[Surgical treatment of injuries of the thoracolumbar transition--3: Follow-up examination. Results of a prospective multi-center study by the "Spinal" Study Group of the German Society of Trauma Surgery]

OBJECTIVES

Prospective, multicenter study addressing late results after operative treatment of acute thoracolumbar spinal injuries.

METHODS

682 patients (T10-L2) were included and 372 (80%) were postoperatively followed for 2 1/4 years (4-61 months).

RESULTS

Comparing the initially included patients (n = 682) with the study group (n = 372), no differences were observed and results were assumed to be representative. A C-type lesion or polytrauma significantly prolonged the hospital stay. The method of operative treatment did not affect the length of the rehabilitation period. Neurological improvement was observed in 3 out of 7 patients with complete, and in 44 out of 64 (69%) with incomplete lesion. The operative method did not affect the improvement rate. The physical capacity significantly decreased. After a mean of 1/2 year of disability only 71% returned to work. 48% returned to their preoperative physical level. The mean Hannover Spine Score was 68 points (preoperative 94, p < 0.001), indicating permanent impairment of function. The angle-stable internal fixator was superior in restoration of spinal alignment and best radiological results were noted after combined stabilization. Posterior stabilization lead to high re-kyphosing. No correlations between radiologic and clinical parameters were observed.

CONCLUSIONS

All treatment methods under study were appropriate for achieving comparable clinical and functional outcome. The internal fixator is superior in restoration of the spinal alignment. Best radiological outcome is achieved by combined stabilization. Merely by direct reconstruction of the anterior column the postoperative re-kyphosing is prevented and a gain in segmental angle is achieved.

[Surgical treatment of injuries of the thoracolumbar transition. 2: Operation and roentgenologic findings]

The authors report on a prospective multicenter study with regard to the operative treatment of acute fractures and dislocations of the thoracolumbar spine (T10-L2). The study should analyze the operative methods currently used and determine the results in a large representative collective. This investigation was realized by the working group "spine" of the German Trauma Society. Between September 1994 and December 1996, 682 patients treated in 18 different traumatology centers in Germany and Austria were included. Part 2 describes the details of the operative methods and measured data in standard radiographs and CT scans of the spine. Of the patients, 448 (65.7%) were treated with posterior, 197 (28.9%) with combined posterior-anterior, and 37 (5.4%) with anterior surgery alone. In 72% of the posterior operations, the instrumentation was combined with transpedicular bone grafting. The combined procedures were performed as one-stage operations in 38.1%. A significantly longer average operative time (4:14 h) was noted in combined cases compared to the posterior (P < 0.001) or anterior (P < 0.05) procedures. The average blood loss was comparable in both posterior and anterior groups. During combined surgery the blood loss was significantly higher (P < 0.001; P < 0.05). The longest intraoperative fluoroscopy time (average 4:08 min) was noticed in posterior surgery with a significant difference compared to the anterior group. In almost every case a "Fixateur interne" (eight different types of internal fixators) was used for posterior stabilization. For anterior instrumentation, fixed angle implants (plate or rod systems) were mainly preferred (n = 22) compared to non-fixed angle plate systems (n = 12). A decompression of the spinal canal (indirect by reduction or direct by surgical means) was performed in 70.8% of the neurologically intact patients (Frankel/ASIA E) and in 82.6% of those with neurologic deficit (Frankel/ASIA grade A-D). An intraoperative myelography was added in 22% of all patients. The authors found a significant correlation between the amount of canal compromise in preoperative CT scans and the neurologic deficit in Frankel/ASIA grades. The wedge angle and sagittal index measured on lateral radiographs improved from -17.0 degrees and 0.63 (preoperative) to -6.3 degrees and 0.86 (postoperative). A significantly (P < 0.01) stronger deformity was noted preoperatively in the combined group compared to the posterior one. The segmental kyphosis angle improved by 11.3 degrees (8.8 degrees with inclusion of the two adjacent intervertebral disc spaces). A significantly better operative correction of the kyphotic deformity was found in the combined group. In 101 (14.8%) patients, intra- or postoperative complications were noticed, 41 (6.0%) required reoperation. There was no significant difference between the three treatment groups. Of the 2264 pedicle screws, 139 (6.1%) were found to be misplaced. This number included all screws, which were judged to be not placed in an optimal direction or location. In seven (1.0%) patients the false placement of screws was judged as a complication, four (0.6%) of them required revision. The multicenter study determines the actual incidence of thoracolumbar fractures and dislocations with associated injuries and describes the current standard of operative treatment. The efforts and prospects of different surgical methods could be demonstrated considering certain related risks. The follow-up of the population is still in progress and the late results remain for future publication.

[Intramedullary compression nailing of long tubular bones]

The biomechanical principle of intramedullary compression osteosynthesis is based on the implantation of a movable intramedullary nail that is statically interlocked in distal round holes and dynamically interlocked in a proximal slot. Distraction of the nail against the proximal interlocking screw by means of a compression screw leads to a relative movement of the proximal fragment directed distally against the nail. This results in direct contact of the main fragments under increasing compression. Simple fractures, pseudarthroses and osteotomies within the diaphyses of the long bones represent promising indications for the use of compression nailing. Furthermore, this method enables extraordinarily stable knee and ankle arthrodeses. Major positive aspects are controlled adaptation of fragments and a significantly increased stability of the fracture as compared to conventional intramedullary nailing techniques, especially as rotational forces are concerned. The biomechanical advantages result in earlier full weightbearing and an increased rate of fracture union in delayed healing. Given the use of optimized implants and instruments, compression intramedullary osteosynthesis offers a remarkable potential for further improvement in both the spectrum and success of intramedullary nailing.

Vascularised knee joint transplantation in man: the first two years experience

OBJECTIVE

To describe our early experience with a new technique for restoring destroyed knee joints to give reasonable functional results.

DESIGN

Observational clinical trial.

SETTING

Level-1-Trauma centre, Germany.

SUBJECTS

5 patients with large bone defects of the knee and loss of the extensor apparatus caused either by serious injury alone, or infection after serious injury.

INTERVENTIONS

Transplantation of fresh and perfused knee joints with a vascular pedicle from multiorgan donors under immunosuppression.

MAIN OUTCOME AND MEASURES

Ability to walk, need to remove one transplanted joint.

RESULTS

Four patients are able to walk, the range of movement being from 50 degrees-120 degrees. The first patient additionally had to be provided with a total knee joint arthroplasty. In the third patient the graft became infected and had to be removed. She finally had an arthrodesis and bone lengthening by the Ilizarov technique.

CONCLUSIONS

Transplantation of the knee joint may be an alternative to bone lengthening or amputation for patients with total loss of the extensor apparatus.

[Surgical treatment of injuries of the thoracolumbar transition. 1: Epidemiology]

The authors report on a prospective multicenter study with regard to the operative treatment of fractures and dislocations of the thoracolumbar spine. 18 traumatologic centers in Germany and Austria, forming the working group "spine" of the German Society of Trauma Surgery, are participating in this continuing study. Between September 1994 and December 1996 682 patients (64% male) with an average age of 39 1/2 (7-83) years were entered. The entry criteria included all patients with acute and operatively treated (within 3 weeks after trauma) fractures and dislocations of the thoracolumbar spine (Th 10-L 2). Part 1 of this publication outlines the protocol and epidemiologic data. The incidence of fractures and dislocations of the thoracolumbar spine and associated injuries were recorded according to a standardized protocol, as well as the different operative methods and complications, duration of hospital stay, rehabilitation and incapacity. The analysis of the clinical social and radiological course was a second focus. The most frequent mechanism of injury was a fall (50%) or traffic accident (22%). Most of the fractures occurred at the L 1 level (49%). All injuries were classified according to the ASIF (AO) classification. 65% sustained an A-type fracture (compression fracture). Associated injuries were observed in 35% and 6% were polytraumatized. Extremities and thorax were most frequently affected. Younger age and traffic accidents lead more often to C-type fracture (fracture dislocation) and polytrauma. An increased number of multisegmental or multilevel lesions were observed in polytraumatized patients. There were 16% with incomplete paraplegia (Frankel/ASIA B-D) and 5% with complete paraplegia (Frankel/ASIA A). The rate of patients with initial neurologic deficits significantly increased with the severity of spinal injury according to the Magerl classification. Until discharge a neurologic improvement (at least 1 Frankel/ASIA grade) was observed in 32% of the partially paralyzed (Frankel/ASIA B-D) and in 12% of the patients with complete paraplegia (Frankel/ASIA A). A neurologic deterioration occurred in 3 patients (0.4%). As a base for further follow-up and late results the individual starting point was determined by collecting relevant data of the patients' history: 277 (40.6%) patients suffered from simultaneous diseases, one half was spine related. At the time of injury 559 (82.0%) patients were employed; 429 (62.9%) doing manual work. 369 (54.1%) patients stated sportive activities before the injury and 561 (82.3%) designated their "back function" as normal. For the time before injury the patients scored an average of 93.4 points in the Hannover Spine Score (0-100 points concerning complaints and function of the back/spine).

[Thoracoscopy-guided management of the "anterior column". Methods and results]

Anterior thoracoscopic interbody stabilization and fusion was performed in 163 patients. Lesions treated were located between T4 and L3, most frequently occurring at T12/ L2. Operative time decreased dramatically as experience was gained with the procedure. 2 patients early in the series successfully were converted to an open procedure. One positioning related pressure harm on the thoracodorsal nerve and one irritation of the L1 root at the entrance site were both transitory. Postoperative control by X-ray and CTscan showed correct positioning of the bone graft, as well as the fixation device in all patients. Our experience with this minimally invasive procedure demonstrated the feasibility of the method. Major advantages compared to the open procedure are reduced morbidity of the approach, postoperative pain reduction, early recovery of function and shortened hospital stay.

Thorascopically guided therapy of the "anterior column". Technique and results

Anterior thoracoscopic interbody stabilization and fusion was performed in 163 patients. Lesions treated were located between T4 and L3, most frequently occuring at T12/L2. Operative time decreased dramatically as experience was gained with the procedure. 2 patients early in the series successfully were converted to an open procedure. One positioning related pressure harm on the thoracodorsal nerve and one irritation of the L1 root at the entrance site were both transitory. Postoperative control by X-ray and CTscan showed correct positioning of the bone graft, as well as the fixation device in all patients. Our experience with this minimally invasive procedure demonstrated the feasibility of the method. Major advantages compared to the open procedure are reduced morbidity of the approach, postoperative pain reduction, early recovery of function and shortened hospital stay.

[Allogeneic vascularized transplantation in cases of bone and joint defects]

This paper presents preliminary results of allogeneic vascularized transplantations of three femoral diaphyses and four total human knee joints. Grafts were harvested from multi-organ-donors and immediately transplanted. Osteosyntheses were performed employing intramedullary nails. Vascular pedicles of the grafts were anastomosed in end-to-side technique. Immunosuppression mainly based on Cyclosporine and Azathioprine. Grafts' perfusion was demonstrated by DSA and Duplex-sonograms, bone metabolism by SPECT-scintigraphy. Five months following transplantation osteotomies demonstrated consolidation in conventional X-rays. Biopsies of the grafted bone revealed intact osteocytes and arthroscopy demonstrated intact synovial, chondral and ligamentous structures. From the technical aspect vascularized transplantation of the femoral diaphyses and total knee joints is feasible. The main problems are of immunologic nature. Transplantations were performed respecting the ABO-compatibility but with a large HLA-mismatch. Acute and chronic rejection crises may damage the grafts. At least in synovial joints live-long immunosuppression of the recipients seems to be unavoidable.

[Therapeutic concept for injuries of the lower cervical spine]

Over a period of two and half years, the Spinal Surgery Working Group of the Deutsche Gesellschaft für Unfallchirurgie (German Association for Trauma Surgery) DGU has carried out a prospective study of relevant injuries of the cervical vertebral column in 544 patients. The lower section C3 to Th1 of the cervical vertebral column was affected in 308 cases (56 per cent). The injuries of the cervical vertebral column were caused primarily by accidents in road traffic and in the pursuit of recreational activities. More than half of the patients had multiple injuries. The share of degenerative concomitant changes as a cause for relevant injuries increased with age considerably. In case of a qualified trauma with the suspicion of an injury, the immobilisation of the cervical vertebral column has to be retained until the X-ray diagnosis inclusive of a computer tomography has been completed as this is obligatory for the clarification of suspected findings or for pre-operative planning, respectively. The diagnostic range is complemented by guided function imaging to reveal instabilities, and magnetic resonance imaging, which has to be carried out in case any X-ray pathology is absent and neurological functional deficit exists. Patients with neurological deficits, which were found in 43 per cent of the cases suffering from injuries of the lower cervical vertebral column, should be treated as quickly as possible with a high dose of methyl prednisolone. A recovery of the neurological abolition by at least one ASIA level was observed in 10 per cent of the patients concerned. A conservative therapy with a cervical collar was pursued in 24 per cent of the cases with stable injuries. An operative treatment indication, which was diagnosed in 76 per cent of the cases, aims at the early recovery of the anatomy with decompression of the spinal cord, reposition, and stabilisation of segments concerned. The point of the operation was determined by the neurological status, the existing dislocation, and the increasing instability as well as the concomitant injuries. Positioning necessary for intensive medical interventions required an early stabilisation of the spinal column. The front access with plate spondylodesis as a standard procedure with various special implants has proved to be safe and reliable in the healing result. Dorsal accesses shall remain reserved for definable individual indications and should be prevented in case of injuries of the cervical medulla, if possible, to spare the cervical muscles.

Therapeutical concept for injuries of the lower cervical vertebral column

Over a period of two and half years, the Spinal Surgery Working Group of the Deutsche Gesellschaft für Unfallchirurgie (German Association for Trauma Surgery) DGU has carried out a prospective study of relevant injuries of the cervical vertebral column in 544 patients. The lower section C3 to Th1 of the cervical vertebral column was affected in 308 cases (56 per cent). The injuries of the cervical vertebral column were caused primarily by accidents in road traffic and in the pursuit of recreational activities. More than half of the patients had multiple injuries. The share of degenerative concomitant changes as a cause for relevant injuries increased with age considerably. In case of a qualified trauma with the suspicion of an injury, the immobilisation of the cervical vertebral column has to be retained until the X-ray diagnosis inclusive of a computer tomography has been completed as this is obligatory for the clarification of suspected findings or for pre-operative planning, respectively. The diagnostic range is complemented by guided function imaging to reveal instabilities, and magnetic resonance imaging, which has to be carried out in case any X-ray pathology is absent and neurological functional deficit exists. Patients with neurological deficits, which were found in 43 per cent of the cases suffering from injuries of the lower cervical vertebral column, should be treated as quickly as possible with a high dose of methyl prednisolon. A recovery of the neurological abolition by at least one ASIA level was observed in 10 per cent of the patients concerned. A conservative therapy with a cervical collar was pursued in 24 per cent of the cases with stable injuries. An operative treatment indication, which was diagnosed in 76 per cent of the cases, aims at the early recovery of the anatomy with decompression of the spinal cord, reposition, and stabilisation of segments concerned. The point of the operation was determined by the neurological status, the existing dislocation, and the increasing instability as well as the concomitant injuries. Positioning necessary for intensive medical interventions required an early stabilisation of the spinal column. The front access with plate spondylodesis as a standard procedure with various special implants has proved to be safe and reliable in the healing result. Dorsal accesses shall remain reserved for definable individual indications and should be prevented in case of injuries of the cervical medulla, if possible, to spare the cervical muscles.

Segment transport employing intramedullary devices in tibial bone defects following trauma and infection

OBJECTIVES

To compare two different methods of segment transport in posttraumatic and postseptic tibial defects by employing intramedullary tibial nails as the fixation system and to evaluate differences in the complication rate between external fixation and wire towropes as the transport system.

DESIGN

Randomized, prospective, nonblinded study.

SETTING

Level 1 trauma center.

PATIENTS

Thirty patients with posttraumatic or postseptic defects of the tibial shaft were admitted at our center between January 1994 and December 1995. For study purposes, they were divided into two groups with fifteen patients in each.

METHODS

All thirty patients underwent a standardized therapy protocol consisting of three phases: (a) eradication of infection, (b) restoration of soft tissue defects, and (c) bone segment transport. The first two phases were identical for both groups. The third phase was different: in Group A transport of the segment was performed with a combination of intramedullary nail and wire towrope; in Group B the intramedullary nail was combined with an external fixation device. We then evaluated both subjective data (patient comfort, restrictions in physiotherapy) and objective data (mobility of knee and ankle joint, transport time, reoperations, complications) to determine treatment success.

RESULTS

Both methods are useful for segment transport in patients with tibial shaft defects following trauma and infection. The relative transport time was shorter in Group A than in Group B (12.2 versus 13.7 days/centimeter; p = 0.002). Group B also recorded a significantly higher complication rate than did Group A (septic complications, twenty-six versus six events; necessary recorticotomies, four versus zero events).

CONCLUSIONS

An intramedullary nail and wire towrope proves to be a reliable combination for segment transport in tibial defects following trauma and infection and provides a relatively high patient comfort rate and a low complication rate.

[Thoracoscopic management of fractures of the thoracic and lumbar spine]

In 90 patients, stabilization of injuries of the thoracic spine and the thoracolumbar junction was performed using minimally invasive thoracoscopy. The method includes partial corporectomy with spinal decompression, interposition of a tricortical bone graft, and anterior spondylodesis by planting. Complications were rare and not severe, with only two conversions to open technique. Compared to the open, standard method benefits included reduced postoperative pain, shorter hospital stay and reduced morbidity.

[Bridging long bone and joint defects with allogeneic vascularized transplants]

Three patients with large osseous defects following trauma and infection received vascularized allogeneic femoral diaphyses and five patients vascularized allogeneic total knee joints. From the surgical aspect these transplantations are technically feasible. The remaining problems are of immunological nature; at least in patients with allogeneic synovial joints, lifelong immunosuppression seems to be currently unavoidable.

[Surgical management of tetraplegia]

The traumatic lesion of the cervical cord implies one of the most serious sequale after accident with severe consequences for lifetime. In patients with a relevant injury of the cervical spine in 28% neurological deficits are seen with an even higher incidence of 44% in the lower cervical spine. The risk of traumatic cervical cord injury further increases with progressing stenosis of the spinal canal and therefore a second peak of occurrence has to be observed in the elderly. In the preclinical phase even suspicion of a cervical cord lesion should lead to effective stabilization of the cervical spine and should be removed only after imaged proof of integrity. A high dosage therapy of methylprednisolon should be started as early as possible in every case of spinal cord injury. Diagnostic procedures are including x-rays of the whole spine, CT-scans for clearance of suspicious findings and pre-operative planning, image intensifiing under controlled stress for hidden instabilities and MRI for spinal cord injuries without abnormal radiological findings. Aims of operative treatment are consisting of decompression, reduction and stabilization with the aims of protection of the neurogenic structures and to secure intensive care treatment. These objectives can be met sufficiently by a single ventral approach in most instances. Dorsal approaches should be avoided whenever possible leaving the important innervation of the paracervical muscles intact. The postacute phase is marked by loss of systemic control mechanis as a consequence of the spinal shock. The consecutive deficits can be mastered only by treatment under intensive care standards. Respirator therapy is advisable especially for higher plegic lesions. Typical complications are frequent and should be watched for carefully because of the absence of pain sensation. Patients with cervical cord injuries should transferred to specialized paraplegic units for early rehabilitation as soon as possible since the rate of specific complications like decubital ulcera increases with the days of stay in non-specialized units.

Interlocking compression nailing: a report on 402 applications

Nailing techniques have changed tremendously in recent years. One significant development has been the interlocking compression nail (ICN) which provides active interfragmentary compression. Apart from its beneficial effect in the treatment of acute fractures, allowing early weight-bearing and mobilization of the patient the ICN is useful in many types of revision operations: resection and stabilization of pseudarthroses without cancellous bone grafts, corrective operations of malalignments through a minimally invasive technique, as well as the readaptation of the resection sites in arthrodeses. Between April 1993 and September 1996, 402 consecutive applications of an ICN were followed prospectively to evaluate the practibility and reliability of the system. A special focus was placed on the active compression device. Along with 153 acute fractures, 112 non-unions and 41 cases of malalignment were treated; 96 arthrodeses were performed. Even for difficult courses of healing only a low complication rate was observed, and a remarkably high percentage was managed successfully.

[Indications for surgical management of injuries of the cervical spine]

The indication for operative treatment of serious injuries to the cervical spine is basically determinated by instability and dislocation. Timing of the operation is based on the neurological deficit. If there is a chance for recovery operative treatment is urgent. For the upper cervical spine defined indications are existing for type-2-fractures of the dens and C 2/C 3-instabilities of the hangman-type with major dislocation. Fractures of C 0 and C 1 are preferably treated by conservative methods. Only cases with compound injury patterns with a high degree of ligamentous instability may require dorsal fusion. For serious injuries of the lower cervical spine operative treatment is needed in most instances. Conservative treatment is only indicated if functional stability can be proofed and injuries to the discs and compression to the myelon are ruled out.

Allogeneic vascularized transplantation of human femoral diaphyses and total knee joints--first clinical experiences

This article has presented the preliminary results of three patients who received vascularized allogeneic femoral diaphyses and three patients having undergone vascularized transplantation of fresh and perfused total human knee joints. The large osseous defects in the femora followed osteomyelitis and chondrosarcoma. The three knee joints were lost due to various trauma mechanisms. All grafts were harvested within 25 hours from multiorgan donors perfused with 4 L of UW solution. All osteosyntheses were performed employing intramedullary nails. Vascular pedicles of the grafts were anastomosed end-to-side to the superficial femoral artery and vein in the adductorial canal of the recipient thigh. Immunosuppression was based mainly on two drugs: CyA and AZA. Perfusion of the grafts was demonstrated by DSA, and bone metabolism in the graft by SPECT scintigraphy. Six months after the operation all osteotomies demonstrated callus formation and osseous consolidation in conventional radiographs. Biopsies of the grafted bone revealed intact osteocytes, and arthroscopy of the transplanted knee joints demonstrated intact synovial, chondral, and ligamentous structures. From the surgical aspect, the vascularized transplantation of the femoral diaphyses and total knee joints is technically feasible. The main problems are immunologic. All transplantations were performed with respect to ABO compatibility, but with a large HLA mismatch. Therefore, acute and chronic rejection crises were observed. In total synovial joints, lifelong immunosuppression of graft recipients seems to be currently unavoidable.

Allogeneic vascularized grafting of human knee joints under postoperative immunosuppression of the recipient

Vascularized knee joint transplantations have been performed in various animal systems. Up to now no allogeneic vascularized transplantation of a fresh and perfused human knee joint has been realized. This paper reports on the first four grafted human knee joints, performed between April 1996 and July 1997 at the Trauma Center Murnau. The indication for transplantation of a human knee joint is total loss of the joint, including the extensor apparatus, following severe trauma. Management of this defect is first to effect closure of the soft tissue defect combined with external transfixation and bone cement spacers. For the second phase the external stabilization is switched to internal stabilization using femoral tibial nails and a temporary knee joint prosthesis manufactured of polyethylene. The transplantations are performed with respect to ABO compatibility, ignoring the HLA system after a negative crossmatch. Osteosyntheses are employed by femoral and tibial nails. The vascular anastomoses are established in an end-to-side technique between the recipient's superficial femoral vessels and the graft vascular pedicles. Immunosuppression starts as quadruple induction therapy for 3 days. Subsequently it is reduced to a two-drug maintenance protocol with cyclosporin A and azathioprine. We utilize radiography, digital subtraction angiography, duplex sonography, scintigraphy, and arthroscopy for graft monitoring. Six months after transplantation the osteotomies were bridged with callus, and the patients were completely mobilized. The motion in the transplanted knee joint ranges from complete extension to 110 degree flexion.

[Endoscopically controlled division of the diaphragm. A minimally invasive approach to ventral management of thoracolumbar fractures of the spine]

On 90 patients with 93 unstable fractures of the thoracic spine and the thoracolumbar junction we treated by a minimal invasive procedure between may 1996 and april 1998, in 46 patients an endoscopic splitting of the diaphragm was performed. The diaphragma was dissected at its attachment at the spine and the adjoining costal base. After partial corporectomy and discectomy, a tricortical bone graft has been inserted. An additional stabilization was done by using a plate and screw system. The incision of the diaphragm was closed by suturing or using an universal endostapler. Controlling the postoperative results a complete closure of the incision was documented by X-ray and CT-scan. There was no conversion to the open procedure or postoperative infection. Splitting the diaphragma opens also the thoracolumbar junction to a minimal invasive treatment and stabilization of fractures.