When and how to operate on thoracic and lumbar spine fractures?

Purpose

To discuss when and how to operate on thoracic and lumbar spine fractures.

Patients and methods

We retrospectively studied 77 consecutive patients with thoracic and lumbar spine fractures treated from 2000 to 2011; 28 patients experienced high-energy spinal trauma and 49 low-energy spinal trauma. Mean follow-up was 5 years (1–11 years). Surgical treatment was done in 15 patients with neurological deficits, and in 16 neurologically intact patients with fractures–dislocations, burst fractures and fractures with marked deformity. Non-surgical treatment was done in 46 neurologically intact patients with simple fracture configurations. Clinical and imaging examination and the Oswestry Disability Index (O.D.I.) questionnaire were obtained.

Results

All patients treated surgically maintained spinal alignment; patients with long fusion maintained the best alignment; however, they experienced back stiffness and moderate low back pain. Patients with combined posterior fusion and kyphoplasty experienced earlier recovery and improved sagittal correction. Mean O.D.I. was 22.4 and 14.2 % at 3 and 12 months postoperatively. Thirty six (78 %) patients treated non-surgically were asymptomatic, 22 (48 %) experienced mild residual kyphosis, 10 (22 %) developed marked deformity during their follow-up and were finally operated; mean O.D.I. was 28.6 and 12.1 % at 3 and 12 months. No difference in O.D.I. was observed between patients who had surgical and non-surgical treatment.

Conclusions

Progressive neurological deficits and/or mechanical instability of the spine are absolute indications for early surgical treatment. Younger patients with high-energy spinal trauma, unstable fractures and neurological deficits should be treated surgically in order to provide optimum conditions for neurologic recovery, early mobilization and possibly ambulation. Most cases can be adequately operated through a posterior only surgical approach; an anterior or combined approach is usually indicated for burst and thoracic spine fractures. Postoperative complications, more common infection and neurological deterioration may occur. Elderly, neurologically intact patients with low-energy, stable spinal fractures without marked spinal deformity may be successfully treated conservatively. Most of these patients will do well; however, follow-up for progressive posttraumatic deformity is required.     

Periprosthetic femoral fractures: What to do,what to do?

Post-operative periprosthetic fractures have an incidence of 1.1% (Berry, 1999 [1]). The periprosthetic fracture is commonly classified by the location of the fracture. The most frequently utilized fracture classification categorizes patients by the location of the fracture including: peritrochanteric, around the stem, or distal to the femoral implant. Additional considerations incorporated in this classification include femoral implant stability and host bone status. We will review the different treatment modalities for each fracture type with consideration given to stem stability and host bone status.     

When should we operate on major fractures in patients with severe head injuries?

BACKGROUND: The widely accepted practice of early fracture fixation (EFF) in multiply injured patients has recently been challenged in the presence of head injury. DATA SOURCES: English and German language articles on the subject were searched using Medline. Keywords included head trauma, intracranial trauma, brain injuries, fractures, fracture fixation, timing, femur fracture, and tibia fracture. CONCLUSIONS: The available literature does not provide clear-cut guidance on the management of fractures in the presence of head injuries. The trend is toward a better outcome if the fractures are fixed early. Treatment should therefore be tailored to the individual patient, with the assumption that full neurologic recovery will take place.     

Vitamin D: do we get enough?

Summary

On September 29, 2011, acknowledged experts in the field of vitamin D, mainly European, were brought together in order to discuss the recent scientific advances in relation to vitamin D: the current requirements and associations with various health outcomes. In this article, the discussions resulting from the meeting are summarized.

Introduction

Several groups at risk for developing vitamin D insufficiency have been identified. Accordingly, reviews indicate that a significant percentage of the population worldwide have serum 25-hydroxyvitamin D levels below 50 nmol/l. In addition to the role of vitamin D in bone health, recent studies suggest that it may play a pivotal role in other systems, e.g., the cardiovascular system, pancreas, muscle, immune system and brain. Most evidence, however, is obtained from observational studies and yet inconclusive.

Methods

To exchange and broaden knowledge on the requirements for vitamin D and its effect on various health outcomes, a workshop entitled “Vitamin D Expert Meeting: Do we get enough?”, was organized.

Results

Despite low vitamin D levels worldwide, consensus on the definition of deficiency is not yet reached. In order to define cut-off points for vitamin D whilst taking into account extraskeletal health effects, randomized controlled trials in these fields are warranted. The experts do emphasize that there is evidence to suggest an important role for vitamin D in the maintenance of optimal bone health at all ages and that vitamin D supplementation, in most studies co-administered with calcium, reduces fracture risk in the senior population.

Conclusion

To reach a serum 25-hydroxyvitamin D level of 50 nmol/l older adults aged ≥65 years are therefore recommended to meet a mean daily vitamin D intake of 20 μg (800 IU), which is best achieved with a supplement.     

What do we know about atypical femoral fractures? Insights and enigmas

Although the existence of atypical femoral fractures is well established and bisphosphonate therapy is thought to be a major risk factor, the underlying mechanisms are poorly understood. Epidemiological data show that atypical femoral fractures account for only a small proportion of diaphyseal subtrochanteric femoral fractures, being about 100 times less common than proximal femoral fractures. Consequently, the existence of atypical femoral fractures does not call into question the extremely favorable risk/benefit ratio of bisphosphonate therapy in patients with osteoporosis. Clearly, the number of fractures prevented by bisphosphonate therapy far exceeds the number of atypical femoral fractures potentially related to bisphosphonates.     

Managing scaphoid fractures. How we do it?

The scaphoid is the common carpal bone to be fractured. Proper clinical and radiological evaluation is required to establish it's diagnosis. The management of acute fractures includes conservative treatment with cast in minimally displaced to open reduction and internal fixation in case of displaced ones. The established nonunion requires open reduction, bone grafting and internal fixation.     

Triplane fractures: do we need cross-sectional imaging?

Introduction

Diagnosis of Triplane fractures remains difficult in common practice. Aim of the study was the evaluation of the fracture pattern and the benefit of cross-sectional imaging in classification of Triplane-fractures.

Material and Methods

A total of 27 pediatric patients treated for ankle fractures were identified from patient charts. Radiographic images of epiphyseal fractures (X-rays and additional cross-sectional imaging) were blinded evaluated by 13 observers to answer a specific questionnaire regarding type or fracture and treatment suggestion.

Results

There were seven Triplane-I and eight Triplane-II fractures. The other physeal ankle fracture group consisted of four patients with a Twoplane-fracture, five Salter-and-Harris (SH) II, one SH-III, and two SH-IV fracture. Accuracy of classification improved considerably depending on the experience of the observer in pediatric trauma care. Surgeons specialized in pediatric trauma care classified correctly with conventional X-rays in 48.1 % of all cases presented versus 31.5 % appropriate diagnosis by younger fellows. Accuracy in exact specification of Triplane-fractures was comparable lesser in younger fellows (31.1 vs. 22 %). Cross-sectional imaging improved classification of all fractures in both groups (75.6 % specialized vs. 47.3 % non specialized). Whereas availability of cross-sectional imaging improved treatment recommendation in specialized surgeons this benefit was not detectable for the doctors without specialization. Evaluation of fracture pattern showed a relatively stereotypical fracture pattern in Triplane-II fractures, whereas Triplane-I fractures were more variable.

Conclusion

The additional information of cross-sectional imaging seems helpful for any physician in finding the right classification of a pediatric ankle fracture. However, the additive information appears especially viable for experienced surgeons to suggest the appropriate treatment.     

Obesity,metabolic and bariatric surgery,and cancer prevention: what do we need to learn and how do we get there?

Obesity and associated metabolic dysfunction are on the rise in the United States and around the world. Metabolic dysfunction often leads to chronic disease, including cancer. Recent evidence suggests that weight loss among individuals with obesity may decrease cancer risk. Metabolic and bariatric surgery (MBS) leads to greater maximum and sustained weight loss than nonsurgical dietary strategies and demonstrates the most convincing evidence that weight loss lowers cancer risk. Caloric restriction diets combined with GLP-1 receptor agonists demonstrate weight loss intermediate between MBS and other nonsurgical diet strategies so long as individuals consistently take the medication. Weight regain after initial loss is a major problem with all weight loss strategies. To better prevent cancer in individuals with obesity, we need to individualize weight loss strategies, determining what strategy works for a given individual and how to implement it. We need to learn (1) what an individual’s impediments to initial and sustained weight loss are; (2) what the optimal weight loss strategy, be it diet modification, diet modification + medication, or MBS followed by diet modification, is; (3) how exercise(s) should be incorporated into weight loss strategies; (4) where medications fit into the treatment strategy of individuals with obesity; and (5) what the mechanisms driving the influence of MBS on cancer risk are. We also need to (6) explore expanding the eligibility of MBS to individuals with a body mass index <35 kg/m². Answers to these questions require a better understanding of how MBS impacts cancer risk, including in which groups (women versus men, which racial and ethnic groups, which cancers, which MBS procedure) MBS works best to reduce risk. The National Cancer Institute, through new funding opportunities, hopes to advance our understanding of how obesity drives cancer risk and how individuals with obesity can prevent cancer development and, among those with cancer, prevent disease recurrence.     

Complex coronoid and proximal ulna fractures are we getting better at fixing these?

Technological advances and improved understanding of functional anatomy about the elbow have lead an evolution regarding operative reconstruction of complex proximal ulnar and coronoid fractures. When treating these complex and challenging fractures, goals of anatomic articular restoration along with balanced soft tissue stability can lead to early range of motion and thus, desired functional outcome. The purpose of this review is to outline and provide tips and pearls to achieve desired results, with a comprehensive update on the most recent literature to support the latest fixation methods and techniques.     

Lycopene and male infertility： do we know enough？

There has been a recent renewed interest in the medical treatment of male subfertility. Akhough, intracytoplasmic sperm injection can surmount many of the reproductive challenges imposed upon couples struggling with male infertility, it remains an invasive and expensive treatment modality.     

Why do we use arthroscopy for distal radius fractures?

The management of distal radius fractures needs to be adapted to the increasingly complex traumas in patients with greater functional requirements. The goal remains to restore normal anatomy in order to preserve function. A pre-operative assessment using x-rays and thin-slice CT scans with three-dimensional reconstructions enables the best possible understanding of the fracture prior to surgery and planning of the pre-operative strategy. Arthroscopy is a technique that allows visualisation of the bone fragments and their displacement, as well as their reduction. It is the only tool that allows diagnostic and prognostic assessment of the associated injuries. Arthroscopy is the gold standard for identifying and grading scapholunate injuries. It allows treatment of the lesions where necessary and a dynamic appreciation of the stability of the osteosynthesis. Recognition of articular fragmentation patterns and instability features can therefore aid treatment choice to prevent poor outcomes due to malunion and degenerative arthritis. We recommend arthroscopic-assisted internal fixation for articular fractures for any active patient, not only for young adults, displaced or a gap by more than 2 mm, potential scapholunate ligament injuries, and fractures of the ulnar styloid. A strong initial learning and a minimal experience are recommended to avoid the complications of this invaluable procedure.