Rudy Reindl

Anterior reduction for cervical spine dislocation.

Study Design. Retrospective analysis of a prospectively followed cohort. Objective. Long-term evaluation of patients with anterior stabilization for dislocations of the cervical spine. Setting. Level 1 trauma center. Summary of Background Data. Anterior stabilization of unstable cervical spine injuries is gaining popularity. However, the method of open reduction is controversial. Methods. Forty-one consecutive patients with unstable dislocations/subluxations of the subaxial cervical spine were included. Closed reduction was attempted in all patients using Gardner-Wells traction. If this failed, an anterior open reduction was performed. Tricortical iliac crest autograft and anterior plating was used. Patients were assessed for: 1) rate of successful reduction and stabilization using only the anterior surgical approach; and 2) complications and long-term clinical and radiologic outcome. Results. Two of eight (25%) anterior open reductions failed requiring posterior surgery. One of these patients had associated pedicle fractures with horizontal rotation of the lateral masses. All grafts had healed successfully at the most recent follow-up visit. Moderate neck discomfort was found in 5 of 41 patients. Significant neurologic improvement was observed. Conclusions. Most subluxations/dislocations of the subaxial cervical spine can be reduced using Gardner-Wells traction and successfully stabilized with anterior surgery alone. If closed reduction fails, anterior open reduction is successful in the majority of cases.

Minimally invasive dynamic hip screw: prospective randomized trial of two techniques of insertion of a standard dynamic fixation device.

Objective This study evaluates the safety and outcome of a minimally invasive technique for inserting a standard dynamic hip screw for intertrochanteric fractures. Hypothesis The use of standard plate in a minimally invasive technique is both possible and advantageous to patient outcome. Design and Methods Prospective surgeon-randomized blinded outcome clinical study comparing new technique to conventional technique. Main Outcome Measure Pain, operative time and mean hemoglobin drop in percutaneous hip fixation. Results The minimally invasive technique had significantly less blood loss (P < 0.001), operative time (P < 0.001) and a trend to less morphine use. Conclusions Minimal invasive technique significantly reduces blood loss and operative time for fixation of intertrochanteric hip fractures without sacrifice of fixation stability or bone healing.

Anterior instrumentation for traumatic C1-C2 instability.

Study Design. Technical note, case report. and review of literature Objective. Description of anterior transarticular internal fixation for traumatic C1–C2 instability. Summary of Background Data. The currently effective posterior approaches for instrumentation of the C1–C2 junction require considerable soft tissue dissection and prone patient positioning. Some medical and anatomic conditions restrict the posterior approach. Materials and Methods. An odontoid screw and anterior transarticular C1–C2 screws were used to instrument an unstable injury at this junction. The lesion consisted of a type II dens fracture and C1 ring disruption. Two high-quality fluoroscopy machines, a radiolucent OSI fracture table, and the Synframe (Synthes, Paoli, PA) retraction system are used for this procedure. The implant of choice is the 4.0-mm cannulated titanium screw Results. At 4-month follow-up, successful stabilization without failure of hardware is documented. The patient’s neurologic status is stable, with a minor residual left upper extremity motor deficit. The patient has restricted C-spine rotation but no neck pain with movement Conclusion. Anterior stabilization through a standard Smith-Robinson approach of the C1–C2 junction with screws into the odontoid and the lateral masses of C1 is effective. Supine positioning and minimal soft tissue dissection are advantages of this method over standard posterior transarticular instrumentation. Knowledge of the local anatomy, strict adherence to the operative protocol, and high-quality fluoroscopy avoid potential surgical complications.

Spontaneous spinal epidural hematoma management: a case series and literature review

Objective:Spontaneous spinal epidural hematoma (SSEH) manifests from blood accumulating in the epidural space, compressing the spinal cord and leading to acute neurological deficits. Standard therapy is decompressive laminectomy, although spontaneous recoveries have been reported. Sub-optimal therapeutic principles contribute to SSEH’s 5.7% mortality—which patient will benefit from surgery remains unclear. This study aims to investigate parameters that affect SSEH’s progression, outlining a best-practice therapeutic approach.Materials and methods:Literature review yielded 65 cases from 12 studies. Furthermore, 6 cases were presented from our institution. All data were analyzed under American Spinal Injury Association (ASIA) score guidelines.Results:Fifty percent of SSEH patients do not fully recover. In all, 30% of patients who presented with an ASIA score of A did not improve with surgery, although every SSEH patient who presented at C or D improved. Spontaneous recovery is rare—only 23% of patients were treated conservatively. Seventy-three percent of those made a full recovery, as opposed to the 48% improvement in patients managed surgically. Thirty-three percent of patients managed conservatively had an initial score of A or B, all improving to a score of D or E without surgery. Regardless, conservative management tends toward low-risk presentations. Patients managed conservatively were three times as likely to have an initial score of D than their surgically managed counterparts.Discussion:The degree of pre-operative neural deficit is a major prognostic factor. Conservative management has proven effective, although feasible only if spontaneous recovery is manifested. Decompressive laminectomy should continue to remain readily available, given the inverse correlation between operative interval and recovery.

An in vitro study on the effects of freezing, spine segment, repeat measurement, and individual cord properties on cord interstitial pressure.

Study Design. In vitro study of the spinal cord tension and pressure relationships before and after thawing in 6 different spinal cord segment from 2 individual pigs. Objectives. To determine if frozen and thawed spinal cord segments had different tension/cord interstitial pressure(CIP) relationships to fresh spinal cord segments. In addition, we will determine if the cord level, individual cord properties, and repeated CIP measurements affect the tension/CIP relationships. Summary of Background Data. Spinal cord distraction is a known cause of spinal cord injury. Several articles published on the pathophysiology of the cord distraction injury suggest that the underlying mechanism of injury is a microvascular ischemic event. We have previously described an increase in CIP with spinal cord distraction, pressures average 23 mmHg at 1 kg loads. Methods. Six cord segments harvested from 2 pigs contained cervical, thoracic, and lumbar segments, and underwent distraction using a series of 7 calibrated weights from 0 to 1000 g weight. The cords were measured at each level of distraction. The cords were then frozen at −20°C for a period of 2 weeks, and then thawed and retested. Multiple linear regression was then performed. Results. There was no difference between the fresh and the frozen-thawed cords; there was statistical difference between the 2 pigs (18 mmHg) (P < 0.001). There are differences between the cervical and the thoracic cord segments (P < 0.001), and between cervical and lumbar cord segments (P = 0.056). There is a significant relation between the tension applied and CIP. Repeated trials showed no drift with repeated measures. Conclusion. Freezing and thawing spinal cords has no effect on the CIP/tension curves. Cord interstitial pressure developed is dependant on cord tension, cord level, individual cord properties, but not on the number of repetitions carried out while testing the spinal cord.

Circumferential Casting of Distal Radius Fractures.

Objectives: To determine the prevalence and predictive factors for the early cast alteration (splitting, trimming, and complete replacement) in patients with distal radius fractures (DRFs) treated in circumferential cast. To determine whether performing early cast alterations affects the fracture alignment. Design: Retrospective Cohort Study. Setting: Level 1 Trauma Center. Patients: All adult patients who presented with a DRF to a tertiary care hospital over a 3-year period. Intervention: All DRFs without immediate surgical indications are initially treated with circumferential casts at this center. Outcome Measurements: The following variables were analyzed: patient demographics, polytrauma at the time of injury, physician subspecialty performing reduction, and type of cast alteration. Radiographs were used to assess initial fracture characteristics and secondary displacement of reduction over time. Analysis was performed primarily to identify predictive variables for the early cast alteration and secondarily to determine the effect of these alterations on fracture alignment. Results: 296 patients were included in the study. One of every 4–5 patients had their cast altered within the first 10 days of treatment. One of 3 polytrauma patients had their cast altered. No type of cast alteration was found to be significantly predictive of loss of fracture alignment at 2 or 6 weeks. Conclusions: Cast alteration is commonplace after casting of DRFs but is not associated with the loss of alignment. Patients with polytrauma may benefit from immediate cast splitting. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Metaphyseal tibial level (MTL) screws: a modified percutaneous technique for lateral plateau depression fractures

AbstractIntroductionLateral tibial plateau fractures are more frequent than medial fractures, and those with articular depression are particularly challenging because of high displacement risk. To prevent secondary subsidence, the gold standard is raft screws with a periarticular or anti-glide plate. Graft is used to fill the metaphyseal defect created by reduction in the depressed fragment. We present a case of Schatzker II fracture managed in a complete percutaneous fashion, with a new combined technique of raft screws and interference screw used as a support. Case reportA 51-year-old female sustained a Schatzker II tibial plateau fracture. Based on pre-operative CT, direction of reduction force to apply was drawn on coronal and sagittal cuts.Operative techniqueUnder fluoroscopic control, the split component of the fracture was reduced. The cortical window was then drilled in the lateral cortex, and a K wire advanced under the depressed fragment under fluoroscopic guidance. After fragment reduction with a bone impacter, internal fixation was completed by percutaneous introduction of two subchondral cortical screws. A bioabsorbable interference screw was then introduced in the impacter tunnel to support impacted bone under the reduced articular surface. Finally, a cortical screw was introduced, from anterior to posterior to prevent screw cut-out.ConclusionThe combination of subchondral screws in a jail technique with a bioabsorbable interference screw that we named metaphyseal tibia level (MTL) screw technique is, to our knowledge, not described. The MTL screw promises to be a true percutaneous reduction and fixation technique for Schatzker II and III fractures in patients with reasonable bone quality.