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The contribution of Lauge-Hansen to the understanding and treatment of ankle fractures cannot be underestimated, an unquestionable merit being the analysis of the ligamentous component of these injuries that are considered as equivalent to the respective malleolar fractures. In numerous clinical and biomechanical studies, the lateral ankle ligaments are ruptured either together with or instead of the syndesmotic ligaments, as predicted by the Lauge-Hansen stages. A ligament-based view on malleolar fractures may deepen the understanding of the mechanism of injury and lead to a stability-based evaluation and treatment of the 4 osteoligamentous pillars (malleoli) at the ankle.

“Chronic syndesmotic injury covers a broad range of symptoms and pathologies. Anterolateral ankle impingement without instability is treated by arthroscopic debridement. Subacute, unstable, syndesmotic injuries are treated by arthroscopic or open debridement followed by secondary stabilization using suture button device or permanent screw placement. Chronic syndesmotic instability is treated by a near-anatomic ligamentoplasty supplemented by screw fixation. In case of poor bone stock, failed ligament reconstruction, or comorbidities, tibiofibular fusion with bone grafting is preferred. Malleolar malunions and particularly anterior or posterior syndesmotic avulsions must be corrected in order to achieve a stable and congruent ankle mortise.”

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Technical note and case series.

Study Design Technical report.Objective Multilevel osteoporotic vertebral compression fractures may lead to considerable thoracic deformity and sagittal imbalance, which may necessitate surgical intervention. Correction of advanced thoracic kyphosis in patients with severe osteoporosis remains challenging, with a high rate of failure. This study describes a surgical technique of staged vertebral augmentation with osteotomies for the treatment of advanced thoracic kyphosis in patients with osteoporotic multilevel vertebral compression fractures.Methods Five patients (average age 62?±?6 years) with multilevel osteoporotic vertebral compression fractures and severe symptomatic thoracic kyphosis underwent staged vertebral augmentation and surgical correction of their sagittal deformity. Clinical and radiographic outcomes were assessed retrospectively at a mean postoperative follow-up of 34 months.Results Patients’ self-reported back pain decreased from 7.2?±?0.8 to 3.0?±?0.7 (0 to 10 numerical scale; p?

Study Design Narrative review.Objective The study aims to critically review the outcomes associated with the surgical repair or conservative management of spondylolysis in athletes.Methods The English literature listed in MEDLINE/PubMed was reviewed to identify related articles using the term “spondylolysis AND athlete.” The criteria for studies to be included were management of spondylolysis in athletes, English text, and no year, follow-up, or study design restrictions. The references of the retrieved articles were also evaluated. The primary outcome was time to return to sport. This search yielded 180 citations, and 25 publications were included in the review.Results Treatment methods were dichotomized as operative and nonoperative. In the nonoperative group, 390 athletes were included. A combination of bracing with physical therapy and restriction of activities was used. Conservative measures allowed athletes to return to sport in 3.7 months (weighted mean). One hundred seventy-four patients were treated surgically. The most common technique was Buck's, using a compression screw (91/174). All authors reported satisfactory outcomes. Time to return to play was 7.9 months (weighted mean). There were insufficient studies with suitably homogenous subgroups to conduct a meta-analysis.Conclusion There is no gold standard approach for the management of spondylolysis in the athletic population. The existing literature suggests initial therapy should be a course of conservative management with thoracolumbosacral orthosis brace, physiotherapy, and activity modification. If conservative management fails, surgical intervention should be considered. Two-sided clinical studies are needed to determine an optimal pathway for the management of athletes with spondylolysis.

AimIdentifying cervical spine injuries in confused or comatose patients with multiple injuries provides a diagnostic challenge. Our aim was to investigate the protocols which are used for the clearance of the cervical spine in these patients in English hospitals.Patients and MethodsAll hospitals in England with an Emergency Department were asked about the protocols which they use for assessing the cervical spine. All 22 Major Trauma Centres (MTCs) and 141 of 156 non-MTCs responded (response rate 91.5%).ResultsWritten guidelines were used in 138 hospitals (85%). CT scanning was the first-line investigation in 122 (75%). A normal CT scan was sufficient to clear the cervical spine in 73 (45%). However, 40 (25%) would continue precautions until the patient regained full consciousness. MRI was performed in all confused or comatose patients with a possible cervical spinal injury in 15 (9%). There were variations in the grade and speciality of the clinician who had responsibility for deciding when to discontinue precautions. A total of 31 (19%) reported at least one missed cervical spinal injury following discontinuation of spinal precautions within the last five years. Only 93 (57%) had a formal mechanism for reviewing missed injuries.Take home message: There are significant variations in protocols and practices for the clearance of the cervical spine in multiply injured patients in acute hospitals in England. The establishment of trauma networks should be taken as an opportunity to further standardise trauma care.Cite this article: Bone Joint J2016;98-B:825–8.

Study Design Prospective follow-up design.Objective Ureteral injury is a recognized complication following gynecologic surgery and can result in hydronephrosis. Anterior lumbar surgery includes procedures like anterior lumbar interbody fusion (ALIF) and total disk replacement (TDR). Anterior approaches to the spine require mobilization of the great vessels and visceral organs. The vascular supply to the ureter arising from the iliac arteries may be compromised during midline retraction of the ureter, which could theoretically lead to ureter ischemia and stricture with subsequent hydronephrosis formation.Methods Potential candidates with previous ALIF or TDR via anterior retroperitoneal access between January 2008 and March 2012 were chosen from those operated on by a single surgeon in a university hospital setting (n?=?85). Renal ultrasound evaluation of hydronephrosis was performed on all participants. Simple descriptive and inferential statistics were used to generate results.Results A total of 37 voluntary participants were recruited (23 male, 14 female subjects; average age 51.8 years). The prevalence of hydronephrosis in our population was 0.0% (95% confidence interval 0 to 8.1%).Conclusions Retraction of the ureter across the midline in ALIF and TDR does not result in an increase in hydronephrosis and appears to be a safe surgical technique.

Vertebroplasty and kyphoplastie have proved to be effective minimally invasive methods in the treatment of osteoporotic vertebral fractures. If adequate precautions are taken the risks involved can be foreseen. This article gives a summary of potential risks and describes how complications can be avoided.

OBJECTIVE: To provide evidence for the existence of a wide range of molecules characteristic of fibrocartilage at normal alar ligament entheses, that may have a bearing on the pathogenesis of rheumatoid arthritis. The alar ligaments provide the mechanical restraint for head rotation and their integrity can be compromised in patients with RA and occasionally in those with spondyloarthropathy. METHODS: Both alar ligaments from 6 cadavers were fixed in 90% methanol and cryosectioned longitudinally. Sections were immunolabelled with antibodies against collagens, glycosaminoglycans, and proteoglycans. The immunohistochemical data were related to estimates of insertional angle change at the entheses that were calculated from measurements of ligament length and dens diameter. RESULTS: Molecules typical of fibrocartilage (including type II collagen, link protein, and aggrecan) were found at both entheses, but labelling was more prominent at the odontoid end. This correlated with a 3-fold greater insertional angle change during 40° of head rotation at the attachment of the ligament to the dens. At the odontoid enthesis, fibrocartilage differentiation was most conspicuous posteriorly. CONCLUSION: The changes in insertional angle mean that compressive forces are prominent at both entheses, but particularly at the odontoid end, where the ligament partly wraps around the dens during head rotation. Thus, mechanical conditions are created that lead to pronounced fibrocartilage development, hence the expression of type II collagen, link protein, and aggrecan. The prominence of these molecules at the entheses raises the possibility that they could be antigenic targets for an autoimmune response in rheumatic diseases.

The steady state and time resolved fluorescence and the triplet–triplet absorption of p-dimethylaminobenzonitrile (DMABN) in presence of α- and β-cyclodextrin (CD) were investigated at various host and guest concentrations and temperatures. The formation of 1 : 1 and 1 : 2 DMABN : α-CD and 1 : 1 and 2 : 2 complexes DMABN : β-CD complexes was ascertained by applying global analysis methods. The “pure” fluorescence spectra as well as the emission quantum yields and lifetimes and the triplet properties of the various associates were determined. The role of environmental features in the radiative and non-radiative deactivation of the LE and ICT excited states of the complexed DMABN was elucidated.

The steady state and time resolved fluorescence and the triplet–triplet absorption of p-dimethylaminobenzonitrile (DMABN) in presence of α- and ß-cyclodextrin (CD) were investigated at various host and guest concentrations and temperatures. The formation of 1: 1 and 1: 2 DMABN: α-CD and 1: 1 and 2: 2 complexes DMABN: ß-CD complexes was ascertained by applying global analysis methods. The “pure” fluorescence spectra as well as the emission quantum yields and lifetimes and the triplet properties of the various associates were determined. The role of environmental features in the radiative and non-radiative deactivation of the LE and ICT excited states of the complexed DMABN was elucidated.

The absorption and induced circular dichroism (icd) spectra of the α-CD:DMABN system in water solution at 20 °C evidenced the presence of 1∶1 and 2∶1 complexes. The β-CD:DMABN system was found to be characterized by 1∶1 and 2∶2 associates. The association constants and the absolute absorption and icd spectra of each species were determined. The structure of the complexes was determined by dynamic Monte Carlo (DMC) calculations including solvation effects and induced circular dichroism calculations.

The intrauterine axial rotational characteristics of the lumbar spine were analyzed and quantified sonographically.

As an essential organ of both weight bearing and locomotion, the spine is subject to the conflict of providing maximal stability while maintaining crucial mobility, in addition to maintaining the integrity of the neural structures. Comparative morphological adaptation of the lumbar spine of mammals, especially in respect to locomotion, has however received only limited scientific attention. Specialised features of the human lumbar spine, have therefore not been adequately highlighted through comparative anatomy. Mathematical averages were determined of 14 measurements taken on each lumbar vertebrae of ten mammalian species (human, chimpanzee, orang‐utan, kangaroo, dolphin, seal, Przewalski's horse, cheetah, lama, ibex). The revealed traits are analysed with respect to the differing spinal loading patterns. All examined mammalian lumbar spines suggest an exact accommodation to specific biomechanical demands. The lumbar spine has reacted to flexion in a predominant plane with narrowing of the vertebral bodies in quadrupeds. Torsion of the lumbar spine is withstood by an increase in the transverse distance between the inferior articular processes in the upper lumbar spine in primates, but lower lumbar spine in humans, quadrupeds and the seal. Sagittal zygapophyseal joint areas resist torsion in the seal and humans. Ventral shear is resisted by frontal zygapophyseal joint areas in humans and primates, and dorsal shear by encompassing joints in the ibex. The human fifth lumbar vertebra is remarkable in possessing the largest endplate surface area and the widest distance between the inferior articular processes, as an indicator of the high degree of axial load and torsion in bipedalism. Anat Rec 264:157–168, 2001. © 2001 Wiley‐Liss, Inc.

As an essential organ of both weight bearing and locomotion, the spine is subject to the conflict of providing maximal stability while maintaining crucial mobility, in addition to maintaining the integrity of the neural structures. Comparative morphological adaptation of the lumbar spine of mammals, especially in respect to locomotion, has however received only limited scientific attention. Specialised features of the human lumbar spine, have therefore not been adequately highlighted through comparative anatomy. Mathematical averages were determined of 14 measurements taken on each lumbar vertebrae of ten mammalian species (human, chimpanzee, orang-utan, kangaroo, dolphin, seal, Przewalski's horse, cheetah, lama, ibex). The revealed traits are analysed with respect to the differing spinal loading patterns. All examined mammalian lumbar spines suggest an exact accommodation to specific biomechanical demands. The lumbar spine has reacted to flexion in a predominant plane with narrowing of the vertebral bodies in quadrupeds. Torsion of the lumbar spine is withstood by an increase in the transverse distance between the inferior articular processes in the upper lumbar spine in primates, but lower lumbar spine in humans, quadrupeds and the seal. Sagittal zygapophyseal joint areas resist torsion in the seal and humans. Ventral shear is resisted by frontal zygapophyseal joint areas in humans and primates, and dorsal shear by encompassing joints in the ibex. The human fifth lumbar vertebra is remarkable in possessing the largest endplate surface area and the widest distance between the inferior articular processes, as an indicator of the high degree of axial load and torsion in bipedalism. Anat Rec 264:157–168, 2001. © 2001 Wiley-Liss, Inc.

The molecular composition of the extracellular matrix in the dorsal capsules of lumbar and thoracic facet joints was analyzed immunohisto-chemically.

Introduction Cauda equina syndrome represents the constellation of symptoms and signs resulting from compression of lumbosacral nerve routes. Combined with subjective neurological findings, a reduction in anal tone is an important sign deeming further imaging necessary. Digital rectal examination (DRE) is an invasive procedure used to assess anal tone despite debated accuracy. Our main objective was to investigate the validity of DRE for assessment of anal tone.Materials and Methods Total 75 doctors completed a questionnaire documenting their grade, especiality, and experience in performing DRE. A model anus, using a pressure transducer surrounding an artificial canal, was assembled and calibrated. Participants performed four DREs on the model (with a break between attempts), and predicted tone as “reduced” or “normal” (35 and 60 mm Hg respectively), followed by a “squeeze” test. Total 30 health care assistants (HCAs) partook as a control group with no training in DRE.Results In each attempt 60, 61, 63, and 72% of doctors correctly identified the anal tone, respectively (average accuracy: 64%). HCAs had an identical average accuracy of 64%. Total 100% of participants correctly felt the squeeze test. For doctors no correlation was found between confidence in assessing anal tone using DRE and a correct result. Total 71% had received previous training in DRE with 64% of these taught how to assess anal tone. Total 43% of doctors felt that further training would be beneficial.Conclusion The results demonstrate that accuracy in assessing anal tone using DRE is limited with overall correctness of 64%. Poor correlation exists between perceived level of skill and study result. Doctors were not significantly more able than HCAs to detect correct tone. Therefore, DRE for the assessment of anal tone is not a wholly accurate tool. A squeeze test may be of greater value if interpreted correctly. I confirm having declared any potential conflict of interest for all authors listed on this abstract Yes Disclosure of Interest None declared

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