Inadequate Fracture Reduction Research Articles

What makes fixation of femoral neck fractures fail? A systematic review and meta-analysis of risk factors

IntroductionThis systematic review aims to provide an overview of predictors for failure of treatment of displaced femoral neck fracture (dFNF) with internal fixation and quantify their risk of fixation failure in a meta-analysis. Patients and methodsPubMed, Embase, Web of Science, Cochrane Library, and EMCare were searched for original studies published from January 2000, including adult patients with an internally fixated dFNF, that reported data on predictors for fixation failure defined as revision surgery due to non-union, avascular femoral head necrosis or cut-out of implant. RevMan version 5 software was used to pool univariable Odds Ratio's (OR) for predictors of fixation failure by means of a random effects model. ResultsThis review included 16 articles (15 articles cohort studies and one randomised trial). Twenty-four predictors for fixation failure were identified and analysed, 16 of which were evaluated in just one study. Data of 7 predictors were pooled in a meta-analysis. Female sex (OR 1.78, 95% confidence interval [CI] 1.26–2.52), smoking (OR 3.64, 95% CI 1.68–7.91), age >50 years (OR 3.64, 95% CI 1.68–7.91), inadequate fracture reduction (OR 2.28, 95% CI 1.62–3.22), fixation with cannulated screws (CS) or pins compared to fixed angle devices (OR 2.16, 95% CI 1.03–4.54) were identified as significant predictors for fixation failure. ConclusionThis study can help surgeons to choose the preferred treatment for patients with a dFNF and substantiate future algorithms and guidelines for treatment of FNF.

Investigation into the problems of Proximal Femoral Nails (PFN) in the management of intertrochanteric fractures

Aim: An investigation into the problems of proximal femoral nails in the management of intertrochanteric fractures. Methods: This research comprised 50 patients with intertrochanteric fractures who received intramedullary fixation with PFN. The limb was adducted and held in traction. Under C-arm guidance, the entry location was seen, and a guide wire was passed over the fracture site. To repair the fracture, a short PFN with proximal and distal locking was inserted under C-arm guidance. Results: There were 33 men and 17 women. In 28 cases, the right side was implicated, whereas the left side was engaged in 22 patient. The average period of follow-up was 13 months. Closed reduction was used in 40 patients, whereas open reduction was used in 10 patients. Complications occurred in 15 of 50 individuals. All were early issues, and the causes of failure were investigated. Complications include a broken nail at the distal locking screw level (2%), screw back out (2%), perioperative proximal femur fracture (4%), inadequate fracture reduction (2%), varus distortion (4%), improper positioning of the distal locking screw (2%), placement of a single screw in the neck (4%), abductor lurch (4%), and Infection on the surface (4%).

Tips and tricks to avoid implant failure in proximal femur fractures treated with cephalomedullary nails: a review of the literature.

Objective:To describe the surgical aspects potentially contributing to hardware failure of cephalomedullary nails.Data Sources:A search of the Embase, PubMed (MEDLINE), Web of Science, and the Cochrane library for reports of hardware failures after intramedullary fixation of proximal femur fractures. Issues of cut out and cut through phenomena related to technique were excluded. Expert opinion of 3 surgeons, each trained on several fixation systems at Level | trauma centers is reported.Data Extraction:Three authors extracted data using a predesigned form. Implant type, reported failure mechanism, and associated factors with implant failure were recorded as well as potential bias.Results:Of 2182 search results screened, 64 articles were deemed relevant for our research question and were included. The authors identified factors associated with implant failure: preoperative patient and fracture characteristics, intraoperative reduction, implant handling, and postoperative nonunion. Issues were identified as independent modifiable intraoperative risk factors: inadequate fracture reduction, varus position of femoral neck, direct damage of the cephalomedullary nail aperture by eccentric drilling related to guide sleeve handling, and implant design mechanism failures.Conclusions:Multiple factors associated with intraoperative handling can influence the healing of proximal femur fractures. Although many of these have been well described and are taught in fracture courses, surgeons should be aware of subtle intraoperative complications reported in the literature that can weaken implants and add to the likelihood of early failure.Level of Evidence: IV

Correction of Traumatic Transverse Mandibular Widening With Interdental Wiring.

Mandibular symphysis fractures pose several technical challenges for the craniomaxillofacial surgeon. One classic challenge is restoration of the transverse dimension when the mandible is widened secondary to splaying of the lingual cortex. Failure to diagnose or correct this problem can result in widening of the lower facial third, inadequate fracture reduction, and/or a malocclusion. Surgeons have traditionally utilized techniques such as manual pressure to the rami or lingual splint application to address transverse defects intraoperatively. However, these methods may be inadequate in situations with significant widening, such as in the case of concomitant subcondylar fractures. More recently, virtual surgical planning and custom hardware have been utilized to address mandibular widening, though this method also has various shortcomings. In this technical note, the authors present a simple technique using interdental wiring to precisely control mandibular width intraoperatively. The technique is cost effective, does not require an assistant, and can be used in conjunction with any of the above methods. The authors also present a case of secondary reconstruction in which use of this technique was necessary given a large degree of mandibular widening not amenable to reduction and fixation with manual pressure alone.

AOFAS Functional Scoring After Antegrade K Wires Fixation of Multiple Metatarsal Neck Fracture: A Case Report

Introduction & Objectives: Metatarsal Bone fractures contribute 3-7% of all fractures of the body, 35% of all fractures from the foot and also contribute 75 new cases per 10.000 persons per year. Another study evaluated the incidence involvement of multiple metatarsal fractures is higher than isolated metatarsal fractures. Metatarsal bone fractures mostly caused by low energy trauma, and also high energy trauma makes the incidence higher. The previous study said, that 43% of metatarsal fractures are the neck of the second and third metatarsal bones. Intramedullary fixation using Kirschner (K) wires has been chosen as a method of operative treatment for metatarsal bone. There are several outcome evaluation instruments for those who sustained a complex ankle or hindfoot injury. Among them, The American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score is commonly chosen by orthopedics for a quantitative and objective measurement. This study wants to evaluate the results obtained through AOFAS Scoring for fractures of the metatarsal neck, represent the clinical and functional results after K-wire management in surgery.Case Report: A 35-year-old man has admitted to the ER with a chief complain of a painful right hindfoot. Previously, a brick fell upon his hind foot while he was working to repair a wall with nothing to protect his hind foot. In our case, direct trauma due to falling object upon of his dorsal hindfoot caused neck fractures of 2nd - 4thmetatarsal bones, which had confirmed by X-Ray photos. His hind foot had been swelling and his fingers were barely able to do flexion and extension. We waited until the edema regresses for the surgery, in order to reduce the risk of developing compartment syndrome. In our case, we delayed surgery for 2 days. An antegrade K wires fixation is achieved by using antegrade wire insertion at the fracture site followed by retrograde fixation of the proximal fragment with the same wire. We have been following the patient from the beginning until 6 months after the K Wires fixation surgery in an outpatient clinic, and also the patient was kept no-weight-bearing within 2 months.Results & Discussion: In 2 months after the surgery, we did the X-Ray and it showed a callus formation. Then we expelled the K wires. We prospectively evaluated the outcome trough the AOFAS score and the score was 95 in the 6th month of the evaluation. We chose antegrade introduction of the K Wires for the best outcome, prevent a high rate of complications related to this type of treatment, minimize soft tissue insult to avoid the unsatisfactory outcome. When metatarsal bone fracture happened and did more than 10 degrees of angulation, it could make a disturbance of load distribution under metatarsal head that leads to mechanical metatarsalgia. Besides, it can also produce painful calluses and traumatic neuroma formation lead to painful trauma and then disturb a function of the lower limb. The antegrade approach prevents plantar displacement of the distal metatarsal fragment during K-wire insertion continues with an exteriorization by the retrograde manner of the wire in the plantar region. The study said that no complications were identified related to using the type of treatment. Another study said that a patient treated by a percutaneous antegrade surgical approach, had higher AOFAS scores, averaging more than 95 points within the 6th-month postoperative period. Inadequate fracture reduction, failure of fixation and pin-site infection could lower the AOFAS Score.Thus Percutaneous antegrade surgical treatment is an effective treatment for metatarsal fractures, with a lower incidence of complications.Conclusions: A metatarsal bone fracture that not treated properly can lead to changes in gait and foot load distribution, as it would decrease the point of AOFAS Score evaluation. We expect that the AOFAS Ankle-Hindfoot Score could give an objective quantitative scoring for the patients’ foot function, not only after the trauma but also after the surgery. A proper diagnosis and management of this fracture result in a good prognosis and low complication rates, presented by higher AOFAS Score.

A study protocol for a randomised controlled trial evaluating the effects of intraoperative computed tomography on the outcomes of zygomatic fractures

BackgroundZygomaticomaxillary complex (ZMC) and zygomatic arch (ZA) fractures are common injuries resulting from facial trauma and frequently require surgical management (Huang et al., Craniomaxillofac Trauma Reconstr 8(4):271-6, 2015). A substantial number of post-operative functional and cosmetic complications can arise from the surgical management of these fractures. These include scarring, inadequate facial profile restoration, facial asymmetries and diplopia (Ellis et al. J Oral Maxillofac Surg 54(4):386-400, 1996; Yang et al. Oral Maxillofac Surg Clin North Am 23(1):31-45, 2011; Kloss et al. Int J Oral Maxillofac Surg 40(1):33-7, 2011). Intuitively, most of these aforementioned complications arise as a result of inadequate fracture reduction; however, current standard practice is to assess reduction post-operatively through plain radiographs or computed tomography (CT) scans. The role of intra-operative CT scanning to assess the reduction of ZMC/ZA fractures and the potential impact on complications, has thus far not been established.MethodsThis is a prospective randomised controlled trial currently being undertaken at the Royal Brisbane and Women’s Hospital. All patients who require operative management of their ZMC or ZA fractures are offered enrollment in the trial. The patients are randomised into two groups: interventional (intra-operative CT) and control (no intra-operative CT). All patients in each group will have post-operative radiographs taken. From these radiographs, the reduction of the ZMC and/or ZA fracture is graded by a blinded assessor. Patients will be reviewed in clinic at 1 week and 6 weeks post-surgery. During these consultations, all patients will be assessed for scarring, diplopia, facial profile restoration and need for revision surgery.DiscussionMany complications associated with surgical management of ZMC and ZA fractures involve poor aesthetic results as a direct consequence of inadequate fracture reduction. Inadequate fracture reduction is predictable given that small incisions are used and only limited visualisation of the fractures is possible during the procedure. This is due to a desire to limit scarring and reduce the risk of damage to vital structures in an aesthetically sensitive region of the body. It follows that an intraoperative adjunctive tool such as a CT scan, which can assist in visualisation of the fractures and the subsequent reduction, could potentially improve reduction and reduce complications.Trial registrationAustralian New Zealand Clinical Trials Registry, ACTRN12616000693426. Registered on 26 May 2016.

A comparative study of rate of fracture union in femur neck fractures- operated within 24 hours and after 24 hours and within 7 days, effect of tamponade on rate of union in cases fixed with cannulated cancellous screws

Background: Osteosynthesis of femoral neck fractures is particularly indicated in patients aged under 60years. A prolonged interval between the fracture and surgical fixation has been associated with avascular necrosis (AVN) of the femoral head. The primary objective of this study was to evaluate the association between the time to surgery and the rate of union in femur neck fractures.Methods: Patients with displaced fractures of the femoral neck (Garden III or IV) who underwent fixation with cannulated screws from August 2016 to August 2018 were evaluated retrospectively for the rate of union in femoral neck fractures.Patients were divided into two groups according to the time to surgery (within 24 hours and within 7days after 24 hours). Union rates were compared between the two groups.Results: 50 patients were included in the study; the duration of follow-up ranged from 12 to 24 months. The time from fracture to surgery ranged from 24 hours to 7 days. Fourty nine patients underwent surgery within 24 hours, and fourty eight patients underwent surgery within 7 days. There were two cases of femoral head necrosis. One patient had an associated infection. There were no statistically significant differences in the overall rate of union between the groups (p=0.999). None of the preoperative parameters or fracture characteristics were predictive factors for union. The only factor which affects the rate of union is inadequate reduction/fixation(odds ratio [OR]= 35.50, 95% confidence interval [CI]= 2.56 to 548.36, p=0.008).Conclusions: The interval between the occurrence of the injury and surgical fixation is not associated with rate of union in fractures of the femoral neck. Inadequate fracture reduction is a predictive factor in rate of union in femur neck fractures fixed with CC screws.

Optimizing Long-Term Outcomes and Avoiding Failure With the Fibula Intramedullary Nail.

To identify risk factors for fixation failure, report patient outcomes, and advise on modifications to the surgical technique for fibula nail stabilization of unstable ankle fractures. Retrospective review. Academic orthopaedic trauma unit. All 342 patients were identified retrospectively from a prospectively collected single-center trauma database over a 9-year period. Unstable ankle fractures managed surgically with a fibula nail. The primary short-term outcome was failure, defined as any case that required revision surgery because of an inadequate mechanical construct. The mid-term outcomes included the Olerud-Molander Ankle Score and the Manchester-Oxford Foot Questionnaire. Twenty failures occurred (6%), of which 7 (2%) were due to device failure and 13 (4%) due to surgeon error. Of the surgeon errors, 8 consisted of inappropriate weight-bearing after syndesmotic diastasis, and 5 were due to inadequate fracture reduction or poor nail placement. Proximal locking screw (PLS) pull-out was the cause of all device failures. Positioning the PLS >20 mm above the plafond significantly increased failure risk (P = 0.003). At a mean follow-up of 5.1 years (range, 8 months-8 years) the median Olerud-Molander Ankle Score and Manchester-Oxford Foot Questionnaire were 80 (interquartile range, 45) and 10.94 (interquartile range, 44.00), respectively. Patient outcome was not negatively affected by the requirement for revision surgery. The fibula nail offers secure fixation and good patient-reported outcomes for unstable ankle fractures. Appropriate postoperative management and surgical technique, including careful placement of the PLS, is essential to minimize construct failure risk. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Three-dimensional Intraoperative Imaging Modalities in Orthopaedic Surgery: A Narrative Review.

Intraoperative imaging and navigation systems have revolutionized orthopaedic surgery for the spine, joints, and orthopaedic trauma. Imaging modalities such as the isocentric C-arm, O-arm imaging, and intraoperative MRI or navigation systems allow the visualization of surgical instruments and implants relative to a three-dimensional CT image or MRI. Studies show that these technologies lower the rates of implant misplacement and inadequate fracture reduction, thereby improving surgical outcomes and reducing reoperation rates. An additional benefit is reduced radiation exposure compared with that for conventional fluoroscopy. Concerns surrounding adoption of these technologies include cost and increased operating times, but improvements in design and protocol may improve the integration of these imaging modalities into the operating room.

Management of neglected acetabular fractures.

Management of neglected acetabular fractures is a difficult task. Osteosynthesis in such cases may not be an ideal solution because of the femoral head damage due to pressure by the fractured acetabular edge, avascular necrosis, difficulty in mobilizing the fragments due to callus formation, difficulty in indirect reduction of the fracture fragments and macerated acetabular fragments all contributing to inadequate fracture reduction. Majority of such fractures are now treated with total hip replacement. While treating such fractures with THR, problems associated with neglected acetabular fractures such as fracture non-union, hip dislocation, protrusio, cavitary bone defect or peripheral bone defect must be considered. 3D computed tomography scan provides a clear view about the acetabular and periacetabular bony anatomy. Impaction grafting and antiprotrusio cage or ring with a cemented acetabular cup can address most of the hip protrusio and cavitary bone defects. Segmental bone defect needs cortical strut-bone graft fixation and subsequent implantation of a cemented or uncemented acetabular cup implantation. Fracture non-union needs approximate reduction and fixation with plates followed by bone grafting and implantation of an acetabular cup. Despite these efforts, the outcome of THR in neglected acetabular fracture is considerable worse than after conventional hip replacement.

Influence of time to surgery on the incidence of complications in femoral neck fracture treated with cannulated screws

BackgroundOsteosynthesis of femoral neck fractures is particularly indicated in patients aged under 60 years. A prolonged interval between the fracture and surgical fixation has been associated with avascular necrosis (AVN) of the femoral head. The primary objective of this study was to evaluate the association between the time to surgery and the development of complications in patients with femoral neck fractures. MethodsPatients with displaced fractures of the femoral neck (Garden III or IV) who underwent fixation with three cannulated screws in the inverted triangle configuration from January 2009 to December 2010 were evaluated retrospectively for the development of orthopaedic complications. Patients were divided into two groups according to the time to surgery (within 7 days or more than 7 days). Complication rates were compared between the two groups. Regression analyses were performed to assess the risk factors for complications. ResultsThirty-one patients were included in the study; the duration of follow-up ranged from 24 to 50 months. The time from fracture to surgery ranged from 3 to 18 days. Fifteen patients underwent surgery within 7 days, and 16 patients underwent surgery after 7 days. There were four cases of femoral head necrosis. One patient had an associated infection; one patient experienced non-union, and another demonstrated osteosynthesis failure. There were no statistically significant differences in the overall rate of complications between the groups (p = 0.999). None of the preoperative parameters or fracture characteristics were predictive factors for complications. The only factor associated with the development of complications was inadequate fracture reduction in the anteroposterior (AP) view (odds ratio [OR] = 35.50, 95% confidence interval [CI] = 2.56 to 548.36, p = 0.008). ConclusionsThe interval between the occurrence of the injury and surgical fixation is not associated with the development of complications in fractures of the femoral neck. Inadequate fracture reduction in the AP view is a predictive factor for complications in these fractures.

Use of Cryoablation and Osteoplasty Reinforced with Kirschner Wires in the Treatment of Femoral Metastasis

We report the case of a 43-year-old man with metastatic breast carcinoma to the proximal right femur resulting in severe painful pathological fracture. The patient experienced severe pain despite large doses of analgesia, resulting in impaired functionality and quality of life. The patient had significant comorbidities, making him a high surgical risk. The patient was treated with cryoablation and osteoplasty, followed by a novel technique consisting of osteoplasty reinforced with bone marrow Kirschner wires (K-wires) which will be described in details in this report. The patient reported significant pain relief after the procedure, and gained right lower extremity functionality, as compared to total immobility before the procedure. Our technique offers an alternative feasible treatment for patients at high surgical risk with pathological fractures in weight-bearing bones, in which osteoplasty alone has a high risk of cement leakage, inadequate fracture reduction, and early refracture. To our knowledge, our technique has not been previously described.

Hematic Cyst in a Barrier-Covered Porous Polyethylene/Titanium Mesh Orbital Floor Implant

Hematic cyst formation after placement of nonporous alloplastic orbital floor implants is well described. A benefit of porous polyethylene is fibrovascular ingrowth without capsular formation. This ingrowth inhibits hematic cyst formation. In the case presented here, a hematic cyst developed on a screw-fixated porous polyethylene/titanium mesh implant (Medpor Titan B-T-M, Porex Surgical, Newnan, GA, U.S.A.). The risk factor for this patient was the nonporous barrier surface of the implant and inadequate fracture reduction. Proper surgical technique, including implant sizing, placement, and fixation, are factors reported to prevent hematic cyst formation. This patient's symptoms resolved after removal of the implant and cyst and replacement of the orbital implant.

Painful Pathologic Fracture of the Humerus: Percutaneous Osteoplasty With Bone Marrow Nails Under Hybrid Computed Tomography and Fluoroscopic Guidance

A case of a 75-year-old patient with a painful pathologic humeral shaft fracture, with unacceptably high surgical risk and unsatisfactory analgesia is reported. In this case, impaired arm function and persistent pain with conservative management resulted in a poor quality of life. Palliation with image-guided percutaneous osteoplasty was considered. Because of potential cement leakage, inadequate fracture reduction, the site of the fracture, and the mobility of the joints in that area, image-guided percutaneous delivery of metallic bone marrow nails implanted together with polymethyl methacrylate (PMMA) osteoplasty was performed. This procedure achieved humeral shaft stabilization, bone fragment alignment, fracture reduction, and pain relief.

Epidemiological analysis of orthognathic surgery in a hospital in Curitiba, Brazil: Review of 195 cases

Objective The present retrospective study explored the spectrum and characteristics of patients treated with orthognathic surgery at the Universidade Federal do Paraná, Brazil. Materials and method Over a six-year period from July 2002 to July 2008, the records of 195 patients with dentofacial deformities who underwent orthognathic surgical procedures were followed up. Results Mean patient age was 25.87 years (range 14 to 65 years) and the female to male ratio was 1.5:1. The predominant racial group was “white”. Most patients belonged to the economically productive population. Sixty-two patients had complete dentition. Only 3.59% patients had local anesthesia (rapid palatal expansion). Transverse maxillary deficiency was the most common deformity, followed by maxillary anteroposterior deficiency associated with mandibular anteroposterior excess. Mandibular set-back was the intervention most frequently performed. The surgical procedures took an average of 3 hours 51 minutes and orthodontic treatments took an average of 44.48 months. Complications occurred in 22.57% of patients, the most common of which were permanent paresthesia of the lower lip (7.17%) and inadequate fracture reduction (5.12%). Conclusions The findings included concepts that were useful for characterizing the profile of patients who undergo orthognathic surgery in southern Brazil. The results also may help to correctly develop protocols for patient care designed to improve the overall results of the procedures.

Controlled Segmental Balloon Kyphoplasy

Case series. To describe a novel kyphoplasty procedure that gives uniform bone expansion in treatment of vertebra with heterogeneous bone structure. Balloon kyphoplasty is used to treat vertebral compression fractures by restoring vertebral height and correcting kyphosis before the injection of bone cement that stabilizes the fracture. In vertebra with heterogeneous bone structure, balloon expansion may be nonuniformly as a result of this heterogeneity and could result in inadequate fracture reduction. In the first part of the procedure, the balloon remains partially in its introducer trocar to inflate only the distal segment of balloon in the stronger bone area that provides high mechanical resistance. This segmental inflation creates a cavity that will allow to initiate fracture reduction in the stronger bone area. In the second part of the procedure, the emerging segment is deflated and the balloon is advanced until it emerges completely from the introducer trocar, after which the balloon is inflated totally in the vertebral body. Seven vertebrae in 5 patients (mean age of 71.4 years) were managed with this procedure. Etiology of fractures included myeloma (2 patients, 4 vertebrae) and senile osteoporosis (3 patients, 3 vertebrae). Twenty-millimeter long kyphoplasty balloons were used in all vertebrae. Polyméthylmetacrylate bone cement was used to fill the cavities. Technical, anatomic and clinical parameters were used for evaluation of the procedure. No complications occurred on balloon inflation. Mean volume of cement injected was 5.8 mL (range, 5-6 mL). Mean maximal inflation pressure was 200 PSI (range, 150-300 PSI). One (14.8%) cement leak was observed at 1 vertebra. Mean restoration of maximal lost height was 42.8% (range, 25%-52.9%). Mean reduction in local kyphosis was 4.4 degrees (range, 0-10 degrees ). All 5 patients were pain free at 1 month post procedure. Morbidity and mortality were nil. The described procedure allows for uniform bone expansion and adequate fracture reduction in vertebrae with heterogeneous bone structure.

Complications after Intramedullary Stabilization of Proximal Femur Fractures: a Retrospective Analysis of 178 Patients.

Secondary dislocation, non-union, re-fracture and implant failure are generally known complications after intramedullary fixation of proximal femur fractures with the PFN(®) (Synthes GmbH, Solothurn, Switzerland). The goal of our study was to assess the impact of patient- and treatment-specific risk factors on these complications. Complex fracture type and poor bone quality were defined as patient-specific risk factors. Inadequate fracture reduction and implant position were defined as treatment-specific risk factors. One hundred and seventy-eight cases were retrospectively analyzed. All patients had at least one clinical and radiological follow-up examination 3-6 months after the operation. Fifty percent of the patients were available for one more follow-up at least 1 year after the operation. All patients without patient-specific risk factors had a good outcome, irrespective of whether treatmentspecific risk factors were present or absent. In 153 of the 178 cases, patients had a complex type of fracture and/or poor bone quality. Of these patients, 27 (15.2%) had a poor result. Twenty-four of these patients needed re-operation within 6 months. Complication rate in these patients highly depended on treatment-specific risk factors. We conclude that the PFN is a secure implant for the stabilization of simple cases. Stabilization of complex proximal femoral fractures with the PFN, however, has a relevant complication rate and should therefore be considered a challenge.

Management of acute odontoid fractures with single-screw anterior fixation.

Accepted management strategies for odontoid fractures include external immobilization and surgical stabilization using anterior or posterior approaches. Displaced Type II fractures and rostral Type III fractures are at high risk for nonunion. Anterior fixation of odontoid fractures with a single cortical lag screw is a relatively new technique that combines rigid internal stabilization with preservation of intrinsic C1-C2 motion. We retrospectively reviewed our series of 26 consecutive patients who underwent odontoid screw fixation, to further define the safety and efficacy of the technique. During a 5-year period, 26 patients presented with acute traumatic Type II odontoid fractures. Ten patients were female and 16 were male, with a mean age of 35 years. All patients underwent anterior odontoid screw fixation by the senior surgeon (RWH), within a mean of 3 days after injury. All patients were postoperatively maintained in external orthoses, for a mean of 7.2 weeks, and were monitored with serial clinical and radiographic examinations. With a mean follow-up period of 30 months, radiographic fusion was documented for 25 of 26 patients (96%). No complications related to the surgical approach were identified, and all patients remained in neurologically stable condition. Two complications (8%) were related to the instrumentation; one patient required external immobilization because of suboptimal screw placement, and one patient required posterior atlantoaxial arthrodesis because of inadequate fracture reduction. Single-screw anterior odontoid fixation was associated with a relatively low complication rate and a high fusion rate in this study. We think that this should be the preferred treatment method for acute Type II odontoid fractures.

The surgical one-stage management of combined Cranio-Maxillo-facial and frontobasal fractures: Advantages of the subcranial approach in 374 cases

The aim of this paper is to emphasize the advantages of a one-stage, step by step repair of facial skeletal injuries as well as the dural tears and lesions of the anterior fossa, by one and the same team. The methods described permit optimal reduction of the pseudohypertelorism and major displacements in severe combined craniofacial injuries. The simultaneous subcranial exposure of the entire basal region of the anterior fossa obviates the intracranial approach or frontal lobe retraction thus making early stage surgical management feasible. The surgical treatment of these injuries as a single entity, as well as further modifications reduce complications such as recurrent CSF leakage, anosmia, mucocoele or secondary operations for inadequate fracture reduction. The significance of primary meticulous reconstruction of the combined cranial vault and midface fractures for the achievement of normal physiological function of the various systems is particularly highlighted.