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BACKGROUND CONTEXT: One traditional treatment for spondylolisthesis is fusion. However, for high-grade spondylolisthesis and spondyloptosis, posterior fusion has had high rates of nonunion, progression, and persistent physical deformity. Thus, some surgeons have recommended reduction and instrumentation. One such technique (Gaines procedure) entails a two-stage procedure: L5 vertebrectomy anteriorly, followed by resection of the L5 posterior elements and instrumented reduction of L4 onto S1. However, to our knowledge, there is no report of reversing the fusion and deformity reduction in a symptomatic patient with previous solid fusion of the spondyloptosis at L5-S1. PURPOSE: To present the first reported revision via the Gaines procedure for failed fusion secondary to spondyloptosis. STUDY DESIGN: Patient report. METHODS: A 24-year-old woman, who had undergone multiple procedures for L5-S1 spondylolisthesis and a final fusion and instrumentation attempt, presented with continued urinary retention, leg and back pain, and inability to stand. She subsequently underwent posterior hardware removal, followed by anterior L5 vertebral body resection. In the second stage, she had posterior osteotomy of the previous L5-S1 fusion, resection of the posterior elements of L5, and reduction and instrumentation of L4 to S1. RESULTS: At the 2-year follow-up, she had full resolution of symptoms, full return of motor strength, and resolution of urinary retention. CONCLUSIONS: The Gaines procedure has been performed successfully in patients without previous fusions at the level of spondylolisthesis or spondyloptosis. Patients for whom the traditional posterior fusion fails still may be candidates for this procedure, albeit at increased risk of neurologic injury.

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STUDY DESIGN: Retrospective study. OBJECTIVES: To determine the frequency of pedicle screw violation of superior nonfused facet joints adjacent to the most cephalad pedicle screws after a midline approach for lumbar fusion. SUMMARY OF BACKGROUND DATA: Facet-joint violations have been evaluated in patients undergoing lumbar pedicle screw instrumentation and fusion with a Wiltse muscle-splitting approach, but not via the more common midline approach. METHODS: Between 1995 and 2003, 204 patients underwent this procedure. Computed tomography scans (within 1 year postsurgery) were evaluated independently for superior facet-joint violation. chi tests were used to examine bivariate associations of superior level facet-joint violation, patient age, construct level, diagnosis, and revision status for significance (P < or = 0.05). RESULTS: Superior-level facet-joint violation occurred in 24% of patients and 15% of screws, twice as often on the left side (P = 0.0396) than on the right, more frequently in single than in multiple-level procedures (P < 0.0001), and most frequently with the most cephalad screws at L5 (48%). We found no significant associations between violation rates and other designated parameters. CONCLUSION: The left side, single-level fusion, and most cephalad pedicle screws at L5 are targets for interventions to reduce pedicle violations in this procedure.

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Patients seeking medical advice increasingly turn to the World Wide Web. To test the hypothesis that Internet-provided medical information often is inaccurate and biased, we selected a common musculoskeletal condition. Three common Internet search engines were used to search "plantar fasciitis" and "plantar fascitis." Combining the first 50 web addresses from each search engine for both phrases and eliminating duplicate sites resulted in a database of 152 websites. Each website then was analyzed for authorship, sponsoring agency, and presence of financial incentive. The informational value score of each site then was graded using a 10-point scale evaluating the following parameters: basic definition of plantar fasciitis, causes and risk factors, clinical symptoms, diagnostic tests, differential diagnosis, conservative and surgical treatment options, and complications. The overall mean information value score for all 152 sites was 3.8 points; 36% of the sites showed financial bias. The highest mean scores among all authorship and sponsorship categories belonged to orthopaedic surgeons and academic institutions with mean scores of 7.1 and 6.1 points, respectively. Sites without obvious financial bias had significantly higher information value scores than sites with financial interests. Healthcare professionals should consider these findings when advising patients.

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This study tested the hypothesis that fixation of a fifth metatarsal tuberosity fracture with a lag screw that engages the intact medial cortex is biomechanically stronger than fixation with a long intramedullary screw (control). The right and left feet from 10 male cadavers were alternately assigned to the two fixation groups. After fracture reduction and fixation, each specimen was potted in acrylic cement and tested on a servohydraulic testing machine. The repairs were then distracted until failure by placing the peroneus brevis tendon under tension at a rate of 1 mm/s. The lag screw technique resulted in a significantly greater mean (+/- SD) load to failure (150 +/- 90 N) than did intramedullary screw fixation (70 +/- 60 N) (p < .05) and may offer a useful method of internal fixation of fifth metatarsal tuberosity fractures when surgical stabilization is indicated.

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