic strategy. A dorso-ventral treatment concept goes along with a higher operative reduction potential.
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Vértebras Lumbares/lesiones , Base del Cráneo/lesiones , Fracturas de la Columna Vertebral/cirugía , Fusión Vertebral/métodos , Vértebras Torácicas/lesiones , Toracoscopía/métodos , Adulto , Tornillos Óseos , Trasplante Óseo , Femenino , Estudios de Seguimiento , Humanos , Fijadores Internos , Estudios Longitudinales , Vértebras Lumbares/diagnóstico por imagen , Vértebras Lumbares/cirugía , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Radiografía , Estudios Retrospectivos , Base del Cráneo/diagnóstico por imagen , Base del Cráneo/cirugía , Vértebras Torácicas/diagnóstico por imagen , Vértebras Torácicas/cirugía , Resultado del TratamientoRESUMEN
INTRODUCTION: Autologous bone graft is the gold standard for vertebral body replacement. Currently, after modern implants for vertebral body replacement are available, controversies exist regarding the optimal implant strategy. PATIENTS AND METHODS: Between 2002 and 2003, 17 patients were included in this study, all suffering from incomplete burst fractures of the thoracolumbar spine. All of them were treated by ventral monosegmental spondylodesis using iliac crest bone graft. The individual treatment strategy depended on the fracture situation and patient's condition. After an average of 74 months (range 66-84) a clinical and computer tomographic follow-up examination was performed in 14 patients (average age, 35.2 years) including VAS spine score and SF 36 score. Nine patients were treated ventral only five patients dorsoventrally. RESULTS: Complete osseous consolidation was visible in nine, partial consolidation (>30 %) in four, and lysis in one patient, without any significant differences between ventral only or dorsoventral approach. After removal of the fixateur interne the level of consolidation improved in all patients, treated dorsoventrally. There was no significant correlation between percentage of osseous consolidation and the clinical follow-up parameters. After 6 years, 71 % of the patients suffered from persistent pain associated with the approach to the iliac crest. Two revision surgeries have been necessary. CONCLUSION: High rates of osseous consolidation are visible 6 years after ventral spondylodesis by iliac crest bone grafts. A further improvement of consolidation can be expected after dorsal implant removal. But the surgical approach to the iliac crest is accompanied with a relevant complication rate.
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Vértebras Lumbares , Fracturas de la Columna Vertebral/cirugía , Fusión Vertebral/métodos , Vértebras Torácicas , Adulto , Trasplante Óseo , Femenino , Estudios de Seguimiento , Humanos , Ilion/trasplante , Masculino , Persona de Mediana Edad , Adulto JovenRESUMEN
There is a growing need for specific revision implants to meet the increasing occurrence of failed total hip arthroplasties displaying massive deficiencies in acetabular bone stock. The developed acetabular revision cup presented in this study is aimed at individual patient solutions using a multi-axial and angular stable fixation peg as well as a modular adaptable lateral flap. To obtain an optimum implant design, a database of computed tomography scans of 69 patients' pelves was collected and computational reconstruction of the pelvic bone morphology was conducted. Based on the anatomic measurements, the direction of the fixation peg of the revision cup was evaluated using custom software and the geometry of the lateral flaps was evaluated using rapid prototyping models of the pelvis. Furthermore, we conducted preclinical examinations of the acetabular revision system with regard to the safety of the angular stable locking mechanism of the fixation pegs and the mechanical stability of the lateral flap. The dynamic tests showed no mechanical failure of the fixation peg and its angular stable connection using a cyclic maximum torque of 24.5 Nm for one million cycles. The lateral flap and its fixation showed no mechanical failure using a cyclic maximum torque of 28.4 Nm for two million cycles. In conclusion, a promising solution to satisfy the requirements for adequate anatomical fit in a wide range of acetabular defects is presented.
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Acetábulo/anatomía & histología , Prótesis de Cadera , Modelos Anatómicos , Pelvis/anatomía & histología , Ajuste de Prótesis/métodos , Acetábulo/cirugía , Cementación , Simulación por Computador , Diseño Asistido por Computadora , Análisis de Falla de Equipo , Humanos , Diseño de PrótesisRESUMEN
A broad variety of 2,2,6,6-tetramethylpiperidine-based N-alkoxyamines were prepared in a newly found reaction. By means of a copper-catalyzed fragmentation reaction of aldehyde peroxides in the presence of TEMPO or TEMPO derivatives, N-alkoxyamines were obtained in moderate to good yields.
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STUDY DESIGN: A retrospective analysis of a case series was performed. OBJECTIVE: To give recommendations for the prevention and operative treatment of thoracic and thoracoabdominal aortic lesions in association with spinal interventions. SUMMARY OF BACKGROUND DATA: Aortic lesions after spinal interventions for traumatic vertebral fractures, segmental spondylodiscitis, or vertebral metastasis are fortunately rare, but associated with a high perioperative mortality rate and absolute numbers are unknown. Therefore, preventive strategies to avoid perioperative major vessel injuries and recommendations for the operative treatment of aortic lesions related to spinal surgery are required. METHODS: The clinical course of 10 patients with an acute aortic hemorrhage or an increased intraoperative risk for aortic injuries in association with primary or secondary spinal interventions is reported. All patients were evaluated before surgery by orthopedic trauma surgeons, vascular surgeons, and diagnostic radiologists. RESULTS: Five patients had preventive vascular interventions to avoid major aortic injuries during spinal reinterventions, and 5 patients were treated as an emergency for acute intraoperative hemorrhage related to spinal interventions. The operative treatment was performed by direct aortic sutures (n = 3), segmental alloplastic reconstructions (n = 2), or endovascular stent graft implantations (n = 3). Prophylactic banding of the thoracic aorta during thoracotomy or a femoral access for possible aortic balloon blockade was performed in patients with an estimated lower risk for an aortic laceration caused by malpositioned pedicle screws. No perioperative mortality was observed in patients treated by this interdisciplinary concept, but 1 patient treated under emergency condition for spondylodiscitis with an initially unrecognized aortic lesion died. CONCLUSION: In patients with complex spinal trauma, spondylodiscitis or difficult vertebral reinterventions, and an increased risk of major vessel injury, a preoperative interdisciplinary evaluation is recommended, even under emergency conditions. Endovascular stent graft technique is an additional option for prevention and treatment of suspected or acute aortic injuries of thoracic and infrarenal aortic lesions, whereas injuries to the visceral aortic segment still require advanced vascular reconstructions.
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Aorta Torácica/cirugía , Enfermedades de la Aorta/prevención & control , Enfermedades de la Aorta/cirugía , Procedimientos Ortopédicos/efectos adversos , Enfermedades de la Columna Vertebral/cirugía , Procedimientos Quirúrgicos Vasculares , Anciano , Aneurisma Falso/etiología , Aneurisma Falso/prevención & control , Aneurisma Falso/cirugía , Aorta Torácica/lesiones , Aorta Torácica/patología , Aneurisma de la Aorta Torácica/etiología , Aneurisma de la Aorta Torácica/prevención & control , Aneurisma de la Aorta Torácica/cirugía , Enfermedades de la Aorta/diagnóstico por imagen , Enfermedades de la Aorta/etiología , Rotura de la Aorta/etiología , Rotura de la Aorta/prevención & control , Rotura de la Aorta/cirugía , Aortografía , Prótesis Vascular , Implantación de Prótesis Vascular/efectos adversos , Servicios Médicos de Urgencia , Femenino , Estudios de Seguimiento , Alemania , Humanos , Masculino , Persona de Mediana Edad , Selección de Paciente , Estudios Retrospectivos , Medición de Riesgo , Enfermedades de la Columna Vertebral/diagnóstico por imagen , Stents , Suturas/efectos adversos , Factores de Tiempo , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Procedimientos Quirúrgicos Vasculares/métodosRESUMEN
While Kyphoplasty is increasingly becoming a recognised minimally invasive treatment option for osteoporotic vertebral fractures and neoplastic vertebral collapse, the experience in the treatment of vertebrae of the mid (T5-8)- and high (T1-4) thoracic levels is limited. The slender pedicle morphology restricts the transpedicular approach at these levels, necessitating extrapedicular placement techniques. Fifty five vertebrae of 32 consecutive patients were treated with kyphoplasty at levels ranging from T2-T8 for vertebral fractures (27 patients) or osteolytic collapse (5 patients). All procedures were performed through the transcostovertebral approach under fluoroscopic guidance. The radioanatomical landmarks of this minimally invasive approach were consistently identified and strictly adhered to. One fracture required open instrumentation due to posterior column injury in addition to kyphoplasty. Identification of specific radioanatomical landmarks allowed precise tool introduction in all cases without intraspinal or paravertebral malplacement. Average operating time for patients with osteoporotic fractures was 30 min per level (range 13-60 min) and 52 min per level (range 35-95 min) in neoplastic cases. Biopsy yield in patients with known or suspected malignancies was 100%. Epidural cement leakage was detected in one patient with pedicular osteolysis. Perforation of the lateral vertebral cortex during balloon inflation occurred in another patient. Both intraoperative complications were without clinical significance. Kyphoplasty in mid- to -high thoracic levels is possible via the transcostovertebral route under fluoroscopic guidance. Strict adherence to a stepwise protocol of tool introduction following defined radioanatomical landmarks is mandatory for the safe completion of this minimally invasive technique.