Balloon Guided Cement Augmentation of Iliosacral Screws in the Treatment of Insufficiency Fractures of the Sacrum - Description of a New Method and Preliminary Results

PURPOSE OF THE STUDY Fragility fractures of the pelvic ring in the elderly population are a serious problem in orthopaedics. The treatment options range from conservative treatment to diverse operative options. We present a balloon guided new technique of implanting cement augmented screws aiming at improved implant anchorage and reduced cement leakage. MATERIAL AND METHODS We describe a new technique of balloon- guided cement augmented iliosacral screws. After the balloon has been insufflated and contrast medium has been instillated for leakage detection, iliosacral screws can safely be placed with a relevant cement depot. RESULTS All patients (n = 8) treated in this way were allowed to weight bear on both legs and mobilisation was tolerated the next day after surgery. In the post-operative controls including X-ray and CT scan we noticed no cement leakage. Pain level as measured by the visual analog scale was significantly reduced to pre- surgery (mean 7.6 pre-operatively, mean 2.5 postoperatively). In addition pain medication could be reduced gradually soon after surgery. CONCLUSIONS The described procedure to address fragility fractures of the pelvic ring is a safe and easy to handle method. There are three advantages: First the osteoporotic S1 vertebral body can by stabilised by the amount of cement; second the cement leakage can be prevented by the balloon-compaction of the cancellous bone and the possibility to control the created cavity with contrast medium; third the bone - screw interface is much stronger compared to other procedures and is biomechanically superior against vertical shear stress. In contrast to sacroplasty, the cement application is guided by the previous use of a balloon. Key words:pelvic ring, fragility fracture, osteoporosis, elderly.

[Hardware removal after pelvic ring injury]

BACKGROUND

Pelvic ring fractures are considered as rare injuries. Minimally invasive sacroiliac screw fixation has been used increasingly in recent years as an operative strategy for the treatment of these injuries, if the dorsal pelvic ring needed to be addressed. Treatment options for the anterior pelvic ring comprise plates, screws or external fixation.

METHOD

Based on the limited number of publications on this subject and our own experience with 80 patients who suffered pelvic ring B- or C-type injuries during a period of 8 years we are able to show that the indication for hardware removal in the pelvic ring should be strictly defined.

RESULTS

In some cases like external fixation, implant-associated infection, malpositioning, allergic implant reaction, critical soft tissue covering, palpable hardware and consolidated juvenile fractures implant removal is certainly indicated. In patients without symptoms and in patients with trauma-associated symptoms which are not definitely associated with the hardware, the removal should be only indicated after thorough consideration of the risks versus the benefits and additionally by taking the initial injury pattern into account. If despite all these objections the hardware removal has been indicated it should always be considered that hardware removal may be challenging with several possible severe complications.

[Refracture of long bones after implant removal. An avoidable complication?]

Refractures of long bones after implant removal are a rare but serious complication, which in most cases make a reoperation necessary. We analysed our own cases and reviewed the scarce literature on this subject. As a result we found that it is possible to reduce this complication by performing thorough preoperative preparation, observing an adequate interim time between initial osteosynthesis and hardware removal, cautiously exposing the weakened bone to force for a certain time period after implant removal and taking the character of the fracture healing into consideration. It is not possible to entirely eradicate this complication because a lot of patients demand the implant removal even though it is known that demineralisation and residual screw holes both induce a reduction of energy-absorbing capacity and therefore predispose the patient to refracture. In some cases the surgeon should recommend that the implants remain in situ.

[Humerus shaft fractures]

Fractures of the humerus shaft are a common injury, mainly in younger patients and often coming with other injuries. The strategies of treatment are the conservative therapy, which was favoured till the late 1970s, and the operative therapy, including intramedullary nailing, plate osteosynthesis and external fixation. The initial procedure should be chosen according to the primary soft tissue damage and the existence of radial nerve palsy. The aim of treatment must be a usable extremity with anatomical axis, length and rotation.

Transossäre Refixation versus Fadenankerreinsertion, mittel- bis langfristige Ergebnisse nach distaler Bizepssehnenruptur

AIM

The aim of this study was to assess the range of movement, isometric and isokinetic postoperative outcome, Morrey score and heterotropic ossifications after refixation of distal biceps tendon rupture with either suture anchor or bone tunnel fixation.

METHODS

48 patients were surgically treated between 1990 and 2005. Elbow function was investigated isometrically and isokinetically with the CYBEX-NORM. The presence and extent of heterotropic ossifications were assessed by A/P and lateral view X-rays. The Morrey score was used to evaluate the clinical outcome.

RESULTS

13 patients received distal biceps refixation with the bone tunnel method and 35 with suture anchors. The range of motion of the elbow was statistically not significantly different except for pronation, which was slightly but significantly reduced after bone tunnel refixation. Isometric and isokinetic results as well as Morrey scores were statistically not different between the two surgical techniques. Both groups showed excellent postoperative results.

CONCLUSION

Bone tunnel and suture anchor techniques are both equal and sufficient methods for the refixation of distal biceps tendon ruptures with excellent clinical and functional postoperative results. The slight but significantly reduced pronation after bone tunnel refixation was clinically not relevant.

[Bone tunnel fixation versus suture anchor: mid- and long-term results after distal biceps tendon rupture]

AIM

The aim of this study was to assess the range of movement, isometric and is okinetic postoperative outcome, Morrey score and heterotropic ossifications after refixation of distal biceps tendon rupture with either suture anchor or bone tunnel fixation.

METHODS

48 patients were surgically treated between 1990 and 2005. Elbow function was investigated isometrically and isokinetically with the CYBEX-NORM. The presence and extent of heterotopic ossifications were assessed by A/P and lateral view X-rays. The Morrey score was used to evaluate the clinical outcome.

RESULTS

13 patients received distal biceps refixation with the bone tunnel method and 35 with suture anchors. The range of motion of the elbow was statistically not significantly different except for pronation, which was slightly but significantly reduced after bone tunnel refixation. Isometric and isokinetic results as well as Morrey scores were statistically not different between the two surgical techniques. Both groups showed excellent postoperative results.

CONCLUSION

Bone tunnel and suture anchor techniques are both equal and sufficient methods for the refixation of distal biceps tendon ruptures with excellent clinical and functional postoperative results. The slight but significantly reduced pronation after bone tunnel refixation was clinically not relevant.