FRACTURE OF COMPRESSION SCREW IN NON-UNION OF FRACTURE OF THE FEMORAL NECK.
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Bone Screws↗
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Open book (AP compression) pelvis fracture.
A simple pelvic fracture classification is presented based on the metaphor of a pelvis as a book. Resuscitative fluid and blood requirements can be estimated by knowledge of the pelvic fracture pattern. Open book (AP compression) pelvis fractures generally have the largest amounts of blood loss.
Adult↗
Percutaneous vertebroplasty: current concepts and local experience.
With the aging population in our country, symptomatic osteoporotic compression fractures are increasingly common. Osteolytic compression fractures from spinal metastasis are also becoming more frequently seen because of the longer life expectancy from improvements in chemotherapy. Percutaneous vertebroplasty with PMMA has been shown to be an efficient procedure to treat pain due to these fractures. It is a minimally invasive procedure performed under local anesthesia and sedation. Injection of PMMA provides immediate stability when it hardens, and permits the patient to ambulate without pain. Appropriate patient selection is the key to clinical success. However, this procedure must be treated with respect, and has to be performed by physicians with the necessary training. Otherwise, increased pain, paralysis, and even death may occur from this seemingly innocuous procedure. In this article, I will deal with the background issues of osteoporotic and osteolytic vertebral compression fractures, patient selection, surgical technique, complications, and review of current literature on vertebroplasty. Key areas of development in this field include the use of kyphoplasty, defining the role of prophylactic augmentation, and improvements in biomaterials.
Animals↗
Vertebral bone marrow perfusion evaluated with dynamic contrast-enhanced MR imaging: significance of aging and sex.
PURPOSE: To investigate blood perfusion of nonfractured, normal-appearing vertebral bodies with regard to age and sex. MATERIALS AND METHODS: Dynamic magnetic resonance imaging (160 images obtained in 80 seconds) was performed from T10 to L5 in 66 patients. Patients were assigned to three groups: group 1, those 50 years or younger without compression fracture; group 2, those older than 50 years without compression fracture; or group 3, those older than 50 years with compression fracture. Peak enhancement percentage and enhancement slope were determined from the time-intensity curve of normal (nonfractured) vertebral body. Comparisons were made between groups, and the effect of age and sex interaction was analyzed. RESULTS: Higher peak enhancement percentage was demonstrated for group 1 compared with group 2 (58.21 +/- 44.65 [SD] vs 21.88 +/- 14.77, P <.005). Group 1 women revealed a higher enhancement percentage compared with group 1 men (87.17 +/- 54.13 vs 38.16 +/- 21.69, P <.05), which significantly decreased in those older than 50 years (from 87.17 +/- 54.13 to 17.98 +/- 13.80, P <.005). For men, this decrease in those older than 50 years was not as pronounced (from 38.16 +/- 21.69 to 25.38 +/- 15.43, P >.05). Presence of compression fracture at other levels of the spine (group 3) was not associated with a different enhancement percentage for normal vertebrae. CONCLUSION: Rate of vertebral bone marrow perfusion revealed a significant decrease in subjects older than 50 years. Women demonstrated a higher marrow perfusion rate than men younger than 50 years and a more marked decrease than men older than 50 years.
Adult↗
Cold defect on bone scan in a vertebral body after percutaneous vertebroplasty.
Percutaneous vertebroplasty using bone cements is increasingly being used to stabilize osteoporotic spinal compression fractures. Although the scintigraphic appearance of compression fractures has been well-described, the post-vertebroplasty bone scan appearance has not. This case report describes a characteristic cold defect of a vertebral body after percutaneous vertebroplasty.
Female↗
Spinal loads after osteoporotic vertebral fractures treated by vertebroplasty or kyphoplasty.
Vertebroplasty and kyphoplasty are routine treatments for compression fractures of vertebral bodies. A wedge-shaped compression fracture shifts the centre of gravity of the upper body anteriorly and generally, this shift can be compensated in the spine and in the hips. However, it is still unclear how a wedge-shaped compression fracture of a vertebra increases forces in the trunk muscle and the intradiscal pressure in the adjacent discs. A nonlinear finite element model of the lumbar spine was used to estimate the force in the trunk muscle, the intradiscal pressure and the stresses in the endplates in the intact spine, and after vertebroplasty and kyphoplasty treatment. In this study, kyphoplasty represents a treatment with nearly full fracture reduction and vertebroplasty one without restoration of kyphotic angle although in reality kyphoplasty does not guarantee fracture reduction. If no compensation of upper body shift is assumed, the force in the erector spine increases by about 200% for the vertebroplasty but by only 55% for the kyphoplasty compared to the intact spine. Intradiscal pressure increases by about 60 and 20% for the vertebroplasty and kyphoplasty, respectively. In contrast, with shift compensation of the upper body, the increase in muscle force is much lower and increase in intradiscal pressure is only about 20 and 7.5% for the vertebroplasty and kyphoplasty, respectively. Augmentation of the vertebral body with bone cement has a much smaller effect on intradiscal pressure. The increase in that case is only about 2.4% for the intact as well as for the fractured vertebra. Moreover, the effect of upper body shift after a wedge-shaped vertebral body fracture on intradiscal pressure and thus on spinal load is much more pronounced than that of stiffness increase due to cement infiltration. Maximum von Mises stress in the endplates of all lumbar vertebrae is also higher after kyphoplasty and vertebroplasty. Cement augmentation has only a minor effect on endplate stresses in the unfractured vertebrae. The advantages of kyphoplasty found in this study will be apparent only if nearly full fracture reduction is achieved. Otherwise, differences between kyphoplasty and vertebroplasty become small or vanish. Our results suggest that vertebral body fractures in the adjacent vertebrae after vertebroplasty or kyphoplasty are not induced by the elevated stiffness of the treated vertebra, but instead the anterior shift of the upper body is the dominating factor.
Arthroplasty↗
An unconventional indication for open kyphoplasty.
BACKGROUND CONTEXT: Kyphoplasty is a means of treatment for painful osteoporotic vertebral body compression fractures. Its efficacy has not yet been totally proven. Even though the conventional percutaneous kyphoplasty is a relatively safe procedure, it is not routinely recommended for use in vertebral body fractures that involve posterior cortical compromise/retropulsion or in fractures associated with neurological deficit. PURPOSE: To see whether the open kyphoplasty procedure can be used in patients with painful vertebral body compression fractures who also have bony retropulsion into the spinal canal. STUDY DESIGN/SETTING: This technical report is based on the experience of one patient. METHODS: A 79-year-old woman with a history of osteoporosis presented with a painful vertebral body compression fracture at T12. Magnetic resonance imaging of her lumbar spine demonstrated an acute compression fracture at T12 with significant decrease in vertebral body height and retropulsion of bone resulting in one-third reduction in canal width. She was not considered a candidate for percutaneous kyphoplasty. Three months after the injury, an open kyphoplasty was performed after a decompression laminectomy at T12. RESULTS: The fractured vertebral body was successfully reduced, and there was no leakage of polymethylmethacrylate into the spinal canal through the fractured posterior cortex using the open kyphoplasty procedure. One month after the operation, the patient was free from mid-back pain and was again able to walk. CONCLUSION: Open kyphoplasty procedure allows direct visualization to the spinal canal. It can be performed safely and effectively in selected vertebral body compression fractures with retropulsed bone associated with neurological deficit.
Aged↗
The mechanics of polymethylmethacrylate augmentation.
Osteoporosis frequently leads to vertebral compression fractures. Percutaneous cement augmentation, one recent technique, may alter the biomechanics of the vertebral body and spinal segment. These alterations reportedly predispose the spinal segment to additional vertebral compression fractures. We investigated the changes in segment stiffness and strength after polymethylmethacrylate augmentation. Twelve thoracic segments consisting of five vertebral bodies were divided into two groups, a pure moment group (Group 1) and an eccentric compression group (Group 2). Baseline measurements of stiffness were taken on each segment followed by the creation of an initial vertebral compression fracture during which stiffness and strength were measured. After augmentation, stiffness was again measured. Finally, a second vertebral compression fracture was created measuring stiffness and strength again. Augmentation did not alter stiffness before and after augmentation in either group. Augmentation also did not result in any difference in strength measured at subsequent fracture when compared with strength measured at initial fracture in either group. The augmentation of vertebral compression fractures by kyphoplasty does not alter the stiffness or the strength of the multilevel segments and eccentric compression in contrast to pure moments leads to a lower strength during mechanical testing.
Adult↗
Complications of treatment of mandibular fractures with compression plates.
A total of 320 mandibular fractures with maxillomandibular fixation under local anesthesia were treated in this study. From this group, 244 fractures were treated with compression osteosynthesis. The complication rate was 13%; several patients had more than one complication. The complication rate decreased with the increase of operator experience. Malunions were recorded in 3.6% of the cases (1% in single and 7.5% in multiple fractures). Comminution, delay in treatment, and gross displacement were some of the factors related to malunion. The infection rate varied from 1% for those treated within the first week to 4% for those treated after at-least 2 weeks after the accident. Except for the delay in treatment, poor local conditions were a predisposing factor for infection. No infection was recorded in cases treated intraorally.
Adult↗
Posterior spinal epidural abscess: an unusual complication of vertebroplasty.
OBJECTIVE: Complications after vertebroplasty are rare. There are few reported infectious complications requiring surgical management such as corpectomy with anterior reconstruction and posterior stabilization, although we have not seen any reports about epidural abscess in the literature. We present a patient in whom posterior epidural abscess developed after vertebroplasty in which drainage and antibiotherapy were required for treatment. METHODS: A 70-year-old female with a painful T12 osteoporotic compression fracture underwent percutaneous vertebroplasty using polymethylmethacrylate without complication. One week after vertebroplasty, however, she had fever and increased back pain. On clinical examination, soft tissue abscess formation was determined at the vertebroplasty site. This was drained surgically and antibiotic treatment was started. At follow-up, she had progressive neurological deterioration (paraparetic) on the 18th day after abscess drainage. MRI of the thoracolombar spine revealed posterior spinal epidural abscess at the T11/12 level. Partial laminectomy and drainage were performed. She had complete neurological recovery in the follow-up period. CONCLUSION: An epidural abscess, which is an unusual complication of vertebroplasty, represents a medical and surgical emergency. Treatment is generally urgent surgical drainage combined with antibiotics. The patient should be evaluated in detail for systemic infectious disease and comorbid conditions before the vertebroplasty procedure.
Aged↗
Arterial injury following percutaneous vertebral augmentation: a case report.
STUDY DESIGN: Case report. OBJECTIVE: To report a case of injury to a segmental branch of the L4 lumbar artery following kyphoplasty. SUMMARY OF BACKGROUND DATA: To our knowledge, arterial injury following vertebral augmentation has not been described. The complications that have been reported rarely require additional intervention. The caliber of the fourth lumbar artery is such that injury to it, or to its more proximal branches, may cause significant morbidity. METHODS: An 84-year-old female who presents 10 days after surgery from L5 kyphoplasty with pulsatile bleeding from the kyphoplasty site. An angiogram revealed an injury to a segmental branch of L4 lumbar artery. RESULTS: A superselective angiogram was performed, followed by embolization of a branch of the L4 lumbar artery. This procedure successfully controlled the bleeding. CONCLUSION: Surgeons performing percutaneous procedures for the augmentation of vertebral compression fractures are not able to visualize the arterial channels on the posterior aspect of the vertebral column. Although injury to these structures may be difficult to prevent, awareness of this complication will improve our response and decrease associated morbidity.
Aged, 80 and over↗
Biomechanical comparison of unipedicular versus bipedicular kyphoplasty.
STUDY DESIGN: A cadaveric study comparing the biomechanics of unipedicular versus bipedicular kyphoplasty in the treatment of osteoporotic vertebral compression fractures. OBJECTIVES: The objectives of this study were to compare unipedicular kyphoplasty to bipedicular kyphoplasty in restoring strength, stiffness, and height to osteoporotic vertebral compression fractures and to study the degree of unilateral wedging when using a unipedicular versus bipedicular approach to kyphoplasty. SUMMARY OF BACKGROUND DATA: Osteoporotic vertebral compression fractures are a common ailment of the elderly that can lead to chronic pain and deformity. Recently developed treatments known as vertebroplasty and kyphoplasty provide pain relief by percutaneously augmenting the fractured vertebral body with polymethyl methacrylate via a transpedicular approach. Vertebroplasty via a unipedicular approach has been shown to provide comparable restoration of vertebral body stiffness when compared to a bipedicular approach. The anticipated benefits of a unipedicular approach include reduction in patient risk, operative time, radiation exposure, and cost. No studies have evaluated the efficacy of unipedicular kyphoplasty. MATERIAL AND METHODS: Two fresh-frozen human cadaveric spines (T3-L5) were disarticulated, and the vertebral bodies (n = 30) were compressed using an Instron 8521 machine, recording load versus displacement. The fractured vertebral bodies then underwent kyphoplasty via either a unipedicular or bipedicular approach. The augmented vertebral bodies were then recompressed. The strength, stiffness, and height restoration of the groups were compared. Following recompression, the risk for lateral wedging was evaluated by comparing lateral height measurements. RESULTS: Following fracture and subsequent kyphoplasty augmentation, the mean strength of the bipedicular group was 1.40 kN (+/- 0.38) versus 1.57 kN (+/- 0.55) in the unipedicular group. Average stiffness in the bipedicular group was 0.4387 kN/mm (+/- 0.2095) compared to 0.6880 kN/mm (+/- 0.3179) in the unipedicular group. Postcompression vertebral body height was restored to 96% of prefracture height in the bipedicular group and 94% of prefracture height in the unipedicular group. The mean absolute value of the difference in height between right and left side of the vertebral bodies was 1.06 mm (+/- 1.01) in the bipedicular group, whereas the unipedicular group had a mean of 1.78 mm (+/- 1.84). Statistical analysis using 1-way analysis of variance revealed no significant difference in any of the outcome measurements between the unipedicular and bipedicular groups (P < 0.05). CONCLUSIONS: Unipedicular kyphoplasty is comparable to bipedicular kyphoplasty in the restoration of vertebral body strength, stiffness, and height in experimentally induced vertebral compression fractures. There was no greater risk for lateral wedging in the unipedicular group compared to the bipedicular group. Given the advantages of a unipedicular approach with respect to vertebral pedicle cannulation risk, operative time, radiation exposure, and cost, this study would support the use of a unipedicular approach to kyphoplasty in the treatment of vertebral compression fractures.
Aged, 80 and over↗
Percutaneous vertebroplasty: a review for the primary care physician.
The purpose of this article is to help primary care physicians who are often challenged with the management of vertebral compression fracture (VCF) by presenting clinical background and identifying candidates for percutaneous vertebroplasty, a minimally invasive procedure for treatment of VCF.
Aged↗
Infected vertebroplasty requiring 360 degrees spinal reconstruction: long-term follow-up review. Report of two cases.
Transpedicular vertebroplasty has been established as a safe and effective treatment of thoracic and lumbar compression fractures. Complications are rare, and infectious complications requiring surgical management have only been reported once in the literature. The authors present two cases of infectious complications requiring surgical management. They emphasize that systemic infection is a contraindication to the performance of vertebroplasty. The serious nature of these infections, their surgical management, and strategies for avoiding them are discussed.
Enterobacteriaceae Infections↗
Percutaneous vertebral augmentation and reconstruction with an intravertebral mesh and morcelized bone graft.
Percutaneous vertebral augmentation (VA) and reconstruction with intravertebral polyethylene mesh sac (OptiMesh) and morcelized bone graft provided a minimally invasive efficacious and controlled delivery mechanism to stabilize and treat painful osteoporotic, traumatic and neoplastic vertebral compression fractures (VCFs), as well as avoided serious complications from Polymethylmethacrylate (PMMA) of Vertebroplasty and Kyphoplasty. Osteoconductive and osteoinductive and can be used to create biologic vertebral reconstruction. The adjacent vertebra integrity should be more protected by the construct with a similar elasticity and physical characteristics of the morcelized bone, more matched to that of adjacent bone than PMMA. The indications and surgical techniques are described herein.
Biocompatible Materials↗
Evidence on the effectiveness and cost-effectiveness of vertebroplasty: A review of policy makers' responses.
This review paper tracks the growth in the evidence supporting the use of percutaneous vertebroplasty for painful osteoporotic vertebral compression fractures. The rapidly increasing numbers of publications in the literature between 1994 and 2004 are documented. Despite the relatively large volume of research on this topic, several technology appraisals undertaken by international health policy makers reported inadequate high-quality evidence. Policy makers' reimbursement decisions for vertebroplasty and their options when faced with imperfect evidence are discussed.
Attitude to Health↗
Technical strategies and anatomic considerations for parapedicular access to thoracic and lumbar vertebral bodies.
OBJECTIVES: To investigate and illustrate a variation on the traditional percutaneous access to the vertebral body via a parapedicular approach. DESIGN: An effective parapedicular access technique that could safely and reliably guide the needle tip into the center of the vertebral body was developed from cadaver dissection observations for the purpose of clinical use. PATIENTS: A total of 102 vertebral compression fractures from T-4 to L-5 were treated via the parapedicular access at our institution between July 2005 and March 2006. There were 72 patients between the ages of 17 and 96 years (mean age: 68.2 years) who underwent treatment. RESULTS: The cadaver dissection revealed a relatively avascular and aneural portion of the vertebral body along the superior margin of the vertebral body-pedicle junction. A total 102 vertebral fractures were treated using the parapedicular access technique without any recognized clinical complications from the needle access or the instrumentation. CONCLUSIONS: The thoracic and lumbar vertebral bodies may be safely, reliably, and reproducibly accessed using a percutaneous parapedicular access technique. The technique presented represents a relatively avascular and aneural approach to vertebral body.
Adolescent↗
Sacral fracture with compression of cauda equina: surgical treatment.
Fractures of the sacrum are rare and generally accompany fractures of the pelvis. Isolated transverse sacral fractures are even less frequent, and extensive neurologic deficits may accompany these injuries. This report describes an unusual case of extradural hemorrhage accompanying a complex fracture of the sacrum. The reversal of a serious neurologic deficit was notably aided by sacral laminectomy.
Adult↗