Does Cement Augmentation of the Sacroiliac Screw Lead to Superior Biomechanical Results for Fixation of the Posterior Pelvic Ring? A Biomechanical Study

Background and Objectives: The stability of the pelvic ring mainly depends on the integrity of its posterior part. Percutaneous sacroiliac (SI) screws are widely implanted as standard of care treatment. The main risk factors for their fixation failure are related to vertical shear or transforaminal sacral fractures. The aim of this study was to compare the biomechanical performance of fixations using one (Group 1) or two (Group 2) standard SI screws versus one SI screw with bone cement augmentation (Group 3). Materials and Methods: Unstable fractures of the pelvic ring (AO/OTA 61-C1.3, FFP IIc) were simulated in 21 artificial pelvises by means of vertical osteotomies in the ipsilateral anterior and posterior pelvic ring. A supra-acetabular external fixator was applied to address the anterior fracture. All specimens were tested under progressively increasing cyclic loading until failure, with monitoring by means of motion tracking. Fracture site displacement and cycles to failure were evaluated. Results: Fracture displacement after 500 cycles was lowest in Group 3 (0.76 cm [0.30] (median [interquartile range, IQR])) followed by Group 1 (1.42 cm, [0.21]) and Group 2 (1.42 cm [1.66]), with significant differences between Groups 1 and 3, p = 0.04. Fracture displacement after 1000 cycles was significantly lower in Group 3 (1.15 cm [0.37]) compared to both Group 1 (2.19 cm [2.39]) and Group 2 (2.23 cm [3.65]), p ≤ 0.04. Cycles to failure (Group 1: 3930 ± 890 (mean ± standard deviation), Group 2: 3676 ± 348, Group 3: 3764 ± 645) did not differ significantly between the groups, p = 0.79. Conclusions: In our biomechanical setup cement augmentation of one SI screw resulted in significantly less displacement compared to the use of one or two SI screws. However, the number of cycles to failure was not significantly different between the groups. Cement augmentation of one SI screw seems to be a useful treatment option for posterior pelvic ring fixation, especially in osteoporotic bone.

Acute scaphoid fractures: making decisions for treating a troublesome bone

Seven aspects of the management of acute scaphoid fractures are open to debate: Diagnosis of true fractures among suspected fractures, assessment of fracture displacement, cast immobilization strategies, the role of surgical fixation, proximal pole fractures, assessment of union, and the underlying objective of treatment. We reviewed current evidence, and our varied interpretations of it, to highlight areas of uncertainty where more evidence might be helpful.

Clinical value of MRI in evaluating and diagnosing of humeral lateral condyle fracture in children

Background Humeral lateral condyle fractures (HLCFs) are common paediatric fractures. Radiographs are hard to accurately evaluate and diagnose the damage of articular epiphyseal cartilage in HLCFs. Methods 60 children who should be suspected to be HLCFs in clinical practice from Dec 2015 to Nov 2017 were continuously included as the first part patients. Subsequently, 35 HLCFs patients with complete follow-up information who had no obvious displacement on radiograph were the second part patients. The sensitivity and specificity of radiograph and MRI in diagnosing of HLCFs and their stability were calculated respectively. Calculated the sensitivity and specificity of each scan sequence of MRI in diagnosing of HLCFs osteochondral fractures. The degree of fracture displacement was measured respectively. Compared the ratio of surgical treatment, secondary fracture displacement and complications between the stable fracture group and the unstable fracture group on MRI in part 2 patients. Results Sensitivity of diagnosing HLCFs by MRI was significantly higher than radiograph (100.00% vs. 89.09%, P = 0.03). Sensitivity of diagnosing integrity of trochlear cartilage chain by MRI was 96.30%, which was significantly higher than that by radiograph (62.96%, P < 0.01). The sensitivity of cartilage sensitive sequence (3D-FS-FSPGR/3D-FSPGR) was different with FS-PDWI and FS-T2WI (P = 0.01 and P = 0.02, respectively). The degree of HLCFs displacement by MRI was higher than radiograph (P < 0.05). In the unstable fracture group, 5 cases (45.45%) had a fracture displacement of more than 2 mm on MRI, which was significantly higher than that in stable fracture group (0.00%, P < 0.01). Conclusions MRI is superior to the radiograph of elbow joint in evaluating and diagnosing children HLCFs and their stability. The coronal 3D-FS-FSPGR/3D-FSPGR sequence is a significant sequence for diagnosing osteochondral fractures in HLCFs. MRI can provide important clinical value for treatment decisions of HLCFs without significant displacement.

The accuracy of gap and step-off measurements in acetabular fracture treatment

The assessment of gaps and steps in acetabular fractures is challenging. Data from various imaging techniques to enable accurate quantification of acetabular fracture displacement are limited. The aim of this study was to assess the accuracy of pelvic radiographs, intraoperative fluoroscopy, and computed tomography (CT) in detecting gaps and step-offs in acetabular fractures. Sixty patients, surgically treated for acetabular fractures, were included. Five observers (5400 measurements) measured the gaps and step-offs on radiographs and CT scans. Intraoperative fluoroscopy images were reassessed for the presence of gaps and/or step-offs. Preoperatively, 25% of the gaps and 40% of the step-offs were undetected on radiographs compared to CT. Postoperatively, 52% of the gaps and 80% of the step-offs were missed on radiographs compared to CT. Radiograph analysis led to a significantly smaller gap and step-off compared to the CT measurements, an underestimation by a factor of two. Approximately 70% of the residual gaps and step-offs was not detected using intraoperative fluoroscopy. Gaps and step-offs that exceed the critical cut-off indicating worse prognosis often remained undetected on radiographs compared to CT scans. Less-experienced observers tend to overestimate gaps and step-offs compared to the more-experienced observers. In acetabular fracture treatment, gaps and step-offs were often undetected and underestimated on radiographs and intraoperative fluoroscopy in comparison with CT scans. This means that CT is superior to radiographs in detecting acetabular fracture displacement, which is clinically relevant for patient counselling regarding treatment decisions and prognosis.

Type II Odontoid Fractures Case Series: History of Seizures a Risk Factor for Failure of Non-operative Treatment of Type II Odontoid Fractures

Introduction:Odontoid fractures are one of the most common injuries to the cervical spine. Type II odontoid fracture treatment varies depending on age, co-morbidities, and fracture morphology. Treatment ranges from cervical orthosis to surgical intervention. Currently fractures with high non-union rates are considered for operative management which includes displacement of >6 mm, increasing age (>40-60 years), fracture gap >1 mm, delay in treatment >4 days, posterior re-displacement >2 mm, increased angulation, and history of smoking. While re-displacement of >2 mm has been associated with increased risk of non-union;, to the best of our knowledge, no studies have looked at the risk factors for re-displacement. Case Report:We present two 26-year-old male patients who were found to have minimally displaced type II odontoid fractures initially treated in a cervical collar. These two patients were subsequently found to have displaced their odontoid fracture after having a documented seizure. Conclusion:We suggest that a history of seizures be considered a risk factor for re-displacement of non-displaced type II odontoid fractures. Keywords:Operative indications odontoid case report, Type II odontoid fracture, Displacement, Seizure, Odontoid fracture displacement, Nondisplaced type ? odontoid fracture.

The influence of fracture location and comminution on acute scaphoid fracture displacement: three-dimensional CT analysis

We aimed to assess the influence of fracture location and comminution on acute scaphoid fracture displacement using three-dimensional CT. CT scans of 51 adults with an acute scaphoid fracture were included. Three-dimensional CT was used to assess fracture location, comminution and displacement. Fracture location was expressed as the height of the cortical breach on the volar and dorsal side of the scaphoid relative to total scaphoid length (%), corresponding to the fracture’s entry and exit point, respectively. We found a near-linear relation between dorsal fracture location and displacement. As dorsal fracture location became more distal, translation (ulnar, proximal, volar) and angulation (flexion, pronation) of the distal fragment relative to the proximal fragment increased. Comminuted fractures had more displacement. Dorsal fracture location predictably dictates the direction of translation and angulation in displaced scaphoid fractures. Surgeon attention to dorsal fracture location can help identify displacement patterns and provide guidance in adequately reducing a displaced scaphoid fracture. Level of evidence: III

Image Fusion of X-ray and Magnetic Resonance Imaging-Based Evaluation of the Stability of Pediatric Lateral Humeral Condyle Fracture

Background: Lateral humeral condyle fracture is the second most common intra-articular fracture in pediatric elbow. Objectives: The present study aimed to analyze the differences between X-ray and magnetic resonance imaging (MRI) in the evaluation of the stability of pediatric lateral humeral condyle fracture and the degree of fracture displacement. Methods: A total of 78 patients with acute elbow trauma were selected and hospitalized in our orthopedic department from July 2018-July 2019. All patients were examined with X-ray and MRI. The sensitivity and specificity of X-ray and MRI in the diagnosis of lateral humeral condyle fracture and the integrity of the trochlear cartilage chain fracture were calculated. The X-ray and MRI were examined respectively to check the value of lateral and posterior fracture space of lateral humeral condyle fracture. Results: Callus repair was observed according to the observation of fracture line during operation or the follow-up imaging examination of conservative treatment. It was confirmed that out of 78 patients with elbow joint trauma, 72 cases were diagnosed with the fracture of lateral condyle of humerus, and the other 6 patients were cured without fracture signs. The sensitivity of MRI in the diagnosis of pediatric lateral condylar fracture was 100%, which was significantly higher than that of X-ray (88.89%) (P<0.05). The results of X-ray and MRI in the diagnosis of pediatric lateral condylar fracture were generally consistent (kappa value = 0.465;< 0.01). Among the 72 confirmed cases, 35 subjects had a fracture of trochlear cartilage chain. The sensitivity of MRI in the diagnosis of pediatric fracture of lateral condyle of humerus was 97.14%, which was significantly higher than that of X-ray (62.86%) (P<0.05). The difference was statistically significant (P<0.05). The sensitivity of 3d-fs-fspgr or 3d-fspgr was significantly higher than that of fs-t2wi and fs-pdwi (P< 0.05). Conclusion: As evidenced by the obtained results, MRI was superior to X-ray in the diagnosis of pediatric humeral epicondylar fracture stability and evaluation of fracture displacement. Furthermore, 3d-fs-fspgr or 3d-fspgr was the best MR sequence to show the pediatric humeral epicondylar fracture. These findings can provide theoretical basis for the establishment of clinical treatment plan.