Andre Jakoi

Adjacent segment disease in the lumbar spine following different treatment interventions.

BACKGROUND CONTEXT Adjacent segment disease (ASD) is symptomatic deterioration of spinal levels adjacent to the site of a previous fusion. A critical issue related to ASD is whether deterioration of spinal segments adjacent to a fusion is due to the spinal intervention or due to the natural history of spinal degenerative disease. PURPOSE The purpose of this review is to summarize the recent clinical literature on adjacent segment disease in light of the natural history, patient-modifiable risk factors, surgical risk factors, sagittal balance, and new technology. STUDY DESIGN This review will evaluate the recent literature on genetic and hereditary components of spinal degenerative disease and potential links to the development of ASD. METHODS After a meticulous search of Medline for relevant articles pertaining to our review, we summarized the recent literature on the rate of ASD and the effect of various interventions, including motion preservation, sagittal imbalance, arthroplasty, and minimally invasive surgery. RESULTS The reported rate of ASD after decompression and stabilization procedures is approximately 2% to 3% per year. The factors that are consistently associated with adjacent segment disease include laminectomy adjacent to a fusion and a sagittal imbalance. CONCLUSIONS Spinal surgical interventions have been associated with ASD. However, whether such interventions may lead to an acceleration of the natural history of the disease remains questionable.

Sports Hernia in National Hockey League Players Does Surgery Affect Performance

Background: Athletic pubalgia is a complex injury that results in loss of play in competitive athletes, especially hockey players. The number of reported sports hernias has been increasing, and the importance of their management is vital. There are no studies reporting whether athletes can return to play at preinjury levels. Purpose: The focus of this study was to evaluate the productivity of professional hockey players before an established athletic pubalgia diagnosis contrasted with the productivity after sports hernia repair. Study Design: Cohort study; Level of evidence, 3. Methods: Professional National Hockey League (NHL) players who were reported to have a sports hernia and who underwent surgery from 2001 to 2008 were identified. Statistics were gathered on the players’ previous 2 full seasons and compared with the statistics 2 full seasons after surgery. Data concerning games played, goals, average time on ice, time of productivity, and assists were gathered. Players were divided into 3 groups: group A incorporated all players, group B were players with 6 or fewer seasons of play, and group C consisted of players with 7 or more seasons of play. A control group was chosen to compare player deterioration or improvement over a career; each player selected for the study had a corresponding control player with the same tenure in his career and position during the same years. Results: Forty-three hockey players were identified to have had sports hernia repairs from 2001 to 2008; ultimately, 80% would return to play 2 or more full seasons. Group A had statistically significant decreases in games played, goals scored, and assists. Versus the control group, the decreases in games played and assists were supported. Statistical analysis showed significant decreases in games played, goals scored, assists, and average time on ice the following 2 seasons in group C, which was also seen in comparison with the control group. Group B (16 players) showed only statistical significance in games played versus the control group. Conclusion: Players who undergo sports hernia surgeries return to play and often perform similar to their presurgery level. Players with over 7 full seasons return but with significant decreases in their overall performance levels. Less veteran players were able to return to play without any statistical decrease in performance and are likely the best candidates for repair once incurring injury.

Gunshot injuries of the spine

BACKGROUND CONTEXT Spinal gunshot injuries (spinal GSIs) are a major cause of morbidity and mortality in both military and civilian populations. These injuries are likely to be encountered by spine care professionals in many treatment settings. A paucity of resources is available to summarize current knowledge of spinal GSI evaluation and management. PURPOSE The aim was to summarize the ballistics, epidemiology, evaluation, treatment, and outcomes of spinal GSI among civilian and military populations. STUDY DESIGN This was a review of the current literature reporting spinal GSI management. METHODS MEDLINE (PubMed) was queried for recent studies and case reports of spinal GSI evaluation and management. RESULTS Spinal GSI now comprise the third most common cause of spinal injury. Firearms that produce spinal GSI can be divided into categories of high- and low-energy depending on the initial velocity of the projectile. Neural and mechanical spinal damage varies with these types and results from several factors including direct impact, concussion waves, tissue cavitation, and thermal energy. Management of spinal GSI also depends on several factors including neurologic function and change over time, spinal stability, missile tract through the body, and concomitant injury. Surgical treatment is typically indicated for progressive neurologic changes, spinal instability, persistent cerebrospinal fluid leak, and infection. Surgical treatment for GSI affecting T12 and caudal often has a better outcome than for those cranial to T12. Surgical exploration and removal of missile fragments in the spinal canal are typically indicated for incomplete or worsening neurologic injury. CONCLUSIONS Treatment of spinal GSI requires a multidisciplinary approach with the goal of maintaining or restoring spinal stability and neurologic function and minimizing complications. Concomitant injuries and complications after spinal GSI can present immediate and ongoing challenges to the medical, surgical and rehabilitative care of the patient.

Perioperative coagulopathy monitoring

AbstractCoagulopathy is common in orthopedic surgery patients either due to acquired factors, such as surgery, trauma, medications, or hemorrhage. Perioperative monitoring of blood coagulation is critical to diagnose the causes of hemorrhage, guide hemostatic therapies, predict the risk of bleeding during surgical procedures, and reduce risk of postoperative cardiac and thromboembolic events. In contrast to previous interventions that measure specific portions of the clotting cascade (such as intrinsic or extrinsic pathways or platelet aggregation), “Point-of-care” coagulation monitoring devices assess the viscoelastic properties of whole blood. These techniques have the potential to measure the entire clotting process, starting with fibrin formation, clot retraction, and fibrinolysis. Furthermore, the coagulation status of patients is assessed in whole blood, allowing the plasmatic coagulation system to interact with platelets and red cells, and thereby providing useful additional information on platelet function. Improved monitoring of coagulopathy is particularly important as new anticoagulant drugs emerge that affect the clotting cascade in novel ways, including the inhibition of intrinsic and extrinsic pathways and platelet function. It is important for orthopedic surgeons to understand the pharmacology and reversal of these drugs in the perioperative setting. The purpose of this review is to review the current techniques to monitoring perioperative coagulopathy and to identify the manner in which novel anticoagulant medications affect the clotting cascade with particular interest in trauma and spine surgery.

Percutaneous Sacroiliac Screw Fixation of the Posterior Pelvic Ring

Percutaneous sacroiliac (SI) screw fixation is indicated for unstable posterior pelvic ring injuries, sacral fractures, and SI joint dislocations. This article provides a review of indications and contraindications, preoperative planning, imaging techniques and relevant anatomy, surgical technique, complications and their management, and outcomes after SI screw insertion.

Tibial Tubercle Avulsion Fractures in Adolescent Basketball Players

Tibial tubercle avulsion fractures most commonly occur in adolescent boys and usually result from pushing off or landing while jumping. These fractures are relatively uncommon but can have a significant functional effect. The purpose of this study was to determine the long-term outcome with return to play in 8 adolescent basketball players with at least 4 years of postoperative reconditioning. Results with return to play at the preinjury level are favorable after treatment of acute tibial avulsion fractures in adolescent basketball players. Long-term outcome was excellent in all patients regardless of fracture type. Open reduction and internal fixation using 1 or 2 cancellous bone screws achieved union in all cases.

Incidence of Orthopedic Surgery Intervention in a Level I Urban Trauma Center With Motorcycle Trauma

BACKGROUND This study summarizes orthopedic injuries sustained in motorcycle collisions in patients presenting to a Level I trauma center. METHODS We performed a retrospective review of orthopedic injuries in motorcycle trauma victims brought into the emergency department. Of 2,634 presenting cases, 151 were identified as involving motorcycle collisions. Variables included age, gender, mechanism of injury, type and location of injury, concomitant injuries, length of hospitalization, number of orthopedic procedures during primary admission, and subsequent readmission. RESULTS A total of 71.5% of patients required orthopedic consultation. Average age was 35.0 years, with men injured at a ratio of 8:1. The most common mechanism of injury was motorcycle versus automobile (n=48). A total of 206 fractures in 108 patients were discovered. The most common site of fracture involved the lower extremities. Open reduction with internal fixation was performed on 110 fractures (69 patients) during primary admission. Fifty-seven patients (52.8%) sustained open fractures requiring emergent orthopedic intervention. Fifty-three patients had various concomitant complications. Two patients died during initial hospitalization. Average hospitalization for patients without orthopedic consultation was 11.9 days versus 13.8 days with orthopedic consultation. The average number of orthopedic procedures performed on patients was 1.6. CONCLUSIONS Motorcycle collisions frequently involve patients in their working prime, thus placing substantial burden on the individual and society. Although these patients must continue to receive Level I trauma care, strengthened prevention and improved education efforts are warranted.

Cessation of teriparatide in order to heal a humeral fracture: a case report.

Teriparatide (Forteo; Eli Lilly, Indianapolis, IN, USA) is a recombinant protein consisting of a biologically active portion of the parathyroid hormone (PTH) molecule. Acting on bone and renal G-protein receptors, the net effect of the medication is to increase cortical and cancellous bone mass. Given in a continuous fashion, Teriparatide can favor bone reabsorption; however, if pulsed by daily dosing, it can favor bone formation. PTH has been proven to increase cortical thickness without increasing porosity in osteoporotic patients. Teriparatide has also been shown to decrease vertebral fracture risk in postmenopausal women with osteoporosis. The drug is currently U.S. Food and Drug Administration-approved to treat patients with severe osteoporosis at high risk for future fracture. Teriparatide’s ability to increase bone mass and decrease fracture risk has led to the investigation of PTH peptide 1-34 as an adjunct to assist in fracture healing. The current literature has focused on teriparatide use as an adjunct to heal acute fractures and fracture nonunions. All of these studies have demonstrated that teriparatide has a positive outcome on fracture healing, but no studies have proven an outright negative outcome with its use. We present a case report of a proximal humeral nonunion with successful healing after termination of teriparatide therapy initially begun for fracture prevention.

Placing Femoral Intramedullary Nails in Severely Bowed Femurs

The authors describe a novel technique of anterograde femoral intramedullary nail fixation for hip fracture using the starting guide pin as a blocking screw. This cost-effective technique uses fluoroscopic radiography to ensure the guidewire is within the posterior aspect of the femur on a lateral view, thereby minimizing the risk of anterior cortical femoral fractures.

Influence of podiatry on orthopedic surgery at a level I trauma center.

Level I trauma centers frequently see trauma at or below the ankle, which requires consultation with the orthopedic surgery department. However, as podiatry programs begin to firmly establish themselves in more Level I trauma centers, their consultations increase, ultimately taking those once seen by orthopedic surgery. A review of the literature demonstrates that this paradigm shift has yet to be discussed. The purpose of this study was to determine how many, if any, lower extremity fracture consultations a newly developed podiatry program would take from the orthopedic surgery department. A retrospective review was performed of emergency department records from January 2007 to December 2011. Seventeen different emergency department diagnoses were used to search the database. Ultimately, each patients emergency department course was researched. Several trends were noted. First, if trauma surgery was involved, only the orthopedic surgery department was consulted for any injuries at or below the ankle. Second, the emergency department tended to consult the podiatry program only between the hours of 8 am and 6 pm. Third, as the podiatry program became more established, their number of consultations increased yearly, and, coincidentally, the orthopedic surgery departments consultations decreased. Finally, high-energy traumas involved only the orthopedic surgery department. Whether the orthopedic surgery department or podiatry program is consulted regarding trauma surgery is likely hospital dependent.