Proceedings of the 2023 Santa Fe bone symposium : Progress and controversies in the management of patients with skeletal diseases

The Santa Fe Bone Symposium (SFBS) held its 23rd annual event on August 5-6, 2023, in Santa Fe, New Mexico, USA. Attendees participated in-person and remotely, representing many states and countries. The program included plenary presentations, panel discussions, satellite symposia, a Project ECHO workshop, and a session on healthcare policy and reimbursement for fracture liaison programs. A broad range of topics were addressed, including transitions of osteoporosis treatments over a lifetime; controversies in vitamin D; update on Official Positions of the International Society for Clinical Densitometry; spine surgery and bone health; clinical applications of bone turnover markers; basic bone biology for clinicians; premenopausal-, pregnancy-, and lactation-associated osteoporosis; cancer treatment induced bone loss in patients with breast cancer and prostate cancer; genetic testing for skeletal diseases; and an update on nutrition and bone health. There were also sessions on rare bone diseases, including managing patients with hypophosphatasia; treatment of X-linked hypophosphatemia; and assessment and treatment of patients with hypoparathyroidism. There were oral presentations of abstracts by endocrinology fellows selected from those who participated in the Santa Fe Fellows Workshop on Metabolic Bone Diseases, held the 2 days prior to the SFBS. These proceedings of the 2023 SFBS present the clinical highlights and insights generated from many formal and informal discussions in Santa Fe

Proximal Humeral Nonunions Treated With Fixed-Angle Locked Plating and an Intramedullary Strut Allograft

OBJECTIVE:To determine if the use of a fixed-angle locked plate plus an intramedullary allograft in the treatment of proximal humeral nonunions resulted in improved union. DESIGN:Retrospective clinical analysis of patientsʼ medical charts and radiographs. SETTING:Clinical practice of senior authors. PATIENTS/PARTICIPANTS:Eighteen patients who presented to the senior authorsʼ clinic between 2001 and 2007 with clinical and radiographic evidence of symptomatic proximal humeral nonunions that were treated with the described method were included for analysis. Patients with severe humeral head bone loss, avascular necrosis, evidence of arthrosis, and less than 12-month clinical follow-up were excluded. INTERVENTION:All patients with a symptomatic viable nonunion of the proximal humerus were treated with a fixed-angle locked plate and an intramedullary cortical allograft. MAIN OUTCOME MEASUREMENT:Patients were followed until radiographic union was achieved, with this being the principle determinant of a successful outcome. RESULTS:Radiographic union was achieved in 17 of 18 patients (94%). The average follow-up was 26.5 months (range 12-49 months). The average time from surgery to radiographic union was 5.4 months (range 2.5-8.8 months). There was 1 failure of fixation, and 2 patients developed transient neurologic sequelae. Range of motion measurements obtained from the most recent clinical follow-up were 115 degrees (range 20-180 degrees) active forward elevation, 37 degrees (range 0-70 degrees) passive external rotation, and active internal rotation was to the 10th thoracic vertebrae. American Shoulder and Elbow Surgeon scores improved from a level of 40 preoperatively to 81 postoperatively, and visual analog scale scores improved from 6.7 to 1.5. CONCLUSION:Intramedullary strut allograft insertion combined with fixed-angle plating is an effective technique for treating viable nonunions of the proximal humerus and was successful in achieving union in 94% of our patients

Management of the mangled extremity

The management of a mangled extremity continues to be a matter of debate. With modern advances in trauma resuscitation, microvascular tissue transfer, and fracture fixation, severe traumatic extremity injuries that would historically have been amputated are often salvaged. Even if preserving a mangled limb is a technical possibility, the question is often raised whether the end result will also be functional and what treatment would lead to the best patient outcome. The road to salvage is often prolonged with significant morbidity, reoperations, financial costs, and even mortality in some instances. Numerous factors have been implicated in the outcome of these injuries, and a number of scoring systems have been designed in an attempt to help guide the treating surgeon in the acute phase. However, much controversy remains on the ability of these grading systems to predict successful salvage of the mangled extremity. In this review, we discuss the mechanisms of injury, various available scoring systems, initial management, outcome and specific differences between lower and upper extremity trauma injurie

Adjacent-level biomechanics after single versus multilevel cervical spine fusion Laboratory investigation

Object. Previous studies have demonstrated that patients with spinal fusion are at greater risk for adjacent-segment disease and require additional surgery. It has been postulated that excessive motion of a given motion segment unit (MSU) leads to an increased risk of disc degeneration. It is the authors' hypothesis that a greater increase in adjacent-segment motion will be observed following a 2-level versus a single-level anterior cervical discectomy and instrumented fusion (ACDF). Therefore, they undertook this study to determine the effect of single-level versus 2-level ACDF on the biomechanics of adjacent MSUs. Methods. Ten fresh-frozen human cervical spines were used in this study. The specimens were potted at C-4 and T-1 and tested in flexion and extension. Range of motion (ROM) was 30 degrees of flexion and 15 degrees of extension at a maximum load of 50 N. The specimens were tested intact and then were randomized into 2 groups of 5 specimens each. Group I underwent a single-level ACDF at the C5-6 level first, and Group 2 underwent the procedure at the C6-7 level. After testing, both groups had the fusion extended to include the C5-7 levels, and the testing was repeated. Changes in overall ROM, stiffness, and segmental motion were calculated and statistically analyzed using a paired Student t-test. Results. An increase in sagittal ROM of 31.30% above (p = 0.012) and 33.88% below (p = 0.066) the fused MSU was found comparing a 2-level with a 1-level ACDF. The overall stiffness of the entire spinal construct increased 37.34% (p = 0.051) in extension and 30.59% (p = 0.013) in flexion as the second fusion level was added. As expected, the overall sagittal ROM of the entire spinal construct decreased by 13.68% (p = 0.0014) with a 2-level compared with a 1-level fusion. Conclusions. This study has shown that the biomechanics at adjacent levels to a cervical spine fusion are altered and that there is increased adjacent-segment motion at the levels above and below, after a 2-level compared with a 1-level ACDF. (DOI: 10.3171/2011.10.SPINE11116

Go to: Negative effects of smoking, workers' compensation, and litigation on pain/disability scores for spine patients

Abstract Background

Smoking Cessation Related to Improved Patient-Reported Pain Scores Following Spinal Care in Geriatric Patients

Introduction: We examined rates of smoking cessation and the effect of smoking cessation on pain and disability scores in a geriatric patient population. Methods: Prospectively maintained database records of 6779 patients treated for painful spinal disorders were examined. The mean duration of care was 8 months. Multivariate statistical analysis was performed with independent variables including smoking status, secondary gain status, gender, treatment type, depression, and age. Results: Of the patients seeking care for painful spinal disorders, 8.9% over the age of 55 smoked compared with 23.9% of those under 55 years of age. Rates of smoking cessation did not differ for those older than 55 years (25.1%) and younger patients (26.1%). Current smokers in both age-groups reported greater pain than those who had never smoked in all pain ratings ( P < .001). Mean improvement in reported pain over the course of treatment was significantly different in nonsmokers and current smokers in both age-groups ( P < .001). Those who quit smoking during the course of care reported greater improvement in pain than those who continued to smoke. The mean improvement in pain ratings was clinically significant in patients in all 3 groups of nonsmokers whereas those who continued to smoke had no clinically significant improvement in reported pain. Conclusion: The results support the need for smoking cessation programs, given a strong association between improved patient-reported pain and smoking cessation. Fewer older patients smoke but they are equally likely to quit

Biomechanical study of 4-hole pubic symphyseal plating: locked versus unlocked constructs

To the authors' knowledge, no published studies have examined the use of locking plates on injuries of the anterior pelvic ring. The purpose of this study was to determine whether locked plates provide enhanced stability in the treatment of pubic symphyseal disruptions. Completely unstable pelvic injuries were simulated in pelvic Sawbones (model 1301; Pacific Research Laboratories, Vashon, Washington) and 2 different fixation constructs used for anterior fixation (4-hole, 3.5-mm pubic symphysis plate with all locked or all unlocked screws). Adjunctive sacroiliac screw fixation with a single 7.3-mm screw placed into S1 was used in all specimens. Specimens were analyzed for motion at the pubic symphysis and sacroiliac joints using a Material Testing System (MTS Systems Corporation, Eden Prairie, Minnesota). Each specimen was subjected to compressive loading in a single-limb stance. Side loading was also examined. The main outcome measurement was motion at the pubic symphysis and sacroiliac joints and overall construct stiffness. No significant difference existed in overall construct stiffness between the 2 methods of pubic symphysis fixation. The motions at the pubic symphysis or injured sacroiliac joints were not significantly different. In addition, motion at the pubic symphysis joint with lateral load was not improved with a locking construct.No significant difference existed between 4-hole locked or unlocked constructs used for fixation of the pubic symphysis. No apparent advantage of locking screws exists for disruptions of the pubic symphysis, and recent reports have questioned the possibility of catastrophic failure