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The aim of this study was to compare two different techniques of performing one-level spondylodesis for thoracolumbar burst fractures using either an autologous iliac crest bone graft (ICBG) or a porous tantalum fusion implant (PTFI). In a prospective nonrandomized study, 44 patients (20 women, 24 men; average age 43.1 +/- 13.2 years) suffering from severe thoracolumbar burst fractures were treated with combined anterior-posterior stabilization. An ICBG was used in 21 cases, and a PTFI was used in the other 23 cases. A two-year clinical and radiographic follow-up was carried out. There were no statistically significant differences in age, sex, localization/classification of the fracture, or visual analog scale (VAS) before injury between the two groups. All 44 patients were followed up for an average period of 533 days (range 173-1567). The sagittal spinal profile was restored by an average of 11.1 degrees (ICBG) vs. 14.3 degrees (PTFI) (monosegmental Cobb angle). Loss of correction until the last follow-up tended to be higher in the patients treated with ICBG than in those treated with PTFI (mean: 2.8 degrees vs. 1.6 degrees). Furthermore, significantly better restoration of the sagittal profile was obtained with the PTFI than with the iliac bone graft at the long-term follow-up (mean: ICBG 7.8 degrees, PTFI 12.3 degrees; p < 0.005). Short-segment posterior instrumentation combined with anterior one-level spondylodesis using either an ICBG or a PTFI resulted in sufficient correction of posttraumatic segmental kyphosis. PTFI might be a good alternative for autologous bone grafting and prevent donor site morbidities.
The calcaneal beak fracture is a rare avulsion fracture of the tuber calcanei characterized by a solid bony fragment at the Achilles tendon insertion. Treatment usually requires osteosynthesis. However, lack of biomechanical understanding of the ideal fixation technique persists. A beak fracture was simulated in synthetic bones and assigned to five different groups of fixation: A) 6.5-mm partial threaded cannulated screws, B) 4.0-mm partial threaded cannulated screws, C) 5.0-mm headless cannulated compression screws, D) 2.3-mm locking plate, and E) 2.8-mm locking plate. Different traction force levels were applied through an Achilles tendon surrogate in a material-testing machine on all stabilized synthetic bones. Outcome measures were peak-to-peak displacement, total displacement, plastic deformation, stiffness, visual-fracture-line displacement, and mode of implant failure. The 2.3- and 2.8-mm plating groups showed a high drop-out rate at 100 N tension force and failed under higher tension levels of 200 N. The fracture fixation using 4.0-mm partial threaded screws showed a significantly higher repair strength and was able to withhold cyclic loading up to 300 N. The lowest peak-to-peak displacement and the highest load-to-failure and stiffness were provided by fracture fixation using 6.5-mm partial threaded cannulated screws or 5.0-mm headless cannulated compression screws. As anticipated, large 6.5-mm screw diameters provide the best biomechanical fixation. Surprisingly, the 5.0-mm headless cannulated compression screws yield reliable stability despite the absent screw head and washer. When such large screws cannot be applied, 4.0-mm screws also allow reasonable fixation strength. Plate fixation should be implemented with precaution and in combination with a restrictive postoperative motion protocol. Finally, clinical cases about the surgical application and recovery are included.
Hintergrund
Die Symphysensprengung mit entsprechender Diastase kann durch eine Symphysenplatte stabilisiert werden.
Fragestellung
Welche Beckenverletzungen werden mit einer Symphysenplatte stabilisiert und wie ist das Outcome?
Material und Methoden
Retrospektive Auswertung von 64 Patienten über einen Untersuchungszeitraum von 24 Monaten.
Ergebnisse
Es waren 56 Patienten männlich, 8 weiblich und das mittlere Alter betrug 44 Jahre (SD ± 17). Unfälle im Straßenverkehr waren der führende Grund für die Beckenverletzung. Die Verteilung nach AO-Klassifikation zeigte sich wie folgt: 14-mal B1-, 10-mal B2-, 5‑mal B3-, 23-mal C1-, 9‑mal C2- und 3‑mal C3-Verletzungen. Die Verteilung nach Young und Burgess ergab: 9‑mal APC-I-, 18-mal APC-II-, 13-mal APC-III-, 9‑mal LC-I-, 3‑mal LC-II-, 2‑mal LC-III- und 10-mal VS-Verletzungen. Der mittlere Injury Severity Score (ISS) betrug 32 und die mittlere stationäre Verweildauer 29 Tage (pos. Korrelation p ≤ 0,001). Im Verlauf war eine radiologische Implantatlockerung bei 52 Patienten nachweisbar. Therapierelevante Komplikationen gab es in 14 Fällen. Hierbei war das Implantatversagen (n = 8) der Hauptgrund für eine operative Revision.
Diskussion
Obwohl die radiologische Implantatlockerung häufig beobachtet wird, ist sie nur selten Grund für einen Revisionseingriff. Kommt es hingegen zum vollständigen Implantatversagen, tritt dies meist innerhalb der ersten postoperativen Wochen auf und ist revisionsbedürftig. Eine frühzeitige Abklärung durch Röntgenbildgebung sollte bei Verdacht erfolgen.