Vertebral Artery Caught in the Fracture Gap after Traumatic C2/3 Spondylolisthesis

Background Context. Patient with a C2 fracture and entrapment of the right vertebral artery in the fracture gap. Purpose. Presentation of a case with follow-up until end of treatment. Study Design. Case report. Methods. A 25-year-old woman was brought into our emergency room after falling while riding a horse. She complained of pain in the cervical spine. Clinical examinations showed local tenderness at the upper cervical spine and painful impairment of the mobility of the neck, with no signs of neurological impairment. Radiological diagnostics revealed a traumatic C2/3 spondylolisthesis. A computer tomography (CT) angiographic scan showed a dislocation of the right vertebral artery into the fracture gap without injury to the artery. Open reduction and osteosynthesis were considered of too high risk. Therefore, we conducted fracture treatment with closed reduction and halo fixation. After removal of the halo fixator, the patient was given a soft cervical collar and was advised to rest for additional 6 weeks before beginning gradual activity. Results. Conventional follow-up revealed osseous consolidation and a CT angiographic scan showed consistent blood flow to the artery. Conclusion. Halo fixation was a safe and effective therapy strategy in the case of vertebral artery entrapment after traumatic C2 spondylolisthesis

Current Minimally Invasive Surgical Concepts for Sacral Insufficiency Fractures

An increasing incidence of sacral insufficiency fractures in geriatric patients has been documented, representing a major challenge to our healthcare system. Determining the accurate diagnosis requires the use of sectional imaging, including computed tomography and magnetic resonance imaging. Initially, non-surgical treatment is indicated for the majority of patients. If non-surgical treatment fails, several minimally invasive therapeutic strategies can be used, which have shown promising results in small case series. These approaches are sacroplasty, percutaneous iliosacral screw fixation (S1 with or without S2), trans-sacral screw fixation or implantation of a trans-sacral bar, transiliac internal fixator stabilisation, and spinopelvic stabilisation. These surgical strategies and their indications are reported in detail. Generally, treatment-related decision making depends on the clinical presentation, fracture morphology, and attending surgeons experience. Zusammenfassung Insuffizienzfrakturen des hinteren Beckenrings nehmen an Haufigkeit zu und stellen eine relevante Herausforderung fur unser Gesundheitssystem dar. Zur Sicherung der Diagnose sollte erganzend zu den konventionellen Rontgenaufnahmen eine Computertomografie und ggf. eine Magnetresonanztomografie erfolgen. Bei Versagen konservativer Therapieregime zeigen kleinere Serien minimalinvasiver operativer Therapieansatze vielversprechende Ergebnisse. Ziel dieser ubersichtsarbeit ist es, die aktuell eingesetzten Techniken der minimalinvasiven operativen Versorgung von Insuffizienzfrakturen des Sakrums aufzufuhren und die jeweiligen Vor- und Nachteile darzulegen. Dies sind aktuell die Sakroplastie, die perkutane iliosakrale Verschraubung S I oder S I/S II, die transsakrale Verschraubung u.a. mithilfe des transsakralen bar und von posterior horizontalen sowie lumbopelvinen Stabilisierungen. Im Allgemeinen hangt die Entscheidungsfindung zur Therapie vom klinischen Erscheinungsbild, der Frakturmorphologie und den Erfahrungen der behandelnden Chirurgen ab

Imaging of Sacral Stress and Insufficiency Fractures

Fractures of the os sacrum without relevant trauma history are defined as stress or insufficiency fractures and often affect the anterior pelvis. Sacral insufficiency fractures are associated with osteoporosis and occur under physiological load. In contrast, sacral stress fractures are caused by mechanical overloading. Diagnostic confirmation is delayed in many of these patients. Thus, MRI and/or CT should be performed early. Fracture stability should be evaluated by CT. MRI is the better approach to rule out fractures and is highly sensitive. It is indicated in young patients and in patients with non-specific lumbosacral pain. Nuclear imaging techniques are viable alternatives in patients with a contraindication for MRI

Risk factors for intraoperative greater trochanteric fractures in hemiarthroplasty for intracapsular femoral neck fractures

Purpose!#!Hemiarthroplasty is widely accepted as the treatment of choice in elderly patients with a displaced intracapsular femoral neck fracture. Intraoperative greater trochanteric fractures thwart this successful procedure, resulting in prolonged recovery, inferior outcome, and increased risk of revision surgery. Hence, this study analyzed factors potentially associated with an increased risk for intraoperative greater trochanteric fracture.!##!Methods!#!This retrospective study included 512 hemiarthroplasties in 496 patients with a geriatric intracapsular femoral neck fracture from July 2010 to March 2020. All patients received the same implant type of which 90.4% were cemented and 9.6% non-cemented. Intra- and postoperative radiographs and reports were reviewed and particularly screened for greater trochanteric fractures.!##!Results!#!Female patients accounted for 74% and mean age of the patients was 82.3 (± 8.7) years. 34 (6.6%) intraoperative greater trochanteric fractures were identified. In relation to patient-specific factors, only a shorter prothrombin time was found to be significantly associated with increased risk of intraoperative greater trochanteric fracture (median 96%, IQR 82-106% vs. median 86.5%, IQR 68.8-101.5%; p = 0.046). Other factors associated with greater trochanteric fracture were a shorter preoperative waiting time and changes in perioperative settings. Outcome of patients with greater trochanteric fracture was worse with significantly more surgical site infection requiring revision surgery (17.6% vs. 4.2%, p = 0.005).!##!Conclusion!#!Prolonged prothrombin time, a shorter preoperative waiting time, and implementing new procedural standards and surgeons may be associated with an increased risk of a greater trochanteric fracture. Addressing these risk factors may reduce early periprosthetic infection which is strongly related to greater trochanteric fractures

Minimal-invasive Stabilisierung bei thorakolumbalen osteoporotischen Frakturen

Background: Minimally invasive stabilization of thoracolumbar osteoporotic fractures (OF) in neurologically intact patients is well established. Various posterior and anterior surgical techniques are available. The OF classification and OF score are helpful for defining the indications and choice of operative technique. Objective: This article gives an overview of the minimally invasive stabilization techniques, typical complications and outcome. Material and methods: Selective literature search and description of surgical techniques and outcome. Results: Vertebral body augmentation alone can be indicated in painful but stable fractures of types OF 1 and OF 2 and to some extent for type OF 3. Kyphoplasty has proven to be an effective and safe procedure with a favorable clinical outcome. Unstable fractures and kyphotic deformities (types OF 3-5) should be percutaneously stabilized from posterior. The length of the pedicle screw construct depends on the extent of instability and deformity. Bone cement augmentation of the pedicle screws is indicated in severe osteoporosis but increases the complication rate. Restoration of stability of the anterior column can be achieved through additional vertebral body augmentation or rarely by anterior stabilization. Clinical and radiological short and mid-term results of the stabilization techniques are promising; however, the more invasive the surgery, the more complications occur. Conclusion: Minimally invasive stabilization techniques are safe and effective. The specific indications for the individual procedures are guided by the OF classification and the individual clinical situation of the patient

Value of MRI imaging prior to a kyphoplasty for osteoporotic insufficiency fractures

Previous studies have shown the safety and effectiveness of balloon kyphoplasty in the treatment of osteoporotic vertebral compression fractures (OVCFs). MRI and particularly the short tau inversion recovery (STIR) sequence are very sensitive for detecting vertebral edema as a result of fresh fractures or micro-fractures. Therefore, it has a great therapeutic relevance in differentiating vertebral deformities seen by conventional X-ray and CT scans. Although an MRI scan is expensive, to my knowledge no study has evaluated the benefits of preoperative MRI in evaluating a therapeutic plan for kyphoplasty. This is a prospective study evaluating the benefit of a preoperative MRI scan regarding changes of kyphoplasty therapy. Twenty-eight patients were included in this study. Twenty-four patients were treated by balloon kyphoplasty, in a total of 40 vertebral bodies. The mean age was 73 years. All patients suffered from OVCFs. As a first step, all patients got a CT scan. The individual therapeutic plan was then defined by the patients’ history, complaints and the results of the CT scan. As far as all criteria for kyphoplasty were fulfilled, an MRI examination including the STIR sequences was performed preoperatively. The number of times a change was made in therapy as a result from the additional information from the MRI was then evaluated. By performing a preoperatively MRI examination, the therapy plan was changed in 16 out of 28 (57%) patients. Eight patients underwent additional levels of kyphoplasty at the same procedure. In five patients, lesions were found to be old fractures and therefore were not treated operatively. Two of these patients received no kyphoplasty at all. Another patient only a part of the originally intended levels was treated. The other two cases received a kyphoplasty at different vertebral levels, as these vertebral bodies showed signs of an acute fracture in the MRI scan. Additionally, an incidental diagnosis of carcinoma of the kidney was made in two patients. Kyphoplasty was deferred and they were referred for further evaluation. One patient was found to have an aortic aneurysm. Kyphoplasty was performed and after that the patient was referred in order to treat the aneurysm. This study confirms the diagnostic benefits of an MRI scan before performing a kyphoplasty. For 16 out of 28 patients, the therapeutic plan was changed because of the information obtained by preoperative MRI. Preoperative MRI helped to generate the correct surgical strategy, by demonstrating the correct location of injury and by detecting concomitant diseases