Aims

Computer-based applications are increasingly being used by orthopaedic surgeons in their clinical practice. With the integration of technology in surgery, augmented reality (AR) may become an important tool for surgeons in the future. By superimposing a digital image on a user’s view of the physical world, this technology shows great promise in orthopaedics. The aim of this review is to investigate the current and potential uses of AR in orthopaedics.

Plate fixation of the proximal humerus fractures may now be more desirable with the use of a biological approach by limiting surgical insult and allowing accelerated rehabilitation by a solid fixation. To evaluate the safety and efficacy of minimally invasive plating of the proximal humerus using validated disease-specific measures.

During a period of one year, thirty patients were operated with use of the LCP proximal humerus plate (Synthes) through a 3cm lateral deltoid splitting approach and a second 2 cm incision at the deltoid insertion. The axillary nerve was palped and easily protected during insertion. Only two-part (N=22) and three-part impacted valgus type (N=8) were included in this study since they can be reduced indirectly thru this percutaneous technique. The average follow-up was thirteen months (eight to twenty months). All patients had the Constant and DASH evaluations.

All fractures healed within the first six months with no loss of correction. The surgical technique was found easy by all surgeons, the axillary nerve was palpated and protect with this new technique. No infection or avascular necrosis were seen. No axillary nerve deficit was identified. At the last follow-up (average nineteen months, twelve months minimum), the median Constant score was sixty-eight points, with an age ajusted score of seventy-six. The mean DASH score was twenty-seven points. Only age was independently predictive of both the Constant and DASH functional scores. Patients improved until one year of follow up.

Percutaneous insertion of a locking proximal humerus plate is safe and produces gives good early functional and radiologic outcomes. Recuperation from a proximal humerus fracture can be seen until one year.

Purpose of the study: We report a series of 12 patients who underwent surgery in 2003 or 2004 for spinal shortening as treatment for thoracic or lumbar metastasis.

Material and method: This series included seven females and five males, mean age 56.5 years (range 34–80 years). The operation was a resection of the vertebral body in a one-stage procedure. A simple posterior approach was used for two patients and a wider costotransversectomy approach was required for ten. Posterior fixation was installed with pedicle screws in the two vertebrae above and two below the resection. Mean operative time was 343 minutes (range 260–420 min). Mean blood loss was 2380 cc (range 600–5000). There were few surgery-related complications: one dural breach and one pulmonary breach.

Results: The decision to undertake surgery was made on the basis of neurological problems in seven patients. All patients were Frankel class C, unable to walk. Among these patients, five died in less than six months. For the two survivors, they were scored 7 on the Tokuhashi scale. The remainder scored 5. For the two survivors, one recovered walking capacity (Frankel D) and the other achieved a normal status (Frankel E). The five other patients underwent surgery for pain related to a kyphosis callus threatening the cord. We used the Karnofsky and the Oswestry score to analyze outcome. The score did not regress in any of the patients after surgery. Three patients improved their score significantly. The three others had an unchanged score. The best correction of the kyphosis callus was obtained when the vertebral collapse was greater than 50%. The preoperative regional deformity was measured at 23.2° (range 15–35°) which postoperatively reached 0.5° (range 20 to −17°).

Conclusion: This technique for spinal shortening appears to be a better alternative to anterior reconstruction, especially when the vertebral collapse is greater than 50%. In this context, this palliative surgery enables improved quality-of-life for a patient with often advanced disease.

Purpose of the study: We report the results of a series of seven cases of non-tuberculos infectious lumbar spondylodiscitis treated by posterior instrumentation and secondary anterior curettage of the infectious focus with bone grafting. This particular osteosynthesis method produces a short monosegmentary fixation limited to the space of the infected disc.

Material and methods: The series included six men and one woman (mean age 61.7 years, age range 37–82 years). The causal germ was identified in all cases: Staphylococcus aureus in five, and in one each, Staphylococcus epidermidis and Pseudomonas aeruginosa. Levels were L1L2 in one, L2L3 in two, L3L4 in three and L5S1 in one. Predisposing factors were history of prostatic cancer in two patients, coronary heart disease in one and chronic renal failure in one. One patient had received corticosteroid injections and two had no recognized co-morbid conditions. The surgical procedure was undertaken due to persistent pain in three patients (one with quadriceps amyotrophy and weakness), spinal instability with risk of neurological injury in two, and after failure of medical treatment in two patients who had persistent abscesses.

Results: Excepting one patient who died from renal failure four months after the surgical procedure, mean follow-up was 31.5 months (range six months to six years). Outcome was excellent in four patients, good in one, and a failure in one patient who was operated on because of instability. Failure of the instrumentation required surgical revision to extend the initial assembly. At last follow-up, all patients had achieved fusion of the instrumented zone and were considered to be cured of their infection.

Discussion: Classically, it is advisable to avoid instrumenting close to an infectious area in order to avoid the vicious circle of infection. Configurations described in the literature are usually extensive, blocking healthy levels beyond the infected area and compromising spinal mobility. However, a short instrumentation limited to one segment can be proposed when the end plates at the outer limits of the infectious focus are theoretically healthy. Careful analysis of the imaging data is required to carefully select patients who can benefit from this short configuration. Magnetic resonance imaging is most helpful.

In our cadaver study plating the fibula in addition to nailing the tibia decreased the mean rotation across the tibial osteotomy site compared to nailing the tibia alone. Although this is statistically significant (p=0.0034) it may not be clinically relevant as the mean values for ROM were 19.10 and 17.96 degrees respectively. Plating the fibula resulted in no statistically significant difference in the mean vertical displacement, angulation or neutral zone.

Therefore, we may conclude that plating the fibula in a combined distal third tibia and fibula fracture does not enhance the stability of tibial IM nailing.

The purpose of this study was to determine if combined distal third tibia and fibula fractures are more stable when fibular fixation is added to the standard tibial IM rodding.

In combined distal third tibia and fibula fractures, plating the fibula does not enhance stability of intramedullary tibial nailing.

No additional incision or soft tissue stripping is required for plating of the fractured fibula.

The average range of motion in rotation was 19.1° for tibial and fibular fixation combined, and 18.0 ° for tibial fixation alone with a difference of 1.1°, which was clinically significant ( p=0.0034). The mean differences in vertical displacement, angulation, and neutral zone were not statistically significant.

Five matched pairs of embalmed cadaveric lower limbs were dissected and stripped of soft tissue. Each tibia received a 9mm solid titanium nail that was locked proximally and distally. Fibular fixation consisted of a seven- hole LCDCP. A 1.5 cm section of tibia and a 1.0 cm section of fibula were removed. Testing was accomplished with an MTS machine. Vertical displacement was tested with an axial load to 500 N, rotation was tested with an internal and external torque of 5 Nm, and angulation was calculated from the vertical displacement data. All displacement data was measured across the osteotomy site.

The mean range of motion in rotation was the only statistically significant finding. However, considering the average range of motion with and without fibular plating of 17.96° and 19.10° respectively, this finding is likely not clinically relevant.

Funding: Tibial nails, bolts, fibular plates and screws provided by Synthes (Paoli, PA, USA)

Many two-part fractures of the proximal humerus are treated conservatively due to the frequent failure of internal fixation. The current investigation examines the biomechanical properties of a unique plate versus a standard plate for internal fixation of proximal humerus fractures. The unique plate employs screws that thread into the plate, creating a multi-planer, fixed angle device. A cadaveric model was developed that relied on the rotator cuff musculature as the primary deforming force. The locking plate displayed significantly greater holding power on the humeral head (p=0.007). This may lead to more consistent results in two-part fractures treated with internal fixation.

The current investigation evaluates a unique plate designed to treat fractures of the proximal humerus. The plate employs screws that thread into the plate creating a fixed angle device. This plate was tested versus a standard cloverleaf plate.

The locking plate displayed greater holding power on the humeral head in the model tested. This may lead to decreased failure rates in two-part fractures treated with internal fixation.

Many two-part fractures of the proximal humerus are treated conservatively due to the frequent failure of common internal fixation modalities. This is done with the acceptance of possible non-union and loss of function. A more reliable method for stable internal fixation is therefore desirable.

A significant difference was found (p=0.007) with the locking plate displaying greater holding capability on the humeral head.

Eight pairs of preserved, cadaveric humeri were dissected and plated with either the locking plate or standard cloverleaf plate followed by an osteotomy at the surgical neck. A servo-hydraulic testing machine was then used to pull on the rotator cuff musculature until failure was achieved. Failure of the plate-head interface was reached in five of the eight pairs. Previous biomechanical studies have not taken into account the clinical mode of failure when testing internal fixation modalities for proximal humerus fractures. The current study has reproduced failure into varus by relying on the rotator cuff musculature as the primary deforming force.

Funding: All implants donated by Synthes, Canada

We examined the relationship between waiting times for ACL surgery and the need for meniscal surgery at time of reconstruction. Using the Provincial Billing Database we identified 3812 ACL reconstructions between 1999–2001. Patients waited on average four hundred and twenty-two days from initial medical visit to reconstruction. 1722 patients (45%) required meniscal surgery with the ACL procedure. The delay to surgery was: two hundred and fifty-one days (no meniscal surgery required), four hundred and thirteen days (meniscal repair) and six hundred and seventy-six days (meniscectomies). This difference was significant, p< .01, ANOVA. The rate of meniscal surgery per time period was also significantly different: 17% if < 3months, 57% if > 6months. Our present Health Care policies place patients at risk of requiring avoidable meniscal surgery and developing osteoarthritis.

The purpose of this study was to examine the relationship between waiting times for ACL surgery and outcome.

The outcome measure was the need for meniscal surgery at the time of ACL reconstruction. The Provincial Data Base Billing information was reviewed for ACL reconstruction between 1999–2001. The simultaneous need for a meniscal procedure was noted. Tracking back in time, all demographic, diagnostic and interventional billing data (ICD & Visit billing code) preceding their ACL surgery was recorded.

Between 1999–2001, 3812 ACL reconstructions were identified. Of these, 1722 patients required a meniscal procedure (45%). On average, patients waited over four hundred and twenty-two days from injury to reconstruction. Patients who did not require any meniscal procedure waited on average two hundred and fifty-one days, meniscal repairs waited four hundred and thirteen days, while meniscectomies waited six hundred and seventy-six days. More importantly, the need for a meniscal procedure correlated with the timing of surgery: 17% of those reconstructed < three months from injury had a significant meniscal injury, compared to 57% at > six months. Almost half of which (48%) required a meniscectomy for significant meniscal injury. These differences all attained statistical significance (p< 0.01).

Previous reports suggest that the ACL-deficient knee increases the risk of meniscal injury and meniscal incompetence hastens OA. Our data show a progressive increase in the rate to meniscal surgery, and meniscal injury complexity with time. These delays and rates are higher than the ones proposed in the literature.

It appears that the experience in our Province simply reproduces (rather than improves upon) the natural history of the ACL injury. We postulate restricting access to specialists and to surgery place the patient at risk for requiring avoidable surgery and developing osteoarthritis

“Delta fixation” was developed to treat low-grade L5 isthmic spondylolisthesis. It involves placement of pedicle screws into L5 and from S1 through the L5/S1 disc into L5 (Fig.1). A biomechanical comparison to standard Posterior Lumbar Interbody Fusion (PLIF) with two anterior cages and pedicle screws in L5 and S1 was made. Eight fresh frozen human specimens were instrumented with both fixations and tested. Delta fixation was significantly more stable in resisting rotation. It requires less manipulation of the nerve roots and spares the cost of the fusion cages.

Our objective is to compare the stability of Delta versus PLIF fixation in the treatment of low grade isthmic spondylolisthesis

Delta fixation provides superior initial stability, and therefore is an acceptable alternative to PLIF for the treatment of low grade isthmic spondylolisthesis of L5-S1.

Symptomatic low-grade isthmic spondylolisthesis of L5 is often managed with PLIF. This procedure requires extensive manipulation of the cauda equine, posterior resection of the disc and the placement of two inter-body cages as spacers in addition to pedicle screws in L5 and S1.

Delta Fixation has been developed to provide stable fixation with less nerve root manipulation and without the use of inter-body cages. It is therefore a safer alternative method of fixation that spares the additional cost of the fusion cages.

When comparing Delta fixation to PLIF fixation the only statistically significant difference was found in axial rotation. Delta fixation had 2.05 degrees less ROM and 0.90 degrees less NZ compared to PLIF fixation with P values of 0.0052 and 0.0104 respectively. This demonstrates that the delta fixation is more stable than PLIF fixation.

Eight fresh frozen human spines were used. Matched pairs were created and block randomization used to create two groups: PLIF fixation and Delta fixation groups. The specimens were instrumented with a grade II spondylolisthesis of L5-S1, tested, and then re-instrumented with the alternative fixation and tested again. Vertical displacement, axial rotation, flexion– extension and side bending were tested using an MTS machine.

Please contact author for tables and/or diagrams.

Non-unions of pilon fractures are difficult Orthopaedic problems. Significant bone loss and infection can lead to amputation. Joint stiffness in conjunction with disuse osteopenia make stabilization in this area challenging. We present the use of a custom blade plate design that offers sufficient stability for successful treatment in six successive cases. With a mean follow-up of thirty-three months, all fractures treated with this method healed. The five infected cases healed without recurrence of infection. With average scores of 70.7 on the Maryland Foot Score, and sixty-eight on the Foot and Ankle Society Ankle-Hindfoot Scale, the patients overall had satisfactory results.

The purpose of this study was to describe a new technique of treating non-unions of distal tibia pilon fractures using a custom blade plate design. A report of successful outcomes in six consecutive cases.

A retrospective analysis of fifty-six pilon fractures treated over a three- year period revealed six patients with significant complications related to their fractures. Of these, all had significant bone loss and five were infected. All six failures were revised using a custom blade plated design with oblique locking screws for triangular fixation of the distal pilon. The average follow-up period was thirty-three months. These patients were evaluated with the Maryland Foot Score (MFS) and the Foot and Ankle Society Ankle-Hindfoot Scale (AHS).

All of the six patients treated with the proposed method went on to heal without recurrence of infection. Three patients required additional surgical interventions including bone grafting, debridement and hardware removal to achieve the final result. Their average MFS and AHS were 70.7 and sixty-eight respectively.

Stable fixation is an absolute necessity for a successful outcome in the failed pilon fracture. A custom blade plate design with oblique interlocked screws offers sufficient long-term stability, despite infection and disuse osteopenia, for healing of the non-united fracture to occur. As shown by our series, satisfactory clinical results can be expected and amputation can be avoided in complicated cases using this surgical technique.

Easier patient positioning and less extensive soft tissue dissection have spurred a trend for anterior instrumentation and fusion for C-spine fracture/ dislocations. We present group of forty-six patients treated over an eighteen month period with an anterior approach. There were no permanent approach related complications, infections, hardware failures or graft displacements. One patient had worsened post-operative neurological findings. One patient required additional posterior stabilization for a missed injury. Two patients were not reducible from the front and required posterior reduction and stabilization followed by anterior instrumentation and fusion. All grafts healed within four months of the operation.

The purpose of this study was to assess the efficacy of anterior instrumentation and fusion for Cervical Spine fracture/ dislocations

Over an eighteen month period, forty-six out of fifty-two patients with C-spine injuries requiring surgical treatment were followed prospectively. All patients underwent anterior approaches to stabilize and fuse the unstable segments using tricortical bone grafting and application of an anterior plate (CSLP, Synthes). Thirty-eight patients had single level injuries treated with discectomy and fusion. Two patients had two level discecomies. Six patients underwent corpectomy and fusions for fractures of the vertebral bodies

There were no approach related complications such as recurrent laryngeal nerve injuries, oesophageal perforations, vascular injuries or strokes. One patient deteriorated neurologically. All other patients either improved neurologically or remained with their original findings. Two patients required oral antibiotics for superficial infections at the donor site. There were no spine infections, hardware loosening or graft extrusions. All bone grafts healed within four months both clinically and radiologically. Forty-one patients complained of minor or no pain after four months. Five patients continued to have moderate discomfort. One of these patients had a missed injury above his two-level fusion with gradual progression into kyphosis requiring posterior stabilization.

Halo vest immobilization and posterior stabilization for C-spine fracture /dislocations have been the treatment of choice for many surgeons. The low complication and failure rate has spurred on a gradual change towards anterior instrumentation and fusion. Our study very strongly supports this trend. We see little indication for the more invasive posterior approach given our present results.

This study attempted to ascertain if patients with high superior pubic ramus fractures (HSPR) have worse clinical functional outcomes than patients with low superior pubic ramus fractures (LSPR). A retrospective cohort of patients was examined. A statistically significant difference was found with respect to Harris Hip Score, MFA score, Bother Index, and Functional Index. Patients with LSPR fractures consistently scored better on mobility and activity of daily living functional testing. Patients with HSPR fractures were limited in physical abilities and lifestyle adjustment. This study illustrates a need to re-examine our treatment of high pubic ramus fractures.

The purpose of this study was to ascertain if patients with high superior pubic ramus fractures have worse clinical functional outcomes than patients with low superior pubic ramus fractures.

Patients with Low Superior Pubic Ramus (LSPR) fractures consistently scored better on mobility and activity of daily living functional testing. Patients with High Superior Pubic Ramus (HSPR) fractures were more limited in physical abilities and lifestyle adjustment.

No distinction of level of this common fracture is routinely distinguished with treatment usually independent of level. This study illustrates a need to re-examine our treatment of high pubic ramus fractures.

A statistically significant difference was found when the HSPR fracture group was compared to the LSPR fracture group with respect to Harris Hip Score (P=0.0024), MFA score (P=0.0304), Bother Index (P=0.0338), and Functional Index (P=0.0385), and had hip pain which was a limiting factor (P=0.011).

This is a retrospective cohort study of patients sustaining a superior pubic ramus fracture. The criterion for grouping was fracture proximity to the acetabulum. MFA (Short Form) and Harris Hip Score were performed. A physical exam was performed on all patients. The two groups were compared using the Wilcoxon test for continuous variables and the Chi-square test for contingency tables.

These fractures are commonly felt to be of minimal significance. Common treatment regimes consist of pain control and early mobilization. The etiology of the increased pain and functional disability in patients with HSPR fractures is unclear. Our hypotheses include labral tear and missed true acetabular fractures.

A variety of surgical procedures are reported for the management of large volumetric bone loss about the ankle. Although the success rates of these various methods are generally adequate for fusion, they commonly utilize autogenous bone graft and usually result in limb shortening. In seven patients a titanium spinal cage was utilized as a structural support augmented with bone graft for complex ankle arthrodesis. This technique offers immediate structural support, maintenance of limb length, and limits autogenous graft morbidity. Early results of ankle arthrodesis with this cage are encouraging with regard to fusion rates, aesthetic attribute and functional outcome.

To present a novel method of tibio-talar and tibio-calcaneal arthrodesis utilizing a titanium spinal cage for the management of bone loss.

Complex ankle arthrodesis management with a spinal cage offers reliable fusion rates (comparable with existing techniques) without limb shortening.

A variety of procedures are reported for the challenging management of bone loss in ankle arthrodesis. Although the success rates of these various methods are generally good, they commonly utilize large autogenous bone grafts and are subject to donor site morbidities. Most methods also require significant shortening with commensurate functional and aesthetic deficits.

Early results of ankle arthrodesis with a titanium spinal cage are encouraging with regard to fusion rates and functional outcome. A cohort of seven patients treated by this technique has resulted in a 100% fusion rate without loss of limb length. Hindfoot and SMFA scores have revealed good functional results for a usually devastating problem.

A titanium cage was utilized as a structural support for complex ankle arthrodesis with large volumetric bone loss. The cage was contoured at the time of each operation to fit in situ. This technique offers immediate structural support and reliable fusion while limiting autogenous graft morbidity and limb shortening.

Using finely reconstructed helical pelvis CT scans of ninety-three cases and image analysis software, we define the “Safe Zone” for the extra-articular placement of screws during internal fixation of the acetabulum, using a Stoppa approach. Screws should be at most: 11mm from the top of the Sciatic notch, 23mm from the tip of the Ischial Spine, and at most 5mm posterior to the top of the Obturator canal, along the pelvic brim.

The purpose of this study was to identify a “safe zone” in the inner pelvis, to allow extra-articular screw placement using the Stoppa approach.

Acetabulum internal fixation screws can safely (extra-articular position) be placed through the Stoppa approach using three identifiable landmarks.

Surgeons can use these identifiable anatomic landmarks for the safe placement of screws along the inner aspect of the acetabulum.

Study Population: males:females 47%:53%, mean age: 51,3yrs (18–88). Reference measurements (means): Femoral Head (FH): 45,5mm (36–6), Inter-SI joint:177,9mm (102–34). Safe distance to joint: 1) from Sciatic notch: 11mm; 2) from Ischial Spine: 23mm; 3) from Obturator roof: 5mm. The Ischial Spine Distance (ISD) showed clustering (p< 0.05) into two groups according to Femoral Head diameter: FH< 47mm: Safe ISD=23mm ; FH≥47mm: Safe IS=28mm.

Ninety-three Helical Pelvis CT scans with fine reconstruction were done between July 1, 1999-June 30, 2000. Axial images were analyzed using GE Vox Tool® v.3.0.3 image analysis software. The femoral head diameter and the Inter-SI joint distance were used as reference. The distance between three identifiable bony landmarks and the point which would allow the placement of a 4mm screw outside the hip joint were measured. Inter and Intra-observer reliability study showed a difference < 1mm in > 90% of cases.

Surgical approaches which avoid extensive dissection and manipulation of the gluteal musculature are gaining in popularity. The Stoppa is such an approach which gives access to the medial acetabular wall and to the inner pelvis from the SI joint to the symphysis along the pelvic brim. This blind approach does not allow visualisation of the joint and confirmation of screw placement. The present paper offers surgeons these reference points.

To determine if immediate closure of open wounds is safe, we examined our results over a five year period. Of the two hundred and ninety-seven open fractures, two hundred and fifty-five (86 %) were closed immediately. Grade III open fractures accounted for 24.2% of cases. The superficial infection rate was 10.9%. The combined deep infection and osteomyelitis rate was 4.7%. Neither region of injury, Gustilo grade, velocity of trauma, nor time to primary closure had a significant influence on the incidence of infection. Primary closure may be a safe practice and could be accepted as a viable treatment plan in the care of most open fractures.

The purpose of this study was to determine if immediate primary closure of open fracture wounds is a safe practice without increased deep infections and delayed/ nonunions?

There was neither an increase in deep infection nor delayed union/non-union. Benefits include a decreased requirement for repeat debridements and soft tissue procedures, minimized surgical morbidity, hospital stay, and cost of treatment. Primary closure may be a safe practice in the care of most open fractures.

The standard of care has been to leave traumatic wounds open after initial emergent surgical debridement. Due to orthopedic advancements and current resource limitations, treatment at our institution has evolved to immediate closure of all open wounds after adequate irrigation and debridement.

Of the two hundred and ninety-seven open fractures, two hundred and fifty-five (86 %) were closed immediately after irrigation and debridement. Grades 3a, 3b and 3c open fractures accounted for 24.2% of cases. The superficial infection rate of primary closure was 10.9 %. All cases resolved with oral antibiotics. The combined deep infection and osteomyelitis rate was 4.7%. Neither region of injury, Gustilo grade, velocity of trauma, nor time to primary closure had a significant influence on the incidence of infection.

The study reviewed all open fractures presenting to a Level One Trauma center over a five-year study period. Patients were followed until fracture union or complication resolution. Multiple variables were examined including patient demographics, injury mechanism, fracture location, Gustilo classification, time to antibiotic administration, surgical debridement and wound closure, and method of wound closure. Outcome measurement included infection or union problems.