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Low-level laser therapy (LLLT) has been actively used for nearly 40 yr, during which time it has been known to reduce pain, inflammation, and edema. It also has the ability to promote healing of wounds, including deep tissues and nerves, and prevent tissue damage through cell death. Much of the landmark research was done by the National Aeronautics and Space Administration (NASA), and these studies provided a springboard for many additional basic science studies. Few current clinical studies in orthopaedics have been performed, yet only in the past few years have basic science studies outlined the mechanisms of the effect of LLLT on the cell and subsequently the organism. This article reviews the basic science of LLLT, gives a historical perspective, and explains how it works, exposes the controversies and complications, and shows the new immediately applicable information in orthopaedics.

Pain is the most common reason for physician consultation in the United States. One out of three Americans is affected by chronic pain annually. The number one reason for missed work or school days is musculoskeletal pain. Currently accepted therapies consist of non-steroidal anti-inflammatory drugs, steroid injections, opiate pain medications and surgery, each of which carries their own specific risk profiles. What is needed are effective treatments for pain which have an acceptably low risk-profile. For over forty years, low level laser (light) therapy (LLLT) and LED (light emitting diode) therapy (also known as photobiomodulation) has been shown to reduce inflammation and edema, induce analgesia, and promote healing in a range of musculoskeletal pathologies. The purpose of this paper is to review the use of LLLT for pain, the biochemical mechanisms of action, the dose response curves, and how LLLT may be employed by orthopedic surgeons to improve outcomes and reduce adverse events. With the predicted epidemic of chronic pain in developed countries, it is imperative to validate cost-effective and safe techniques for managing painful conditions which would allow people to live active and productive lives. Moreover the acceptance of LLLT (which is currently being used by many specialties around the world) into the armamentarium of the American health care provider would allow for additional treatment options for patients. A new cost-effective therapy for pain could elevate quality of life while reducing financial strains.

Attainment of successful lumbar fusion in adults with spondylolisthesis has historically been unpredictable. Recent results and conclusions have been conflicting regarding the role of instrumentation in improving the fusion rate and clinical outcome in this patient population. In a retrospective multicenter clinical study, we assessed the outcome of 42 adults with spondylolisthesis who underwent posterolateral lumbar fusion by using pedicular instrumentation with AO DC plates. No attempt was made to reduce slippage. Follow-up clinical outcome was obtained from a patient questionnaire administered and assessed by an independent reviewer. Fusion status was assessed by anteroposterior, lateral, and oblique radiographs at the most recent follow-up examination. Spondylolisthesis was classified as degenerative in 21 patients and isthmic in 21 patients. Solid fusion was achieved in 32 (76%) patients; pseudoarthrosis occurred in two (5%) patients; the fusion mass was indeterminate in eight (19%) patients. Clinical outcome parameters rated 73% excellent to good and 27% fair to poor. Complications included four infections and two screw breakages. Poor results correlated strongly with cigarette smoking and multiple previous surgeries. In this study, fusion rate and clinical outcome were consistent with previous reports of adult spondylolisthesis. Rates of successful fusion varied according to the type of spondylolisthesis.

Acute unstable thoracic and lumbar spine fractures were treated with either Harrington rods and hooks, Luque rods with sublaminar wires, or A-O dynamic compression plates with pedicle screws. The results demonstrated failure of all three techniques to maintain the sagittal plane correction at 12 months' follow-up. Furthermore, in lumbar fractures, Harrington rods did not restore or maintain sagittal plane alignment as well as Luque rods or pedicle screws and plates. Lastly, the pedicle screw fixation system required a shorter segment fusion.

The past century has resulted in an explosion of knowledge centering around the basic pathophysiology of cervical spinal cord injury and treatment. We have gained significant ground in the fight for overcoming paralysis. In the next century, we must focus on continued and better educational programs for injury prevention, as well as molecular analysis of injury for reversal.

A series of 36 patients with 20 subtrochanteric fractures, 12 ipsilateral neck/shaft fractures, and five intertrochanteric fractures with shaft extension underwent closed intramedullary nailing with the Russell-Taylor reconstruction (RECON) nail. The average Injury Severity Score was 16, and seven of the fractures were open. All fractures were acute injuries, and all but one were treated within 24 hours of admission. Follow-up was obtained at three, six, nine, 12, and 24 months or until the fracture healed. The range of follow-up was one to three years. Complete follow-up was obtained in 33 of 36 patients. Union was achieved in all acute fractures. Shortening occurred in two cases and chondrolysis and avascular necrosis occurred in another patient. Excellent hip and knee range of motion were obtained except in a few cases of ipsilateral limb injuries. While many complex femoral shaft fractures can be treated successfully with first generation locking nails, this study demonstrates that second generation locking nails, such as the RECON nail, offer the added strength and design features necessary for more effective treatment of complex proximal and ipsilateral femoral neck/shaft fractures.

A multicenter study was undertaken to analyze postoperative wound infections after posterior spinal instrumentation and fusion. The infection rate of these procedures has been documented in multiple reports. From these results, a classification scheme was developed that can guide therapy and determine the populations at risk. The patients were categorized according to two parameters, the first being the severity or type of infection, and the second being the host response or physiologic classification of the patient. This classification scheme is based on the clinical staging system for adult osteomyelitis developed by Cierny. The severity of infection is divided into three groups. Group 1 is a single-organism infection, either superficial or deep. Group 2 is a multiple-organism, deep infection. Group 3 is multiple organisms with myonecrosis. The host response, likewise, is divided into three classes. Class A is a host with normal systemic defenses, metabolic capabilities, and vascularity. Class B patients demonstrate local or multiple systemic diseases, including cigarette smoking. Class C requires an immunocompromised or severely malnourished host. Our data have demonstrated that single organisms, Group 1, generally can be dealt with by single irrigation and debridement, and closure over suction drainage tubes without the use of an inflow-irrigation system. The Group 2 patients, with multiple organisms and deep infection, required an average of three irrigation debridements. They have a higher percentage of successful closures with closed inflow-outflow suction irrigation systems when compared to simple suction drainage systems without constant inflow irrigation. Multiple-organism infections with myonecrosis, Group 3, are exceedingly difficult to manage, and portend a poor outcome. Patients without normal host defenses, Classes B and C, are at high risk for developing postoperative wound infection. Specifically, this study demonstrated that cigarette smoking may be a significant risk factor.

A prospective investigation of internal fixation of acute thoracic and lumbar spine fractures using pedicle screws and dynamic compression plates was performed. This article details the results of 23 patients who were followed for an average of 20 months. The indications for the procedure were an unstable fracture--dislocation below the eighth thoracic vertebra or low lumbar fractures that would be difficult to treat with conventional spinal implants. The patients were divided into three groups based on the fracture pattern and the level of the fracture. Group I consisted of fracture--dislocation injuries at the thoracic level and thoracolumbar junction. Group II patients sustained lumbar fracture--dislocations, and Group III contained lumbar burst fractures. Sagittal and coronal angles as well as anterior and posterior vertebral body height were measured at the injury level preoperatively, postoperatively, and at 3-month intervals. Statistical analysis of these angles demonstrated that Group I and III patients had significant correction of their relative kyphotic deformity after surgery; however, there were no differences in kyphotic angle at the 3-month interval. Despite this eventual return to preoperative angles, all patients except one developed solid fusion. There was no increase in neurologic deficit. One patient developed an asymptomatic pseudarthrosis demonstrated by breakage of both plates through unfilled screw holes at the motion segment. Other complications included one wound infection, one case of arachnoiditis after an intradural bone fragment was excised, and one dural tear created by a Kirschner wire, which did not result in a neurologic deficit or a cerebrospinal fluid leak.(ABSTRACT TRUNCATED AT 250 WORDS)

Magnetic resonance imaging (MRI) provides a noninvasive method of monitoring the pathologic response to spinal cord injury. Specific MR signal intensity patterns appear to correlate with degrees of improvement in the neurologic status in spinal cord injury patients. Histologic correlation of two types of MR signal intensity patterns are confirmed in the current study using a rat animal model. Adult male Sprague-Dawley rats underwent spinal cord trauma at the midthoracic level using a weight-dropping technique. After laminectomy, 5- and 10-gm brass weights were dropped from designated heights onto a 0.1-gm impounder placed on the exposed dura. Animals allowed to regain consciousness demonstrated variable recovery of hind limb paraplegia. Magnetic resonance images were obtained from 2 hours to 1 week after injury using a 2-tesla MRI/spectrometer. Sacrifice under anesthesia was performed by perfusive fixation; spinal columns were excised en bloc, embedded, sectioned, and observed with the compound light microscope. Magnetic resonance axial images obtained during the time sequence after injury demonstrate a distinct correlation between MR signal intensity patterns and the histologic appearance of the spinal cord. Magnetic resonance imaging delineates the pathologic processes resulting from acute spinal cord injury and can be used to differentiate the type of injury and prognosis.

The current study examined the medical and economic impact of various treatment modalities of unstable cervical spine dislocations. Thirty-five patients with dislocations of the cervical spine were reviewed retrospectively from two large university hospitals. There were 23 unilateral and 12 bilateral facet dislocations. Fourteen patients were treated nonoperatively and 21 patients were treated with early surgery. Nine of the 14 patients treated nonoperatively redisplaced their dislocations while in an orthosis and required late surgery. Analysis of variance shows that it is the amount of injury (unilateral versus bilateral) that results in statistically significant difference in the injury severity score, Glasgow coma scale, trauma motor index, and the number of complications. Of the treatment groups (operative versus nonoperative), the operative group showed a statistically significant difference in the length of hospital stay. Also noted in the operative group was less traction time, earlier erect physical therapy, an average financial savings of $18,407.00, and equal morbidity or mortality to the nonoperative treatment group. Based on this limited experience, it would appear that "diagnosis related groups" are not capable of supporting traumatic spinal care and, if adopted by other states and third party payers, the concept of trauma and/or spinal cord injury centers may be in jeopardy.

Magnetic resonance imaging (MRI) was performed on 37 patients with acute spinal injury using T1- and T2-weighted images. Three different types of MRI signal patterns were detected in association with these spinal cord injuries. A classification was developed using these three patterns. Type I, seen in ten (27.0%) of the patients, demonstrated a decreased signal intensity consistent with acute intraspinal hemorrhage. Type II, seen in 16 (43.2%) of the patients, demonstrated a bright signal intensity consistent with acute cord edema. Type III, seen in three (8.1%) of the patients, demonstrated a mixed signal of hypointensity centrally and hyperintensity peripherally consistent with contusion. The remaining eight patients had normal cords by MRI. All 37 patients had an admitting neurologic assessment and classification of their spinal injury according to the Frankel classification and the Trauma Motor Index (TMI). At an average of 12.1 months postinjury, their neurologic function was reassessed. Patients with Type I patterns showed no improvement in their Frankel classification and minimal improvement in their TMI, 32.1 to 42.4. In comparison, all of the Type II and III patterns improved at least one Frankel classification. The Type II TMI increased from 70.8 to 91.9 and Type III from 37.3 to 75.7. This preliminary report indicates a distinct correlation between the pattern of spinal cord injury as identified by MRI and neurologic recovery. It appears that the ability of MRI to aid in examination of the condition of the spinal cord will offer a means of predicting neurologic recovery following acute spinal cord injury.

Posterior hip dislocation associated with acute injury to the thoracic aorta is a previously unrecognized injury complex. This study reveals that 8% of patients with posterior hip dislocation have associated injury to the thoracic aorta because of abrupt deceleration injuries. This study defines the association of traumatic posterior hip dislocation and acute traumatic injury of the thoracic aorta, describes the mechanism of injury, and discusses the evaluation of a patient with a suspected acute traumatic aortic injury.

Modern methods of open fracture management, skeletal fixation, and soft-tissue and bone reconstruction have dramatically improved the potential for limb salvage. The absence of adequate objective parameters on which to base the decision for salvage results in delayed amputations in many cases. The present study was undertaken to review the medical and economic impact of delayed versus primary amputations following severe open fractures of the tibia. From January 1980 to August 1986, 263 patients with grade III open tibia fractures were treated at a major trauma center: 43 ultimately had amputations. This group included 38 males and five females with an average age of 31 years (range, 15-73). All patients were taken to the operating suite for consideration of limb salvage procedures including debridement, fasciotomy, revascularization, or rigid fixation. The standard subjective criteria including color, consistency, bleeding, and contractility were used to determine muscle viability at the time of debridement. If substantial muscle mass was found to be nonviable then amputation was considered. Fourteen (32.6%) of the patients had primary amputations. They averaged 22.3 days hospitalization, 1.6 surgical procedures to the involved lower extremity, and $28,964 hospital costs (range, $5,344-$81,282). The 29 patients with delayed amputations had an average of 53.4 days hospitalization, 6.9 surgical procedures, and $53,462 hospital costs (range, $14,574-$102,434). Six (20.7%) of the delayed amputation patients developed sepsis secondary to their involved lower extremity and died; no patient in the primary amputation group developed sepsis or died.(ABSTRACT TRUNCATED AT 250 WORDS)

Of 2023 patients treated for acute spinal injuries, 729 sustained acute injuries in thoracic and lumbar regions; 295 surgically treated patients were reviewed for evidence of postoperative neurological complications. Of the 295 patients, 150 were intraoperatively monitored using somatosensory-evoked potentials (SSEP). Six patients (4%) revealed intraoperative deterioration of the SSEP; however, only one of the six revealed a new postoperative neurological deficit (0.7%). The remaining 145 patients were included in the unmonitored or wake-up test group in which ten (6.9%) demonstrated new postoperative deficits. Of the 11 patients with new postoperative neurological deficits, eight patients demonstrated motor weakness, two had radiculopathy, and one had bowel-bladder incontinence. The intraoperative use of SSEP was not able to identify subtle alterations in neurological function; however, due to early warning, SSEP appears capable of preventing profound surgically induced neurological alterations. A new protocol is designed for the management of intraoperative neurological deterioration as detected by SSEP.

Forty-three magnetic resonance studies were performed on 28 patients with suspected spinal cord injury using a 1.5 Tesla magnet and surface coils. Imaging was performed between day 1 and day 16 post injury. In several patients, repeat magnetic resonance studies were performed to evaluate the resolution of the cord lesions. Three types of magnetic resonance signal patterns were seen in association with the cord injuries. Patients with intraspinal hemorrhage did not have significant neurological recovery, whereas patients with cord edema/contusion recovered significant neurological function. Magnetic resonance imaging appears to be useful in the diagnosis of acute cord injury and also appears to demonstrate the potential for predicting neurological recovery.

Thirty-seven magnetic resonance (MR) imaging studies were performed with a 1.5-T magnet and surface coils in 27 patients with suspected spinal cord injuries. Imaging was performed 1 day to 6 weeks after injury. Cord abnormalities were seen with MR in 19 patients, while skeletal and/or ligamentous injuries were seen in 21 (78%). Three types of MR signal patterns were seen in association with cord injuries. Acute intraspinal hemorrhage was seen in five patients with cord injuries and demonstrated decreased signal intensity on T2-weighted images obtained within 24 hours of injury. Cord edema and contusion had high signal intensity on T2-weighted images and were observed in 12 cases with cord injury. Neurologic recovery, determined in 16 patients, was insignificant in patients with intraspinal hemorrhage; however, patients with cord edema or contusion recovered significant neurologic function. MR at 1.5 T is extremely useful in the diagnosis of acute cord injury and also demonstrates potential in predicting neurologic recovery.

This retrospective study surveys patients treated between 1960 and 1978 for slipped capital femoral epiphyses. The parameters reported are fusion time, blood replacement, hospitalization time, aseptic necrosis, cartilage necrosis, and complications. Twenty-eight hips (24 patients) were treated by pinning, and three hips (three patients) were treated by Smith-Petersen nails. The Heyman or Howorth bone pegging procedures were performed in 48 hips in 41 patients. The average fusion time was 9.4 months for hips treated with Knowles pins, 3.7 months for Hagie or Tachdjian pins, and 4.8 months for bone pegging procedures. Blood loss, hospitalization time, surgical scars, and duration of anesthesia were greater for the bone pegging procedures.

Intradural disc herniation of an intervertebral disc is a rare occurrence. The clinical presentation varies in severity and a high level of suspicion is necessary to determine the diagnosis. This is a case report of an intradural disc herniation in a young male. A review of the literature identifying the pathophysiologic mechanisms of intradural disc herniation, diagnostic imaging techniques, and treatment is presented.

A case of thoracic chordoma successfully treated with surgical excision is reported and described. Thoracic chordomata presenting as posterior superior mediastinal tumors occur infrequently and may be highly malignant lesions. Early radical surgery through thoracotomy provide the best hope of cure, and radiation offers only temporary regression of tumor.

An analysis of clinical characteristics and pelvic fracture management in a recent 5-year period is presented. Ninety-eight percent of pelvic fractures were the result of a motor vehicle accident, which included 61% auto-pedestrian accidents. Seventy-nine percent of patients sustained one or more major injuries while 21% sustained an isolated pelvic fracture. Head injury was the most common concomitant injury (23% of patients). Forty-six percent of patients required blood transfusions (mean 15.8 mL/kg). Forty-one (72%) patients were treated with bedrest. The remainder were treated with traction (5), spica cast immobilization (5), open reduction and internal fixation (4), or anterior external fixation (2). Overall mortality was 14%. In comparing nonsurvivors with survivors there were significant differences in Modified Injury Severity Scores and Glasgow Coma Scores. The types of pelvic fractures that occur in children were found to be similar to those of adults. There was no significant difference in mortality among children with different types of pelvic fractures. In contrast to adults, pelvic fracture hemorrhage was not a major contributing cause of death in this series of patients. All eight deaths were secondary to severe closed head injury.

A biomechanical analysis of cervical distraction is presented, and a model comparing closed reduction of cervical spine dislocations to spring mechanics is developed. Behavior of a spring may be described as F = k delta x where F = distraction force; delta x = elongation of the spring; and k = spring constant. The records and roentgenograms of 24 cervical spine dislocations were reviewed retrospectively. Evaluation of cervical distraction vs traction weight indicates that Ftraction = kneck delta x; where F = traction weight and x = distraction at the injured level. The constant, kneck, is different for bilateral and unilateral dislocations (P less than .001) and is a function of magnitude of injury and neck morphology. As determined in this study, traction weight needed for reduction of facet dislocations may be estimated using the formulae: Ftx = 107.1 lbs/cm (x) unilateral, and Ftx = 76.4 lbs/cm (x) bilateral.

Thirty-seven patients with fractures of the thoracic or lumbar spine underwent anterior corpectomy (partial or complete) and vertebral body replacement for either destructive lesions from tumor or infection (13 patients) or trauma (24 patients). The vertebral bodies were replaced using either rib (12 patients) or tricortical iliac crest (25 patients) autografts. The Dunn device was utilized in conjunction with the autografts in 19 patients. Posterior stabilization was used in five patients; three prior to anterior stabilization and two after anterior stabilization. Within 2 weeks of the operative procedure, all patients began walking or sitting. Of the 37 patients, 21 with incomplete neurologic deficits improved, and 10 of those went onto complete recovery. Of the 27 patients who have been followed for a minimum of 1 year, 25 have obtained solid fusions, one developed a pseudarthrosis that required regrafting, and one had a delayed union prior to death from metastatic disease. There were two deaths in the immediate postoperative period and three deaths in the first six postoperative wounds due to metastatic disease. The purpose of this study is to present a consecutive series of patients who have undergone corpectomy and vertebral body replacement as well as to define the adequacy of stabilization.

Between July 1979 and July 1983, 24 patients with cervical facet dislocations were treated. There were 11 unilateral and 13 bilateral facet dislocations. The treatment consisted of axial skeletal tractions, Stryker frame, Gardner-Wells tongs, and judicious manipulation. Cadaver studies were important for learning the anatomy and principles of cervical manipulation. Seventeen (71%) of the 24 patients were reduced successfully by a closed method without any progression of neurologic deficit or facet fracture. Seven (29%) of the 24 patients could not be reduced closed. Ninety percent (9 of 10) of incomplete spinal cord injuries improved when evaluated by the Frankel classification at least one grade. The program of treatment proved to be safe and effective in achieving closed reduction of either unilateral or bilateral facet dislocations.

Records of 52 polytraumatized patients with closed pelvic fractures were reviewed retrospectively to determine if spica cast application decreased mortality due to exsanguination. Twelve patients had supplemental stabilization with external fixators or internal fixation of the pelvis. Their results indicated that the spica cast is effective in decreasing or controlling bleeding since no patient died of exsanguination. Several patients did die, however, but the cause of death in these patients was usually adult respiratory distress syndrome with or without other sepsis. Injury severity score, age, hypotension, and platelet count were found to be prognostic indicators for both transfusion requirements and mortality. A spica cast may be a useful adjunctive method for decreasing blood loss in the immediate postinjury period, but prolonged or improper use may lead to additional complications and death.