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Background: Diffuse pigmented villonodular synovitis of the knee is a difficult tumor to eradicate. We report our experience with a combined open posterior and anterior synovectomy with and without adjuvant postoperative radiation therapy in patients with advanced extracapsular disease. Methods: A single surgeon operated on forty patients, with an average age of thirty-five years (range, fourteen to sixty-eight years), who had diffuse pigmented villonodular synovitis of the knee. All patients had been referred to us after having initially undergone arthroscopic or open surgical procedures without eradication of the disease. Patients were retrospectively placed into one of three groups: Group I received surgery alone (five patients), Group II had surgery and intra-articular radiation synovectomy with use of dysprosium-165 (thirty patients), and Group III had surgery and external beam radiation (five patients). Adjuvant radiation was performed three months postoperatively. Magnetic resonance imaging was used for all patients for preoperative staging and postoperative follow-up. Results: The average Knee Society score for the entire series improved from 61 points preoperatively to 92 points at the time of follow-up, at an average of five years (range, 1.5 to eight years) (p < 0.001). There was also a significant (p < 0.001) increase in the average range of motion of the knees across all groups. On the basis of the Knee Society scores, thirty-seven patients (93%) had a good or excellent result, two patients had a fair result, and one patient had a poor result. Complications included stiffness requiring manipulation in three knees, one case of reflex sympathetic dystrophy, advanced osteoarthritis leading to a total knee replacement in four patients, and seven recurrences (a prevalence of 18%) after operative treatment and radiation therapy. Conclusions: This surgical technique allows excellent visualization and removal of intra-articular and extra-articular diffuse pigmented villonodular tissue and yields excellent functional results and a low prevalence of knee stiffness. However, the rate of recurrence detected by magnetic resonance imaging was 18%. Adjuvant intra-articular radiation therapy may be beneficial for eradication of small foci of residual disease, but complete resection of all pigmented villonodular tissue appears to be the key to preventing recurrence. Magnetic resonance imaging was essential for accurate preoperative staging of the tumor and for follow-up since the presence of residual disease did not reliably correlate with the clinical findings. Patients with minimal degenerative arthritis and primary or recurrent extra-articular disease will benefit most from this approach.

Arthroscopic treatment of diffuse pigmented villonodular synovitis of the knee is reported to have low recurrence rates and morbidity. The purpose of the current study was to evaluate demographic information, clinical symptoms, treatment parameters, and functional outcome in a group of 38 consecutive patients referred to the authors' hospital with persistent extraarticular diffuse pigmented villonodular synovitis of the knee after arthroscopic synovectomy. There were 23 males and 15 females with an average age of 31.7 years (range, 11-65 years) at the time of arthroscopy. All had an average of 1.7 (range, 1-5) arthroscopies. Thirty-four of 38 (89.5%) patients had some improvements of their symptoms after arthroscopic synovectomy, but all had worse symptoms and function at the latest followup of 3.63 years (range, 0.25-19.5 years). Although arthroscopic synovectomy offered some short-term relief, a critical review of prior reports and the data in the current study suggest poor outcomes in patients who have extraarticular diffuse pigmented villonodular synovitis of the knee after arthroscopic synovectomy. Magnetic resonance imaging is recommended for accurate staging of the disease and for long-term followup after arthroscopic treatment.

Although fractures of the radial head traditionally are not associated with healing problems, delayed union and nonunion are being seen more frequently after operative and nonoperative treatment. Given the tenuous blood supply to the head of the radius, problems with healing are not surprising. As the current review of five patients with nonunion of nonoperatively treated radial head fractures treated during a 6-year period shows, healing problems rarely are symptomatic and often may go unrecognized. Even when the fracture still is apparent on radiographs obtained more than 1 year after the injury, healing still may occur. Operative treatment, although rarely necessary, achieved union in one of the current patients.

We reviewed the biological elements supporting the usefulness of a specifically designed particulate form of demineralized bone matrix (DBM) with spinal fusion, and report some limitations of its use described in the medical literature and in the interbody space using a cadaveric biomechanical model. A literature review and description of the techniques used to augment spinal fusion are presented, including a more thorough review of recent findings of cadaveric biomechanical flexibility studies using DBM alone at different percentage fills of the existing disc space and DBM with a polyetheretherketone (PEEK) interbody cage. The need for DBM was established by reviewing limitations of autografts and allografts in spinal fusion. Demineralized bone matrix used alone did not increase stability post discectomy at L4-L5, but was demonstrated to exhibit satisfactory stability when used with a PEEK interbody cage. There may be a future role for DBM that hardens and fills disc space more rigidly, overcoming this limitation to its use.

Placing an interpositional fat graft over the dura has been practiced to prevent sciatica due to nerve tethering from scar. We assessed feasibility, outcomes, and complications of free fat grafts in patients undergoing lumbar microdiscectomy for herniated discs using an access cannula. Retrospective review of prospectively collected data on 69 consecutive patients: those who received autologous fat graft (Group I) and those who did not (Group II). Clinical evaluation of leg pain and nerve tension sign was performed in the immediate postoperative period and at 1 month, 6 months, 12 months, and 24 months. The combined visual analog scale (VAS) scores for leg pain improved from 8.3 preoperatively to 1.3 (P0.5). The average VAS score for leg pain was 1.4 (0 to 3) in Group I and 1.3 (0 to 3) in Group II (P0.05). Ninety-one percent had resolution of their leg pain immediately postop and 96% at final follow-up. This study found no increased complications with the use of fat graft, but no clinical benefit, therefore the use of fat graft should be discouraged. The potential complication with the use of fat graft is the "mass effect" on the dura, and therefore, the width of the graft should be1 cm.

The following report describes two consecutive brothers from a nonimmigrant family, with no identifiable predisposing factors, who presented with osteosarcomas of their distal femurs, one at the age of 18 years and the other at the age of 21 years. Until a cost-effective program is developed to screen for osteosarcoma, a detailed family history should be obtained from every new patient with osteosarcoma and parents should be urged to schedule early evaluations of siblings with complaints of painful extremities. Increased frequency of cytogenetic studies to screen for genetic abnormalities in patients with osteosarcoma is recommended to help elucidate the cause of osteosarcoma.

The authors studied 10 consecutive patients with closed femoral shaft or supracondylar fractures who were nonambulatory and who were treated by reamed retrograde intramedullary nailing via an intercondylar notch approach. The study consisted of five women and five men with an average age of 60.7 years (range, 40-89 years). Six patients had spinal cord lesions, one had a brain injury, one had cerebral palsy, one had multiple sclerosis, and one had progressive myelopathy. Three fractures were supracondylar, and seven fractures involved the mid-distal diaphysis. The average time of surgery was 110 minutes (range, 70-225 minutes) with an average estimated blood loss of 288 mL (range, 150-400 mL). There were two postoperative deaths (at 15 days and 2 months, respectively) after the procedure that were attributable to pneumonia. The remaining eight patients were observed for an average of 13 months (range, 6-20 months) after surgery. All fractures healed as evaluated radiographically. Retrograde intramedullary nailing is a simple, safe, and effective alternative to nonoperative treatment for femoral shaft or supracondylar fractures in patients who are nonambulatory. Stabilization by this method allows fracture healing and rapid return of patients to their previous level of function. There were no nonunions, malunions, significant shortening, implant failure, or wound infections.

Background: Proximal migration of the ununited greater trochanter following total hip arthroplasty may produce pain and substantial functional disability. Successful reattachment of the migrated fragment is difficult following multiple hip procedures. The purpose of this report is to describe four patients in whom a severely migrated trochanteric fragment was reattached successfully with a modified Charnley-Harris wiring technique after subperiosteal advancement of the abductor muscles from their origin on the iliac wing. Methods: This series consisted of one man and three women with an average age of sixty years (range, fifty-one to sixty-eight years) at the time of the index procedure. The patients were followed for an average of eighty-one months (range, fifty-five to ninety-six months). All patients had undergone mobilization of the abductor muscles based on the superior gluteal neurovascular pedicle to aid with trochanteric reattachment, and all had undergone prior hip operations (average, two). Advancement of the abductor muscles was achieved through a separate transverse curvilinear incision over the iliac crest, and subperiosteal releases of the entire origins of the gluteus minimus, medius, and maximus muscles from the ilium were performed. Results: Roentgenographic union of the trochanteric fragment occurred in all four patients. There were three excellent functional outcomes (Harris hip scores of 90, 94, and 96 points) and one fair functional outcome (76 points). The average improvement in the Harris hip score was 47.5 points (range, 35 to 58 points). Two patients continued to have a mild or moderate Trendelenburg gait postoperatively. Two patients had heterotopic bone formation of no clinical importance. Conclusions: Use of this technique resulted in union of the greater trochanter, pain relief, and decreased functional disability without major complications in these four patients. More widespread use of this technique may be indicated for the treatment of symptomatic nonunion of the greater trochanter when the fragment cannot be reattached to its anatomical location with the hip in less than approximately 20 degrees of abduction.

We report the morphology and treatment of 2 cases of a triplane intra-articular bicondylar fracture of the head of the proximal phalanx. Fracture lines in the coronal, sagittal, and transverse planes characterize this fracture, making it highly unstable. Open reduction and internal fixation using two 1.5-mm interfragmentary screws oriented in a dorsal to volar direction resulted in anatomic restoration of the articular surfaces and satisfactory functional results. In 1 case, autogenous cancellous bone graft was harvested from the ipsilateral radial styloid to support the articular fragments.

We describe the technique of wire-loop fixation to treat 4 young men with a unique variant of Melone's type 4 articular fracture of the volar lunate facet, characterized by a displaced rotated articular fragment supported by a limited amount of subchondral bone. This is an unusual injury that threatens the integrity of both the radiocarpal and distal radioulnar joints. It is the result of a compressive force to the wrist and may require trispiral computed tomography for delineation. Open reduction and internal fixation is recommended to maintain stability and articular congruity. The displaced volar-articular fragment, however, may be relatively small; therefore, direct manipulation could lead to soft tissue stripping and osteonecrosis. We have found the technique of wire-loop fixation to be a simple, reproducible, and effective alternative method of internal fixation for these difficult fractures. Malunion, non-union, loss of fixation, tendon rupture, infection, arthrosis, or pain caused by hardware has not occurred. Use of this technique is not recommended in patients with osteoporotic bone. (J Hand Surg 1999;24A:525–533. Copyright © 1999 by the American Society for Surgery of the Hand.)

A case of spontaneous staphylococcus arthritis of the wrist with associated carpal and distal radius osteomyelitis is reported. Following sequential debridements and a 6-week course of parenteral antibiotics, an extensive defect was bridged with a vascularized fibular autograft to achieve a successful fusion. There was no donor site morbidity or recurrent infection. Follow-up radiographs 41 months later demonstrated complete incorporation and hypertrophy of the graft.

To gain insight into the management of patients with hand and wrist injuries, a series of clinical and psychological analyses was performed on 9 surgeons, each of whom underwent operative fixation of a hand or wrist fracture. The results of these analyses suggest that the functional outcome after hand surgery was affected by the surgeons' personality, motivation, and ability to accept and adapt to the injury, the nature of the injury, and the importance of the hand to the surgeons' careers. Surgeons are highly motivated and compulsive individuals who consider their career involvement a major source of identity and self-worth. Most returned to their operative duties ahead of the schedule set by their hand surgeons (average, 25 days after surgery), regarded their injuries as a positive challenge, and changed their lifestyles after injury to protect their hands.

A 66-year-old woman was seen and treated for a chronic lymphocystic leukemic infiltrate of a proximal interphalangeal joint, which presented with clinical and radiologic signs consistent with a pyogenic arthritis.

The surface area of the chick (Gallus domesticus) tympanic membrane (TM) increases by as much as 400% from hatching to 70 days of age (Cohen et al. [1992] J. Morphol. 212:187–193). The present study is concerned with the processes that contribute to this remarkable size increase. Middle-ear specimens were harvested in embryos aged between E10 and E18, and in post-hatch animals between days P1 and P57. Specimens were embedded in paraffin, cut in serial sections, stained for collagen fibers, and examined with light microscopy. Four locations were examined in each specimen: the anterior and posterior perimeter of the TM, the TM over the extra-stapedius, and the TM at the tip of the extra-columella. The thickness of the epithelial, respiratory, and lamina propria layers was measured at each location. The radial collagen fibers in the lamina propria were also counted at each location, and fiber density per square micrometer was determined at each age. Thickness of the epithelial and respiratory layers remains relatively constant throughout development in all areas of the TM, whereas the lamina propria at the extra-columella and extra-stapedius continues to thicken with increasing age. Collagen density also increases during development, and this is attributed to an increase in fiber number and a reduction in the space between fibers. The results suggest that collagen may be synthesized first in the central regions of the TM and then later in more peripheral areas of the TM. J. Morphol. 233:257–266, 1997. © 1997 Wiley-Liss, Inc.

Paralysis is the most feared postoperative complication of ACDF and occurs most often due to an epidural hematoma. In the absence of a clear etiology, inadequate decompression or vascular insult such as ischemia/reperfusion injury are the usual suspects. Herewith we report a case of complete loss of somatosensory evoked potentials (SSEPs) during elective ACDF at C4-5 and C5-6 followed by postoperative C6 incomplete tetraplegia without any discernible technical cause. A postoperative MRI demonstrated a large area of high signal changes on T2-weighted MRI intrinsic to the cord “white cord syndrome” but no residual compression. This was considered consistent with spinal cord gliosis with possible acute edema. The acute decompression of the herniated disc resulted in cord expansion and rush-in reperfusion. We postulate that this may have led to disruption in the blood brain barrier (BBB) and triggered a cascade of reperfusion injuries resulting in acute neurologic dysfunction. At 16 months postoperatively our patient is recovering slowly and is now a Nurick Grade 4.

Background context There is little understanding of cervical plate misalignment as a risk factor for plate failure at the plate-screw-bone interface. Purpose To assess the torsional strength and mode of failure of cervical plates misaligned relative to the midsagittal vertical axis. Study design Plastic and foam model spine segments were tested using static compression and torsion to assess effects of misaligned and various lengths anterior cervical plate (ACPs). Methods Different length ACPs and cancellous fixed angle screws underwent axial torsional testing on a servo-hydraulic test frame at a rate of 0.5°/s. A construct consisted of one ACP, four screws, one ultrahigh–molecular weight polyethylene inferior block, and one polyurethane foam superior block. Group 1 had ACPs aligned in the midsagittal vertical axis, group 2 plates were positioned 20° offset from the midline, and group 3 had the ACP shifted 5 mm away and 20° offset from midline. Torques versus angle data were recorded. The failure criterion was the first sign of pullout determined visually and graphically. Results Group 1 had a more direct screw pullout during failure. For the misaligned plates, failure was a combination of the screws elongating the holes and shear forces acting between the plate and block. The misaligned plates needed more torque to failure. The failure torque was 50% reduced for the longer versus the shorter plates in the neutral position. Graphically shown initial screw slippage inside the block preceded visual identification of slippage in some cases. Conclusions We observed different failure mechanisms for neutral versus misaligned plates. Clinically, misalignment may have the benefit of needing more torque to fail. Misalignment was a risk factor for failure of the screw-bone interface, especially in longer plate constructs. These comparisons of angulations may be a solid platform for expansion toward a more applicable in vivo model.

STUDY DESIGN: Technique tips and retrospective review of prospectively collected data. OBJECTIVE: To describe a technique for centralizing cervical plates using the center of the manubrium as a primary external guide and its alignment with the mandible as a secondary guide. SUMMARY OF BACKGROUND DATA: Proper alignment of cervical plates is desirable to avoid improper placement of screws and possibly altered biomechanical performance. Large body habitus may portend suboptimal exposure, a limited utility of skin surface landmarks for level determination, and may make it difficult to reliably centralize plates in the coronal plane during anterior cervical surgery. METHODS: We describe a technique that uses the center of the manubrium to determine the midline of the cervical spine and align a line drawn through the manubrium with the center of the mandible to provide a central axis for placing cervical plates along the entire cervical spine. We used anteroposterior fluoroscopy to validate that a line from the middle of the manubrium to the mandible bisected the spinous processes and midline of the vertebral bodies. We prospectively collected data on 39 consecutive patients undergoing anterior cervical discectomy and fusion with cervical plates using this technique. RESULTS: The mean amount of angulation and translation about a midline axis were 2.24 degrees +/- 1.49 degrees and 1.04 +/- 0.86 mm, respectively. There were no statistical differences among 1-level, 2-level, and 3-level fusions (P > 0.05). The intraobserver correlation coefficient for the measurement technique was R = 0.90 (P = 0.0016). CONCLUSION: We validated that the midline of the cervical spine is in line with a straight bovie cord connecting the midline of the manubrium to the midline of the mandible using anteroposterior fluoroscopy. Using this line, we prospectively centered cervical plates with no significant difference between levels. These data may also serve as a benchmark for assessing cervical plate alignment.

Natural history studies have focused on risk for progression in lumbar curves of more than 30 degrees, while smaller curves have little data for guiding treatment. We studied curve progression in de novo degenerative scoliotic curves of no more than 30 degrees. Radiographs of 24 patients (17 women, 7 men; mean age, 68.2 years) followed for up to 14.3 years (mean, 4.85 years) were reviewed. Risk factors studied for curve progression included lumbar lordosis, lateral listhesis of more than 5 mm, sex, age, convexity direction, and position of intercrestal line. Curves averaged 14 degrees at presentation and 22 degrees at latest follow-up and progressed a mean of 2 degrees (SD, 1 degrees) per year. Mean progression was 2.5 degrees per year for patients older than 69 years and 1.5 degrees per year for younger patients. Levoscoliosis progressed 3 degrees per year and dextroscoliosis 1 degrees per year (P.05). Forty-six percent of patients had lateral listhesis of more than 5 mm at L3 and L4. Curve progression was not linear and might occur rapidly, particularly in women older than 69 with lateral listhesis of more than 5 mm and levoscoliosis. Small curves can progress and therefore should be individualized in the context of other risk factors.

Background context Osteochondroma is the most common primary benign bone tumor and is usually located in the metaphyses of long bones and rarely in the spine or anterior sacrum. To the best of our knowledge, en bloc excision of a solitary osteochondroma of the anterior sacrum in an adult patient has not been previously reported in a peer-reviewed journal. Purpose The purposes of this study were to document the first report of an osteochondroma of the anterior sacrum along with the clinical course and operative management and review the literature on solitary osteochondroma of the sacrum. Study design/setting The study setting is an academic institution. This is a case report and review of the literature. Patient sample The patient is an adult female. Outcome measures The outcome measure is the visual analog score for pain. Methods A 54-year-old woman presented with 9/10 disabling low back and radicular pain in the left lower extremity. Radiologic studies showed a pedunculated mass occurring from the anterior sacrum thought to be causing nerve root compression. The patient received en bloc excision of the mass through an abdominal retroperitoneal approach. We also conducted a literature review of solitary sacral osteochondroma in peer-reviewed journals. Results Histologic studies confirmed the mass to be an osteochondroma without pathologic signs of malignant transformation. The patient complained of dysesthesia in the left leg after surgery, which progressively improved completely over 8 months after the operation. At the 2-year follow-up, there was no evidence of local recurrence and she was pain free. A literature review revealed one previous case of en block resection of a solitary osteochondroma, but it involved the posterior sacrum. Conclusions Solitary osteochondroma can rarely present in the sacrum as low back pain and sciatica. In general, when osteochondroma causes pain in an adult, we should think that some structure is impinged or that it could have initiated a malignant transformation, so en bloc excision should be used to remove the tumor and histologic studies performed to assess for malignant transformation. Battered nerve root syndrome may take up to 8 months to resolve.

Study design Prospective radiographic analysis with clinical correlates. Objective The purpose of this study was to determine whether patients with cervical plates protruding off the vertebral body more prominently than pre-existing osteophytes had higher rates of dysphagia, suggesting a mechanical role. Summary of background data Plate prominence due to mechanical causes has been implicated as a cause of dysphagia after anterior cervical fusion. This study therefore assessed the potential of plate prominence as a cause of dysphagia after anterior cervical fusion and the predictive role of preoperative osteophyte heights. Methods Osteophyte heights measured on the preoperative radiographs of 63 patients, 41 males and 23 females with mean age 54 years (range, 31 to 75), who underwent anterior fusion (2 mm SYNTHES CSLP plates). After surgery, the distance of the plate from the vertebral body was measured and compared with preoperative osteophyte heights. Group I contained 30 patients who had cervical plates protrude less than or equal to the height of the tallest preoperative osteophyte. Group II contained 34 patients who had plates protrude greater than the height of the tallest preoperative osteophyte. Results No patients had preoperative dysphagia. Five of 30 Group I patients had dysphagia (>1 month). Six of 34 group II patients had dysphagia. There was no difference between groups I and II in rate of dysphagia (beta > 0.90). Plates at C3 and shorter cervical constructs trended higher rates of dysphagia. Conclusion Long-term postoperative dysphagia in Group I patients and the lack of a difference in rates of dysphagia between group I and group II, made it improbable plate thickness of 2 mm or prominence between 3 and 7 mm consistently played roles in dysphagia. Preoperative osteophyte height did not predict which patients developed postoperative dysphagia. Plates at the C3 and shorter constructs trended to have higher rates of dysphagia.

Cervical spine infections can have disastrous consequences, but techniques for minimizing infections should be evidence based. In this article, we report the incidence of spine infections in a large cohort of consecutive patients who underwent anterior cervical fusions without iodophor-impregnated incision drapes (3M Ioban; 3M Health Care, St. Paul, Minn) covering the surgical site. We reviewed the records of 581 consecutive patients (294 men, 287 women) who underwent 616 anterior cervical fusions without such drapes over the incision site and who were followed for 1 to 21 years after surgery. Mean age at the time of surgery was 52 years (range, 17-83 years). There was 0% incidence of cervical spinal infections in the group. Need for iodophor-impregnated incision drapes during anterior cervical fusion was not demonstrated. These drapes added unnecessary cost and may decrease skin mobility, making adequate exposure more difficult.

STUDY DESIGN Technical note. OBJECTIVE To demonstrate a controlled extension osteotomy technique of the cervical spine in a prone position and using the head elevator mechanism on the Jackson operating table to correct a chin-on-chest deformity in a patient with ankylosing spondylitis. SUMMARY OF BACKGROUND DATA Catastrophic cord injury causing quadriplegia and death has been associated with correction of chin-on-chest deformity in patients with ankylosing spondylitis. Manual control of spinal column motion during and after osteoclasis or osteotomy can be difficult, inexact, and anxiety inducing. METHODS A 45-year-old woman with ankylosing spondylitis and severe chin-on-chest deformity underwent a posterior C7 pedicle subtraction osteotomy, deformity correction, and instrumented fusion in a prone position on the Jackson operating table. RESULTS By using the elevator mechanism attached to the head of the operating table and Mayfield tongs, the patient's cervicothoracic junction was placed into extension by over 30 degrees in controlled increments. CONCLUSION We present a technique for controlled extension osteotomy correction of chin-on-chest deformity in a prone position. Use of the operating table mechanism in conjunction with a closing-wedge osteotomy diminishes the risk of translation, decreases risk of air embolus associated with a sitting position, and promotes greater opportunity for fusion through the osteotomy, and the stability allows for placement of modern instrumentation.

Background context Although the prevalence of indications and contraindications to lumbar total disc replacement (TDR) has been evaluated, no study to date has quantified the potential candidacy for cervical disc replacement in practice. Purpose To report the potential candidacy rate for cervical TDR from both an academic and private practice spine surgery setting. Study design/setting Retrospective case series. Patient sample Patient record review of 167 consecutive patients who underwent cervical spine surgery by 1 of 2 orthopedic spine surgeons between January 1, 2003 and January 1, 2005. Outcome measures Evaluation of potential candidacy for cervical TDR, with emphasis on both contraindications and indications. Methods In this study, we used the published contraindications and indications listed in trials of four different cervical disc arthroplasty devices: ProDisc-C (Synthes Spine, West Chester, PA), PRESTIGE LP (Medtronik Sofamor Danek, Memphis, TN), Bryan Cervical Disc prosthesis (Medtronik Sofamor Danek, Memphis, TN), and Porous Coated Motion (PCM; Cervitech, Rockaway, NJ). The proportion of patients who met both inclusion and exclusion criteria was calculated. We also examined the proportion of patients who would be candidates for cervical TDR if the indications were expanded to include the treatment for adjacent segment disease (ASD). Results Of the 167 patients (mean age 50.8 years, range 20–89 years) reviewed, 91.6% (153/167) had fusion surgery and 8.4% (14/167) had nonfusion surgery. Fifty-seven percent (95/167) had absolute contraindications to cervical TDR, and within this group the average number of contraindications was 2.1 (SD=1.2, range 0–5). Forty-three percent (72/167) met the strict inclusion criteria, and had no exclusion criteria. If the indications were expanded to include treatment for ASD, an additional 4.2% (7/167) of the patients would have qualified as candidates for cervical TDR. Conclusions Compared with lumbar TDR, total disc replacement may have a larger potential role in the treatment of cervical degenerative conditions, as 43% of patients would have met the strict criteria for TDR candidacy, or 47% if the indications were expanded to include treatment for ASD.

Background context A linear relation exists between the insertional torque when placing a screw and the ultimate screw pullout strength; therefore, undertapping of the pedicle followed by insertion of a larger screw may enhance the pullout strength of the screw. Purpose To report the risk of pedicle wall breech with placement of 6.2-mm pedicle screws after undertapping with a 5.2-mm tap and to evaluate the effectiveness of direct visualization to identify these breeches. Study design/settings Prospective evaluation of risks of pedicle wall breech with undertapping for a larger screw and the utility of directly visualizing pedicle walls during access and placement of pedicle screws for evidence of breech. Patient sample Sixty-five consecutive patients. Outcome measures Intraoperative direct visualization of pedicle wall breech. Postoperative radicular leg symptoms. Methods We prospectively analyzed placement of pedicle screws in sixty-five consecutive patients during lumbar-instrumented fusions after laminectomies performed by a single spine surgeon. Forty-four patients were primary fusions, and 21 were revisions. Twenty-seven were male, and 38 were female, with a mean age of 54.7 years (range, 15–85 years). Four hundred twenty-eight total pedicle screws were placed for an average of 6.6 screws per patient (range, 2–12 screws). Results The incidence of pedicle wall breech during access was 0.7% (3/428) and 1.6% (7/428) after screw placement. 71% (5/7) of the screw breeches were noted with direct inspection of the pedicles intraoperatively, and 29% (2/7) were identified on postoperative X-ray films as lateral breakthroughs that were missed on intraoperative fluoroscopy and direct visualization. Therefore, 100% of misplaced screws potentially harmful to nerve roots were identified on direct visualization. Eighty percent occurred from L2–4. Conclusions This study provides evidence that undertapping of pedicles followed by placement of a larger diameter pedicle screw may breech the pedicle cortices. Although the risk is low, the authors recommend direct visualization of the pedicle walls during screw placement to identify caudad, medial, and cephalad breeches. This technique is for open laminectomies and should be added to the armamentarium of other techniques and not as a replacement.

Giant cell tumors are hypervascular tumors that represent approximately 5% of all primary bone neoplasms. Vertebral tumors often require surgery to maintain spinal stability or to relieve spinal cord and nerve root compression. However, surgical resection of hypervascular tumors like giant cell tumors can be hazardous because of the risk of excessive intraoperative hemorrhage. Preoperative embolization can be useful to decrease perioperative blood loss in primary and metastatic vertebral tumors, and preoperative embolization for vertebral tumor surgery is relatively safe. We report a patient who had the unusual but serious complications of paralysis and paresthesia at the T12 vertebra and below as a result of preoperative embolization. At 6 months followup, the patient was disease-free but without neurologic function from T12 and below. Therefore, it is imperative physicians be aware of the possible preoperative embolization complication of cord infarction and the safety measures proposed in this article to avoid this complication.

Study design In vivo fluoroscopic quantification of segmental cervical spinal motion in asymptomatic volunteers during mastication. Objective To quantify the degree of segmental cervical spine motion in patients during mastication and while wearing several commonly used cervical orthoses. Summary of background data Cervical orthoses are routinely used to stabilize the cervical spine after trauma or cervical fusion and are, in some cases, prescribed to be worn at all times, including during eating. Methods Seven volunteers with an average age of 31 years (range, 26-42 years) had 5 seconds of continuous lateral cervical fluoroscopic imaging while they chewed gum without any cervical orthosis (control) and while wearing a soft collar turned forward then backward, a Philadelphia collar, a Miami J collar, or a two-poster brace. Still images were created from the fluoroscopy video, which allowed for quantification of the amount of segmental motion. Results All cervical collars produced statistically greater motion at occiput-C1 and C1-C2 when compared with no collar. The motion was greatest at the occiput-C1 junction and decreased to the C4 level. No motion was detected in any subject in any brace below C4. The two-poster brace produced the most segmental motion at occiput-C1 (6.3 degrees +/- 2.0 degrees) compared with the soft collar turned backwards (1.9 degrees +/- 1.9 degrees). No subject had any segmental motion below C2 in the soft collar. No segmental spinal motion was observed without a cervical brace. Conclusions To limit upper cervical spine segmental motion during mastication, for patients with unstable cervical spines, we propose a two-poster brace with removal of the mandibular component to allow for free mandibular action. For stable spines, we propose a soft collar turned backwards. Patients should be educated with this information.

OBJECTIVE Prior cadaveric research showed that the lateral mass and facets are landmarks to determine the initial starting point for lateral mass screws and that the optimum screw trajectory was 30 degrees lateral and 15 degrees cephalad. The missing link was an intraoperative landmark to guide the trajectory for drilling according to these angles. The authors hypothesized that spinous processes can be used to guide the trajectory for lateral mass screw placement. METHODS The authors analyzed 144 lateral masses of 72 cervical vertebrae in 18 cadavers (7 males and 11 females). The lateral and cephalocaudad angles were measured for each lateral mass from C3 to C6 while using the spinous processes of the adjacent three caudad vertebrae at each level to guide the starting trajectories for a total of 864 angles. The lateral and cephalad trajectory angles at each spinous process relative to the starting hole were compared with 30 degrees and 15 degrees . For each angle measured at a particular level, the same starting hole was used in the lateral mass, and the superolateral cortex of each spinous process was the most medial point. RESULTS When drilling for the C3 and C4 lateral mass screws, the C4 and C5 spinous processes provided an accurate starting point, respectively, for the lateral angle but moderately overestimated the cephalocaudad angle. For C5 and C6 lateral mass screws, the C6 and C7 spinous processes provided an accurate starting point, respectively, for both the lateral and the cephalocaudad angles. CONCLUSION The spinous processes can be an accurate local anatomic guide for lateral mass screw trajectory and will allow greater safety while drilling before performing laminectomies. These guides may change in patients with cervical spinal deformities.

Background: Traumatic atlanto-occipital dislocation in children and adolescents is a rare and often fatal injury. Although historically most reported cases have been fatal, the advent of modern prehospital care has led to an increase in survival following this injury. As a consequence, some patients may achieve or maintain satisfactory neurologic function following early intervention, stabilization, and definitive management. We analyzed the data on children and adolescents in whom traumatic atlanto-occipital dislocation had been treated with modern resuscitation techniques at our institution. Methods: Atlanto-occipital dislocation is defined as disruption of the ligaments and other supporting soft tissues as indicated by displacement in either a transverse or vertical direction. With use of the Trauma Registry database at our institution, we identified sixteen such injuries that had occurred between 1986 and 2003. The hospital charts, clinic notes, and radiographs were reviewed. A careful neurological evaluation was performed for all of the survivors at the time of the latest follow-up. Results: The mean age of the sixteen patients at the time of the injury was 7.6 years. The mechanisms of injury were diverse. The mean Glasgow Coma Scale score was 7.4 points. Eleven of the sixteen patients underwent intubation in the field, two were intubated in the emergency department, and three were not intubated. Eight of the sixteen patients were declared dead on arrival in the emergency department. The eight surviving patients initially were immobilized with either a halo vest or another orthosis. All patients except one received intravenous steroids in the emergency department. Three of the patients who survived the initial injury subsequently died while undergoing neurosurgical procedures for the treatment of extensive intracranial injuries. Four of the remaining five survivors underwent occiput-C2 fusion, and one was managed with a Minerva cast. At the time of the final follow-up, at a mean of 4.2 years after the injury, one patient was neurologically normal, three had mild spastic hemiparesis and were very functional, and one had spastic quadriplegia and was ventilator-dependent. Conclusions: Prompt recognition and treatment of traumatic atlanto-occipital dislocation in children and adolescents can result in improved survival. Early diagnosis, prompt intubation, early and adequate immobilization of the head and neck, and the use of intravenous steroids appear to facilitate survival. We recommend arthrodesis from the occiput to C2 (or the nearest adjacent intact and stable vertebra caudad to C2) for all children who survive a traumatic atlanto-occipital dislocation, particularly those with an incomplete spinal cord injury. Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Technologic advances in communications potentially may affect the patient-doctor relationship. We assessed call patterns, reasons for calling, and attitudes if patients had their surgeon's cellular telephone number, to determine if there are potential benefits to this practice. Postoperative calls made by patients to the surgeon, secretary, and surgical scheduler were categorized as urgent or nonurgent. Twenty of 32 (63%) consecutive patients made 65 calls during a 2-month period. Only 12 calls (18%) were to the surgeon. Fifty percent were urgent, as opposed to 14% and 15% of calls to the secretary and surgical scheduler, respectively. Subsequently, 201 patients were prospectively administered a 10-question survey assessing patient attitudes if given direct access to their surgeon. Eighty percent owned a cellular telephone, 85% would call the surgeon, and 30% would prefer the surgeon as the first line of communication. Communicating through E-mail or home phone was less desirable than through the nurse or cellular telephone. Seventy-two percent thought that having cellular telephone access suggested that their surgeon was more caring. Patients desired to communicate directly with surgeons, but act with restraint and call as a last resort for mostly urgent issues if given the physician's cellular telephone number. The cellular telephone has promising benefits for the patient-physician relationship.

This study evaluated risk factors for patellar dislocation after primary total knee arthroplasty and determined functional outcomes in patients following revision. Thirty-nine knees in 39 patients averaging 68 years (range, 27-91 years) at the time of revision were evaluated at a mean of 3.2 years (range, 2-7 years). Mean Knee Society and Function scores significantly improved from 34 and 35 to 77 and 54, respectively. Patellar dislocation most commonly resulted from errors in technique such as soft-tissue imbalance and malaligned components that led to poor tracking of the patella. Patellar tracking only improved after soft-tissue realignment in combination with revision of malaligned or loose components. Although revision significantly improved active knee extension and Knee Scores, two thirds of the patients had residual disabilities and pain.

Purpose To determine whether the radial nerve should be explored when there is a complete sensory and motor deficit after a high-energy fracture of the humeral diaphysis. Methods Twenty-four patients aged 16 years or older with a high-energy, diaphyseal fracture of the humerus and complete motor and sensory radial nerve palsy were reviewed retrospectively. Eleven fractures were open—6 of these were part of a very complex upper-extremity injury (multiple ipsilateral fractures in 3 patients and near amputation in 3). All 11 patients with open fractures and 3 of 13 patients with closed injuries had radial nerve exploration. Results All 6 patients with a transected radial nerve had an open humerus fracture and were part of a complex upper-extremity injury. Five of 6 had primary repair of the radial nerve, and none recovered. All 8 intact explored nerves and 9 of 10 unexplored nerves recovered; the only nonrecovery occurred in a patient treated with closed intramedullary rod fixation who may have had iatrogenic nerve injury. The average time to initial signs of recovery was 7 weeks (range, 1–25 weeks). The average time to full recovery was 6 months (range, 1–21 months). Conclusions Transection of the radial nerve is usually associated with open fractures of the humerus that are part of a very complex upper-extremity injury. The results of primary nerve repair in this circumstance are poor, likely related to an extensive zone of injury and the need for nerve grafting. Intact nerves and nerve palsies that are part of a closed fracture nearly always recover, even after high-energy injuries. Because the first signs of nerve recovery and complete recovery of the nerve can be quite delayed, patience is merited before considering tendon transfers.

Nonunion of distal tibia metaphyseal fractures after trauma is a major problem. Treating these nonunions is made more challenging by the presence of symptomatic ipsilateral tibiotalar arthrosis. The current study examined the use of the 90 degrees cannulated blade plate as an alternative method of stable internal fixation for 13 distal tibia metaphyseal nonunions and simultaneous fusion of three arthritic tibiotalar joints in 13 patients (seven males and six females) with an average age of 42.4 years (range, 21-73 years). Each patient had an average of three prior procedures (range, 2-6). Patients were followed up for an average of 34.2 months (range, 24-55 months). All 13 patients achieved radiographic and clinical union an average of 15.6 weeks (range, 12-20 weeks) from the date of the definitive procedure. There were two broken screws, but no secondary procedures were required to obtain fusion. All patients were ambulatory without support at the last followup. The implant proved effective for stable internal fixation of distal tibia metaphyseal nonunions alone or with simultaneous fusion of the tibiotalar joint.

Arthroscopic treatment of diffuse pigmented villonodular synovitis of the knee is reported to have low recurrence rates and morbidity. The purpose of the current study was to evaluate demographic information, clinical symptoms, treatment parameters, and functional outcome in a group of 38 consecutive patients referred to the authors' hospital with persistent extraarticular diffuse pigmented villonodular synovitis of the knee after arthroscopic synovectomy. There were 23 males and 15 females with an average age of 31.7 years (range, 11-65 years) at the time of arthroscopy. All had an average of 1.7 (range, 1-5) arthroscopies. Thirty-four of 38 (89.5%) patients had some improvements of their symptoms after arthroscopic synovectomy, but all had worse symptoms and function at the latest followup of 3.63 years (range, 0.25-19.5 years). Although arthroscopic synovectomy offered some short-term relief, a critical review of prior reports and the data in the current study suggest poor outcomes in patients who have extraarticular diffuse pigmented villonodular synovitis of the knee after arthroscopic synovectomy. Magnetic resonance imaging is recommended for accurate staging of the disease and for long-term followup after arthroscopic treatment.

The anteroposterior (AP) and medial-lateral (ML) dimensions of 200 consecutive osteoarthritic knees (100 males and 100 females) undergoing unilateral primary total knee arthroplasty were compared. For all patients, the mean AP dimension was 57.3 mm (range: 49-66 mm) and the dimension was 10.5% taller in height in men than women. The mean ML dimension was 71.6 mm (range: 56-85 mm), and the dimension was 13.7% wider in men than women. The mean AP/ML ratio was 0.8 for all patients, 0.82 (range: 0.73-0.93) for females and 0.79 (range: 0.70-0.89) for males (P.001). The data suggest that for any given AP femoral dimension, women tend to have a narrower ML dimension than men, independent of AP height, and an AP/ML ratio of 0.80 most closely approximates a standard-sized distal femur across gender. This report documents important gender differences that may serve as a reference for femoral implant designers and knee surgeons.

Flexor tenosynovitis complicating meningococcal septic polyarthritis may be sterile and could be misdiagnosed as disseminated gonococcal infection. Awareness of clinical findings associated with meningococcal polyarthritis is recommended to prevent onset of fulminant meningococcemia (Waterhouse-Friderichsen syndrome).