Mechanical testing of a device for subcutaneous internal anterior pelvic ring fixation versus external pelvic ring fixation

BACKGROUND: Although useful in the emergency treatment of pelvic ring injuries, external fixation is associated with pin tract infections, the patient’s limited mobility and a restricted surgical accessibility to the lower abdomen. In this study, the mechanical stability of a subcutaneous internal anterior fixation (SIAF) system is investigated. METHODS: A standard external fixation and a SIAF system were tested on pairs of Polyoxymethylene testing cylinders using a universal testing machine. Each specimen was subjected to a total of 2000 consecutive cyclic loadings at 1 Hz with sinusoidal lateral compression/distraction (+/−50 N) and torque (+/− 0.5 Nm) loading alternating every 200 cycles. Translational and rotational stiffness were determined at 100, 300, 500, 700 and 900 cycles. RESULTS: There was no significant difference in translational stiffness between the SIAF and the standard external fixation when compared at 500 (p = .089), 700 (p = .081), and 900 (p = .266) cycles. Rotational stiffness observed for the SIAF was about 50 percent higher than the standard external fixation at 300 (p = .005), 500 (p = .020), and 900 (p = .005) cycles. No loosening or failure of the rod-pin/rod-screw interfaces was seen. CONCLUSIONS: In comparison with the standard external fixation system, the tested device for subcutaneous internal anterior fixation (SIAF) in vitro has similar translational and superior rotational stiffness

Biomechanical comparison of different external fixation configurations for posttraumatic pelvic ring instability

Background. External fixation is useful in the primary treatment of pelvic ring injuries. The present study compared the biomechanical stability of five different configurations of an external pelvic ring fixation system. Methods. Five configurations of an anterior external pelvic ring fixation system were tested using a universal testing machine. One single connecting rod was used in group “SINGLE,” two parallel connecting rods in group “DOUBLE,” two and four rods, respectively, in a tent-like configuration in groups “SINGLE TENT” and “DOUBLE TENT,” and a rhomboid-like configuration in group “RHOMBOID.” Each specimen was subjected to a total of 2000 consecutive cyclic loadings at 1 Hz lateral compression/distraction (±50 N) and torque (±0.5 Nm) loading alternating every 200 cycles. Translational and rotational stiffness were determined at 100, 300, 500, 700, and 900 cycles. Results. The “SINGLE TENT” and “RHOMBOID” configurations already failed with a preloading of 50 N compression force. The “DOUBLE” configuration had around twice the translational stability compared with the “SINGLE” and “DOUBLE TENT” configurations. Rotational stiffness observed for the “DOUBLE” and “DOUBLE TENT” configurations was about 50% higher compared to the SINGLE configuration. Conclusion. Using two parallel connecting rods provides the highest translational and rotational stability

Postoperative Spinal Implant Infections (PSII)—A Systematic Review: What Do We Know So Far and What is Critical About It?

Study Design: Systematic review. Objectives: Postoperative spinal implant infections (PSII) are an increasing challenge in the daily clinical routine. This review summarizes existing knowledge in the field of PSII, including definitions, epidemiology, classifications, risk factors, pathogenesis, symptoms, diagnosis, and treatment. Methods: A systematic review was performed using a structured PubMed analysis, based on the PRISMA criteria. The search terminology was set as: “spinal implant associated infection OR spinal implant infection OR spinal instrumentation infection OR peri spinal implant infection.” PubMed search was limited to the categories randomized controlled trials (RCT), clinical trials, meta-analysis and (systematic) reviews, whereas case reports were excluded. Studies from January 2000 to December 2020 were considered eligible. A total of 572 studies were identified, 82 references included for qualitative synthesis, and 19 for detailed sub analysis (12 meta-analysis, 7 prospective RCT). Results: Structural problems in the field of PSII were revealed, including (1) limited level of evidence in clinical studies (missing prospective RCT, metanalyzes), (2) small patient numbers, (3) missing standardized definitions, (4) heterogeneity in patient groups, and (5) redundancy in cited literature. Conclusion: Evidence-based knowledge about spinal implant-associated infections is lacking. All involved medical fields should come together to define the term PSII and to combine their approaches toward research, training, and patient care

Treatment of femoral neck fractures in elderly patients over 60 years of age - which is the ideal modality of primary joint replacement?

BACKGROUND: Femoral neck fractures in the elderly are frequent, represent a great health care problem, and have a significant impact on health insurance costs. Reconstruction options using hip arthroplasty include unipolar or bipolar hemiarthroplasty (HA), and total hip arthroplasty (THA). The purpose of this review is to discuss the indications, limitations, and pitfalls of each of these techniques. METHODS: The Pubmed database was searched for all articles on femoral neck fracture and for the reconstruction options presented in this review using the search terms "femoral neck fracture", "unipolar hemiarthroplasty", "bipolar hemiarthroplasty", and "total hip arthroplasty". In addition, cross-referencing was used to cover articles eventually undetected by the respective search strategies. The resulting articles were then reviewed with regard to the different techniques, outcome and complications of the distinct reconstruction options. RESULTS: THA yields the best functional results in patients with displaced femoral neck fractures with complication rates comparable to HA. THA is beneficially implanted using an anterior approach exploiting the internervous plane between the tensor fasciae latae and the sartorius muscles allowing for immediate full weight-bearing. Based on our findings, bipolar hemiarthroplasty, similar to unipolar hemiarthroplasty, cannot restorate neither anatomical nor biomechanical features of the hip joint. Therefore, it can only be recommended as a second line of defense-procedure for patients with low functional demands and limited live expectancy. CONCLUSIONS: THA is the treatment of choice for femoral neck fractures in patients older than 60 years. HA should only be implanted in patients with limited life expectanc

Mediating Medical Comorbidities in Geriatric Patients Undergoing Surgery for OVCF: From Preoperative Screening to Risk and Outcomes Optimization

Objectives: Osteoporotic vertebral compression fractures (OVCF) are a common increasing entity in elderly patients and represent a tremendous economic burden. Surgical treatment is related to high complication rates and little is known about patient-specific and internal risk factors associated with poor clinical results. Methods: We carried out a comprehensive, systematic literature search according to the PRISMA checklist and algorithm. Risk factors for perioperative complications, for early inpatient readmission, for the duration of the hospital stay, the hospital mortality, the total mortality and the clinical result were analyzed. Results: A total of 739 potentially usable studies were identified. After considering all inclusion and exclusion criteria, 15 studies with 15,515 patients were included. Non-adjustable risk factors were age >90 years (OR 3.27), male gender (OR 1.41), BMI less than 18.5 kg/m 2 (OR 3.97), ASA score >3 (OR 2.7), activity of daily live (ADL) (OR 1.52), dependence (OR 5.68), inpatient admission status (OR 3.22), Parkinson disease (OR 3.63) and disseminated cancer (OR 2.98). Adjustable factors were insufficient kidney function (GFR <60 mL/min, and Creatinine Clearance below 60 mg/dl) (OR 4.4), nutrition status (hypalbuminemia (<3.5 g/dl)), liver function (OR 8.9) and further cardiac and pulmonary comorbidities. Discussion: We identified a couple of non-adjustable risk factors, which should be considered preoperatively in terms of risk assessment. However, even more important were adjustable factors that can be influenced preoperatively. In conclusion, we recommend a perioperative interdisciplinary cooperation, especially with geriatricians, to achieve the best possible clinical results in geriatric patients undergoing surgery for OVCF

Combined Odontoid (C2) and Atlas (C1) Fractures in Geriatric Patients: A Systematic Review and Treatment Recommendation

Study DesignSystematic review.ObjectiveThe aim of this study was to conduct a systematic overview of the pathogenesis and the treatment options of combined odontoid and atlas fractures in geriatric patients.MethodsThis review is based on articles retrieved by a systematic search in the PubMed and Web of Science databases for articles published until February 2021 dealing with combination fractures of C1 and C2 in geriatric patients.ResultsAltogether, 438 articles were retrieved from the literature search. A total of 430 articles were excluded. The remaining eight original articles were included in this systematic review depicting the topics pathogenesis, non-operative treatment, posterior approach, and anterior approach. The overall level of evidence of the studies is low.ConclusionCombined odontoid and atlas fractures in the geriatric population are commonly caused by simple falls and seem to be associated with atlanto-odontoid osteoarthritis. Non-operative treatment with a cervical orthosis is a feasible treatment option in the majority of patients with stable C2 fractures. In case of surgery posterior C1 and C 2 stabilization and anterior triple or quadruple screw fixation are possible techniques. Some patients may also deserve an occipito-cervical fusion. A possible treatment algorithm is proposed

Value of routine transpedicular biopsies in kyphoplasty and vertebroplasty for vertebral compression fractures: A survey among 250 spine surgeons

Zusammenfassung Hintergrund: Transpedikuläre Zementaugmentationen sind eine etablierte Therapieoption in der Behandlung pathologischer Kompressionsfrakturen der Wirbelsäule. Neben der Osteoporose sind auch immer wieder metastasierte Grundleiden oder seltener ein primärer Knochentumor Ursache für Wirbelkompressionsfrakturen ohne adäquates Trauma. Ziel: Erstellung eines aktuellen Meinungsbildes unter Wirbelsäulenchirurgen in Deutschland, der Schweiz und Österreich zum Stellenwert der transpedikulären Biopsie während Kypho- und Vertebroplastien von Wirbelkörperfrakturen. Material und Methoden: Es wurde ein webbasierter UmfrageOnline®-Fragebogen mit 11 Fragen erstellt und an die E‑Mail-Verteiler der Deutschen Wirbelsäulengesellschaft (DWG), der Österreichischen Gesellschaft für Wirbelsäulenchirurgie (spine.at) und der Schweizerischen Gesellschaft für spinale Chirurgie (SGS) sowie an den E‑Mail-Verteiler der Sektion Wirbelsäule der Deutschen Gesellschaft für Orthopädie und Unfallchirurgie (DGOU) versendet. Ergebnisse: Von insgesamt kontaktierten 2675 Wirbelsäulenchirurgen beantworteten 250 (9,3 %) die Umfrage. Rund ein Drittel (29,8 %) der Befragten führt regelhaft bei jeder Kypho- oder Vertebroplastie eine transpedikuläre Biopsie durch. Genannte Gründe für eine Biopsie waren ein bildmorphologischer (79,7 %) oder anamnestischer Verdacht auf eine Tumorerkrankung (66,0 %) oder das Vorliegen einer solchen (71,4 %). Als Gründe gegen eine routinemäßige Biopsie wurden die damit verbundenen Kosten und die limitierte Aussagekraft der gewonnenen Biopsate genannt. Diskussion: Fast ein Drittel der befragten Wirbelsäulenchirurgen führt regelhaft bei jeder Kypho- oder Vertebroplastie eine transpedikuläre Biopsie durch. Fast alle Befragten führen Biopsien zumindest dann durch, wenn eine Tumorerkrankung bekannt ist bzw. aufgrund von Risikofaktoren vermutet wird. Zukünftige Studien müssen die Kosteneffizienz der transpedikulären Biopsie weiter abklären.Abstract Background: Transpedicular cement augmentation is an established therapeutic option in the treatment of pathologic compression fractures of the spine. In addition to osteoporosis, underlying metastatic diseases or, more rarely, a primary bone tumor are recurrent causes of vertebral compression fractures without adequate trauma. Objective: To obtain a current opinion among spine surgeons in Germany, Switzerland, and Austria on the value of transpedicular biopsy during kyphoplasty and vertebroplasty of vertebral body fractures. Material and methods: A web-based (UmfrageOnline®) questionnaire with 11 questions was created and sent to the email distribution lists of the German Spine Society (DWG), the Austrian Society for Spine Surgery (spine.at), and the Swiss Society for Spinal Surgery (SGS), as well as to the email distribution list of the Spine Section of the German Society for Orthopedics and Trauma Surgery (DGOU). Results: Of a total of 2675 spine surgeons contacted 250 (9.3%) responded to the survey. Approximately one third (29.8%) of respondents regularly perform a transpedicular biopsy with each kyphoplasty or vertebroplasty. Reasons cited for biopsy were image morphology (79.7%) or history of suspected (66.0%) or present (71.4%) tumor disease. Reasons cited against routine biopsy were the associated costs and the limited informative value of the biopsies obtained. Discussion: Nearly one third of the spine surgeons surveyed regularly perform a transpedicular biopsy with each kyphoplasty or vertebroplasty. Almost all respondents perform biopsies at least when there is an imaging morphologic suspicion of tumor disease or tumor disease is known or suspected based on risk factors. Future studies need to further clarify the cost-effectiveness of transpedicular biopsy

Treatment and Outcome of Osteoporotic Thoracolumbar Vertebral Fractures With Anterior or Posterior Tension Band Failure (OF 5): Short-Term Results From the Prospective EOFTT Multicenter Study.

STUDY DESIGN Subgroup analysis of a multicenter prospective cohort study. OBJECTIVE To analyse surgical strategies applied to osteoporotic thoracolumbar osteoporotic fracture (OF) 5 injuries with anterior or posterior tension band failure and to assess related complications and clinical outcome. METHODS A multicenter prospective cohort study (EOFTT) was conducted at 17 spine centers including 518 consecutive patients who were treated for an osteoporotic vertebral fracture (OVF). For the present study, only patients with OF 5 fractures were analysed. Outcome parameters were complications, Visual Analogue Scale (VAS), Oswestry Disability Questionnaire (ODI), Timed Up & Go test (TUG), EQ-5D 5L, and Barthel Index. RESULTS In total, 19 patients (78 ± 7 years, 13 female) were analysed. Operative treatment consisted of long-segment posterior instrumentation in 9 cases and short-segment posterior instrumentation in 10 cases. Pedicle screws were augmented in 68 %, augmentation of the fractured vertebra was performed in 42%, and additional anterior reconstruction was done in 21 %. Two patients (11 %) received short-segment posterior instrumentation without either anterior reconstruction or cement-augmentation of the fractured vertebra. No surgical or major complications occurred, but general postoperative complications were observed in 45%. At a follow-up of mean 20 ± 10 weeks (range, 12 to 48 weeks), patients showed significant improvements in all functional outcome parameters. CONCLUSIONS In this analysis of patients with type OF 5 fractures, surgical stabilization was the treatment of choice and lead to significant short-term improvement in terms of functional outcome and quality of life despite a high general complication rate

Georg Schmorl prize of the German spine society (DWG) 2022: current treatment for inpatients with osteoporotic thoracolumbar fractures-results of the EOFTT study

AIM Osteoporotic thoracolumbar fractures are of increasing importance. To identify the optimal treatment strategy this multicentre prospective cohort study was performed. PURPOSE Patients suffering from osteoporotic thoracolumbar fractures were included. Excluded were tumour diseases, infections and limb fractures. Age, sex, trauma mechanism, OF classification, OF-score, treatment strategy, pain condition and mobilization were analysed. METHODS A total of 518 patients' aged 75 ± 10 (41-97) years were included in 17 centre. A total of 174 patients were treated conservatively, and 344 were treated surgically, of whom 310 (90%) received minimally invasive treatment. An increase in the OF classification was associated with an increase in both the likelihood of surgery and the surgical invasiveness. RESULTS Five (3%) complications occurred during conservative treatment, and 46 (13%) occurred in the surgically treated patients. 4 surgical site infections and 2 mechanical failures requested revision surgery. At discharge pain improved significantly from a visual analogue scale score of 7.7 (surgical) and 6.0 (conservative) to a score of 4 in both groups (p < 0.001). Over the course of treatment, mobility improved significantly (p = 0.001), with a significantly stronger (p = 0.007) improvement in the surgically treated patients. CONCLUSION Fracture severity according to the OF classification is significantly correlated with higher surgery rates and higher invasiveness of surgery. The most commonly used surgical strategy was minimally invasive short-segmental hybrid stabilization followed by kyphoplasty/vertebroplasty. Despite the worse clinical conditions of the surgically treated patients both conservative and surgical treatment led to an improved pain situation and mobility during the inpatient stay to nearly the same level for both treatments

Treatment and Outcome of Osteoporotic Thoracolumbar Vertebral Fractures With Anterior or Posterior Tension Band Failure (OF 5): Short-Term Results From the Prospective EOFTT Multicenter Study

Objective: To analyse surgical strategies applied to osteoporotic thoracolumbar osteoporotic fracture (OF) 5 injuries with anterior or posterior tension band failure and to assess related complications and clinical outcome. Methods: A multicenter prospective cohort study (EOFTT) was conducted at 17 spine centers including 518 consecutive patients who were treated for an osteoporotic vertebral fracture (OVF). For the present study, only patients with OF 5 fractures were analysed. Outcome parameters were complications, Visual Analogue Scale (VAS), Oswestry Disability Questionnaire (ODI), Timed Up & Go test (TUG), EQ-5D 5L, and Barthel Index. Results: In total, 19 patients (78 ± 7 years, 13 female) were analysed. Operative treatment consisted of long-segment posterior instrumentation in 9 cases and short-segment posterior instrumentation in 10 cases. Pedicle screws were augmented in 68 %, augmentation of the fractured vertebra was performed in 42%, and additional anterior reconstruction was done in 21 %. Two patients (11 %) received short-segment posterior instrumentation without either anterior reconstruction or cementaugmentation of the fractured vertebra. No surgical or major complications occurred, but general postoperative complications were observed in 45%. At a follow-up of mean 20 ± 10 weeks (range, 12 to 48 weeks), patients showed significant improvements in all functional outcome parameters. Conclusions: In this analysis of patients with type OF 5 fractures, surgical stabilization was the treatment of choice and lead to significant short-term improvement in terms of functional outcome and quality of life despite a high general complication rat