1/654. Transoral fusion with internal fixation in a displaced hangman's fracture. STUDY DESIGN: A case is reported in which late displacement of a "hangman's fracture" was managed by transoral C2-C3 fusion by using bicortical iliac crest graft and a titanium cervical locking plate. OBJECTIVES: To review the management of unstable fractures of the axis and to study other reports of transoral instrumentation of the cervical spine. SUMMARY OF BACKGROUND DATA: Undisplaced fractures of the axis are considered to be stable injuries. Although late displacement is unusual, it can lead to fracture nonunion with persisting instability and spinal cord dysfunction. In this situation, an anterior fusion of the second and third cervical vertebrae is preferred to a posterior fusion from the atlas to the third cervical vertebra, which would abolish lateral rotation between C1 and C2. methods: The literature on hangman's fractures was reviewed. Clinical and radiographic details of a case of C2 instability were recorded, and the particular problems posed by late displacement were considered. RESULTS: There are no other reports of transoral instrumentation of the cervical spine. A sound fusion of C2-C3 was obtained without infection or other complications. Good neck movement returned by 6 months after surgery. CONCLUSION: Undisplaced fractures of the axis are not always stable. The transoral route allows good access for stabilization of displaced hangman's fractures. In special circumstances, a locking plate may prove useful in securing the bone graft. The cervical spine locking plate can be inserted transorally with no complications and by using standard instrumentation. ( info) |
2/654. Spontaneous regression of periodontoid pannus mass in psoriatic atlantoaxial subluxation. Case report. STUDY DESIGN: A case report of a 41-year-old man with psoriasis who had cervical myelopathy caused by atlantoaxial subluxation and periodontoid pannus mass. OBJECTIVE: To describe the possible mechanism underlying the periodontoid pannus formation and the optimal treatment for such cases. SUMMARY OF BACKGROUND DATA: Atlantoaxial subluxation causing spinal cord compression at the craniocervical junction may develop in patients with rheumatoid or psoriatic arthritis. Periodontoid pannus formation plays an important role in compromising the anteroposterior diameter of the spinal canal and in causing neurologic deficits. Transoral transpharyngeal excision of the pannus is sometimes thought necessary for anterior decompression of the spinal cord. Spontaneous resolution of the periodontoid pannus after posterior atlantoaxial fusion and fixation has been documented in rheumatoid arthritis, but not in psoriatic arthritis. methods: The patient underwent posterior atlantoaxial fusion and Halifax fixation. RESULTS: The patient experienced clinical improvement. Regression of the periodontoid pannus mass was observed on magnetic resonance imaging. CONCLUSIONS: Posterior fusion and instrumentation resulted in spontaneous regression of the pannus mass and symptomatic relief. This report provides evidence that atlantoaxial instability may be the sine qua non for the formation of periodontoid pannus, and that amelioration of such instability leads to spontaneous resolution of the pannus mass. ( info) |
3/654. A clinico-pathological study of cervical myelopathy in rheumatoid arthritis: post-mortem analysis of two cases. Two patients who developed cervical myelopathy secondary to rheumatoid arthritis were analyzed post mortem. One patient had anterior atlanto-axial subluxation (AAS) combined with subaxial subluxation (SS), and the other had vertical subluxation (VS) combined with SS. In the patient with AAS, the posterior aspect of the spinal cord demonstrated severe constriction at the C2 segment, which arose from dynamic osseous compression by the C1 posterior arch. A histological cross-section of the spinal cord at the segment was characterized by distinct necrosis in the posterior white columns and the gray matter. In the patient with VS, the upper cervical cord and medulla oblongata showed angulation over the invaginated odontoid process, whereas no significant pathological changes were observed. At the level of SS, the spinal cord was pinched and compressed between the upper corner of the vertebral body and the lower edge of the lamina. Histologically, demyelination and gliosis were observed in the posterior and lateral white columns. ( info) |
4/654. Spontaneous or traumatic premature closure of the tibial tubercle. A premature closure of the physis of the tibial tubercle in a young man has given rise to a shortening of the tibia, a patella alta and a reversed tibial slope of 20 degrees with clinical genu recurvatum. After a proximal open wedge tibial osteotomy all three postural deformities could be restored. The etiology of this complex deformity is discussed. ( info) |
5/654. Anterolateral approach for cervical spinal cord tumors via an anterior microforaminotomy: technical note. A cervical spinal cord tumor located anteriorly to the spinal cord is conventionally approached through an anterior vertebrectomy followed by bone-graft reconstruction. In order to make a surgical approach minimally invasive, an anterior microforaminotomy technique is used for removal of a tumor located anterior to the spinal cord. When the senior author's experience increased with anterior microforaminotomy for cervical radiculopathy and myelopathy, it was observed that intradural pathology could also be taken care of through the anterior microforaminotomy which did not require bone fusion or postoperative immobilization. For tumor resection, the anterior foraminotomy is made like a flask-shaped hole, with a smaller outer opening similar to that for radiculopathy but incorporating a larger inner opening to accommodate the extent of the tumor in a longitudinal and transverse dimension. The surgical technique is described with two illustrated patients. Postoperatively, the patients did not require a cervical brace. Although their postoperative discomfort was minimal, they were kept in the hospital overnight postoperatively. Spinal stability was well maintained 6 weeks postoperatively. Postoperative imaging of the spine confirmed resection of the tumors. Anterior microforaminotomy is a minimally invasive microsurgical technique which can provide safe and successful removal of tumors located anteriorly to the spinal cord. ( info) |
| We studied the ultrastructural changes of the human anterior cruciate ligament (ACL) with transmission electron micrograph cross-sections following isolated posterior cruciate ligament (PCL) injury. biopsy specimens were obtained from the proximal third and anteromedial aspect of the ACL. Fourteen patients with PCL-deficient knees at a mean of 22.1 months from injury to surgery and 5 normal knees amputated secondary to malignant tumors or traumatic injuries were used as controls. A significant difference was found in the number of collagen fibrils per 1 microm2 between the PCL-deficient knee group and the control group. There was a significant difference found in the collagen fibril diameter between the PCL-deficient knee group and the control group. The collagen packing density (the percentage of sampled area occupied by collagen fibrils) was also significantly different between the PCL-deficient knee and the control group. The current study shows that an isolated PCL insufficiency can induce morphological changes in ACL collagen fibrils, suggesting that a PCL insufficiency can have adverse effects on other ligamentous structures in the knee joint. ( info) |
7/654. Treatment of unstable osteochondritis dissecans lesions of the knee using autogenous osteochondral grafts (mosaicplasty). Symptomatic osteochondritis dissecans lesions with minimal fragmentation that may be replaced within their crater have classically been treated by reattachment. The choice for internal fixation is varied. This article reports on the treatment of unstable osteochondritis dissecans lesions using autogenous osteochondral plugs as a means of biological internal fixation. The appearance on magnetic resonance imaging of osteochondral plugs at 6 and 9 months after transplantation is also presented. ( info) |
8/654. Pediatric atlantoaxial instability: management with screw fixation. Sixteen pediatric patients (age range 3-15 years; mean 9.4 years) with atlantoaxial instability underwent screw fixation at Columbus Children's Hospital between 1992 and 1998. Three patients with type II odontoid fractures underwent odontoid screw fixation. The remaining group of 13 patients had posterior C1-2 transarticular screw fixation and Sonntag C1-2 fusion. The group included 3 patients with rotatory C1-2 fixation, 4 patients with os odontoideum, 4 patients with congenital atlantoaxial instability and 2 patients with traumatic C1-2 instability. Postoperatively, all patients were placed in a Miami-J collar only. At 3 months follow-up, all patients achieved fusion. Bony fusion across the fracture line was clearly evident in patients with odontoid screws. The only complications in this series were a transient swallowing difficulty that resolved spontaneously in 2 weeks, and another patient's C1-2 fusion had extended to C2-3 at 9 months follow-up. This study demonstrates that children at 3 years of age and older, who sustain a type II odontoid fracture with an intact transverse ligament, can be safely managed with odontoid screws if the fracture is less than 4 weeks old. Posterior C1-2 transarticular screw fixation can be done safely and results in a high fusion rate in children older than 4 years of age. The technical difficulties of screw fixation in children are discussed. ( info) |
9/654. An unusual complication of an ankle arthroscopy and its management. This report describes a case of a routine ankle arthroscopy which went awfully wrong. In trying to excise a loose body the surgeon had excised the distal fibula. A reasonable solution to the problem now facing the patient would have been an ankle fusion. The authors, however, performed an osteoarticular fibular grafting. At 34 months, this has been a success so far clinically and radiologically. Both the complication and its treatment have not been described before. ( info) |
10/654. Palmar oblique ligament reconstruction for carpometacarpal joint dislocation in an 11-year-old: a case report. Traumatic dislocation of the thumb carpometacarpal joint has been rarely reported in children. An 11-year-old boy presented with a traumatic dislocation of the trapeziometacarpal joint. He was successfully treated surgically with ligament reconstruction as previously described. ( info) |