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Purpose Effective pain management for patients undergoing orthopedic surgery, using pharmacological and nonpharmacological strategies, is essential. This pilot study evaluated music as an adjuvant therapy with prescribed analgesics to reduce acute pain and analgesic use among patients undergoing arthroplasty surgery. Design Prospective randomized controlled trial of 50 participants scheduled for arthroplasty surgery at a large university-affiliated hospital. Methods Participants were randomly assigned to treatment (music and analgesic medication; n = 25) or control (analgesic medication only; n = 25) groups. The intervention consisted of listening to self-selected music for 30 minutes, three times per day postoperatively in hospital and for 2 days postdischarge at home. Participants rated pain intensity and distress before and after music listening (treatment group) or meals (control group). Analgesic medication use was assessed via medical records in hospital and self-report logs postdischarge. Results Forty-seven participants completed the study. Participants who listened to music after surgery reported significantly lower pain intensity and distress in hospital and postdischarge at home. There were no statistically significant differences in analgesic medication use after surgery between groups. Conclusions Study findings provide further evidence for the effectiveness of music listening, combined with analgesics, for reducing postsurgical pain, and extend the literature by examining music listening postdischarge. Music listening is an effective adjuvant pain management strategy. It is easy to administer, accessible, and affordable. Patient education is needed to encourage patients to continue to use music to reduce pain at home during the postoperative recovery period.

BACKGROUND: Orthopaedic trauma patients frequently experience mobility impairment, fear-related issues, self-care difficulties, and work-related disability [12, 13]. Recovery from trauma-related injuries is dependent upon injury severity as well as psychosocial factors [2, 5]. However, traditional treatments do not integrate psychosocial and early mobilization to promote improved function, and they fail to provide a satisfying patient experience. QUESTIONS/PURPOSES: We sought to determine (1) whether an early psychosocial intervention (integrative care with movement) among patients with orthopaedic trauma improved objective physical function outcomes during recovery compared with usual care, and (2) whether an integrative care approach with orthopaedic trauma patients improved patient-reported physical function outcomes during recovery compared with usual care. METHODS: Between November 2015 and February 2017, 1133 patients were admitted to one hospital as orthopaedic trauma alerts to the care of the three orthopaedic trauma surgeons involved in the study. Patients with severe or multiple orthopaedic trauma requiring one or more surgical procedures were identified by our orthopaedic trauma surgeons and approached by study staff for enrollment in the study. Patients were between 18 years and 85 years of age. We excluded individuals outside of the age range; those with diagnosis of a traumatic brain injury [28]; those who were unable to communicate effectively (for example, at a level where self-report measures could not be answered completely); patients currently using psychotropic medications; or those who had psychotic, suicidal, or homicidal ideations at time of study enrollment. A total of 112 orthopaedic trauma patients were randomized to treatment groups (integrative and usual care), with 13 withdrawn (n = 99; 58% men; mean age 44 years ± 17 years). Data was collected at the following time points: baseline (acute hospitalization), 6 weeks, 3 months, 6 months, and at 1 year. By 1-year follow-up, we had a 75% loss to follow-up. Because our data showed no difference in the trajectories of these outcomes during the first few months of recovery, it is highly unlikely that any differences would appear months after 6 months. Therefore, analyses are presented for the 6-month follow-up time window. Integrative care consisted of usual trauma care plus additional resources, connections to services, as well as psychosocial and movement strategies to help patients recover. Physical function was measured objectively (handgrip strength, active joint ROM, and Lower Extremity Gain Scale) and subjectively (Patient-Reported Outcomes Measurement Information System-Physical Function [PROMIS®-PF] and Tampa Scale of Kinesiophobia). Higher values for hand grip, Lower Extremity Gain Scale (score range 0-27), and PROMIS®-PF (population norm = 50) are indicative of higher functional ability. Lower Tampa Scale of Kinesiophobia (score range 11-44) scores indicate less fear of movement. Trajectories of these measures were determined across time points. RESULTS: We found no differences at 6 months follow-up between usual care and integrative care in terms of handgrip strength (right handgrip strength β = -0.0792 [95% confidence interval -0.292 to 0.133]; p = 0.46; left handgrip strength β = -0.133 [95% CI -0.384 to 0.119]; p = 0.30), or Lower Extremity Gain Scale score (β = -0.0303 [95% CI -0.191 to 0.131]; p = 0.71). The only differences between usual care and integrative care in active ROM achieved by final follow-up within the involved extremity was noted in elbow flexion, with usual care group 20° ± 10° less than integrative care (t [27] = -2.06; p = 0.05). Patients treated with usual care and integrative care showed the same Tampa Scale of Kinesiophobia score trajectories (β = 0.0155 [95% CI -0.123 to 0.154]; p = 0.83). CONCLUSION: Our early psychosocial intervention did not change the trajectory of physical function recovery compared with usual care. Although this specific intervention did not alter recovery trajectories, these interventions should not be abandoned because the greatest gains in function occur early in recovery after trauma, which is the key time in transition to home. More work is needed to identify ways to capitalize on improvements earlier within the recovery process to facilitate functional gains and combat psychosocial barriers to recovery. LEVEL OF EVIDENCE: Level II, therapeutic study.

Background In an effort to minimize backside polyethylene wear and osteolysis associated with titanium tibial baseplates, many manufacturers have transitioned to cobalt chromium alloys. Recent literature has implicated thicker cobalt chromium designs as a potential source of increased stress shielding and resorption. We report the incidence of proximal tibial bone resorption in a large consecutive series of patients undergoing total knee arthroplasty, with a modern total knee design. Methods Four hundred thirty-two consecutive primary total knee arthroplasties, performed by 2 fellowship-trained arthroplasty surgeons were identified over a 24-month period. In addition to review of the medical records, analysis of preoperative and postoperative radiographs was performed. Utilizing a novel classification system, the severity of resorption was quantified and correlated with patient and implant characteristics. Results After exclusions, 339 knees were evaluated in 292 patients. Mean follow-up was 13.2 months (range 6-41). Resorption was present in 119 knees (35.1%). Average time to diagnosis of bone loss was 6.9 months (range 2-32) postoperatively. There was a statistically significant difference between resorption and nonresorption groups with regards to gender and preoperative alignment. Most cases were classified as Grade 1. During the study period, 2 patients required revision for aseptic tibial loosening. Conclusions Our findings suggest that proximal tibial resorption is common with this particular implant, particularly in men and patients with preoperative varus deformity. Although this typically occurs relatively early in postoperative period and in most cases appears to remodel and stabilize, its ultimate clinical significance and effect on implant survivorship remains unclear.

Objective Prehospital personnel who lack advanced airway management training must rely on basic techniques when transporting unconscious trauma patients. The supine position is associated with a loss of airway patency when compared to lateral recumbent positions. Thus, an inherent conflict exists between securing an open airway using the recovery position and maintaining spinal immobilization in the supine position. The lateral trauma position is a novel technique that aims to combine airway management with spinal precautions. The objective of this study was to compare the spinal motion allowed by the novel lateral trauma position and the well-established log-roll maneuver. Methods Using a full-body cadaver model with an induced globally unstable cervical spine (C5-C6) lesion, we investigated the mean range of motion (ROM) produced at the site of the injury in six dimensions by performing the two maneuvers using an electromagnetic tracking device. Results Compared to the log-roll maneuver, the lateral trauma position caused similar mean ROM in five of the six dimensions. Only medial/lateral linear motion was significantly greater in the lateral trauma position (1.4 mm (95% confidence interval [CI] 0.4, 2.4 mm)). Conclusions In this cadaver study, the novel lateral trauma position and the well-established log-roll maneuver resulted in comparable amounts of motion in an unstable cervical spine injury model. We suggest that the lateral trauma position may be considered for unconscious non-intubated trauma patients.

Background It has been proposed that cricoid pressure can exacerbate an unstable cervical injury and lead to neurologic deterioration. Objective We sought to examine the amount of motion cricoid pressure could cause at an unstable subaxial cervical spine injury, and whether posterior manual support is of any benefit. Methods Five fresh, whole cadavers had complete segmental instability at C5–C6 surgically created by a fellowship-trained spine surgeon. Cricoid pressure was applied to the anterior cricoid by an attending anesthesiologist. In addition, the effect of posterior cervical support was tested during the trials. The amount of angular and linear motion between C5 and C6 was measured using a Fastrak, three-dimensional, electromagnetic motion analysis device (Polhemus Inc., Colchester, VT). Results When cricoid pressure is applied, the largest angular motion was 3 degrees and occurred in flexion-extension at C5–C6. The largest linear displacement was 1.36 mm and was in anterior-posterior displacement of C5–C6. When manual posterior cervical support was applied, the flexion-extension was improved to less than half this value (1.43 degrees), and this reached statistical significance ( p = 0.001). No other differences were observed to be significant in the other planes of motion with the applications of support. Conclusions Based on the evidence presented, we believe that the application of cricoid pressure to a patient with a globally unstable subaxial cervical spine injury causes small displacements. There may be some benefit to the use of manual posterior cervical spine support for reducing motion at such an injured segment.

Objectives Pelvic circumferential compression devices are commonly used in the acute treatment of pelvic fractures for reduction of pelvic volume and initial stabilisation of the pelvic ring. There have been reports of catastrophic soft-tissue breakdown with their use. The aim of the current investigation was to determine whether various pelvic circumferential compression devices exert different amounts of pressure on the skin when applied with the force necessary to reduce the injury. The study hypothesis was that the device with the greatest surface area would have the lowest pressures on the soft-tissue. Methods Rotationally unstable pelvic injuries (OTA type 61-B) were surgically created in five fresh, whole human cadavers. The amount of displacement at the pubic symphysis was measured using a Fastrak, three-dimensional, electromagnetic motion analysis device (Polhemus Inc., Colchester, VT). The T-POD, Pelvic Binder, Sam Sling, and circumferential sheet were applied in random order for testing. The devices were applied with enough force to obtain a reduction of less than 10 mm of diastasis at the pubic symphysis. Pressure measurements, force required, and contact surface area were recorded with a Tekscan pressure mapping system. Results The mean skin pressures observed ranged from 23 to 31 kPa (173 to 233 mm of Hg). The highest pressures were observed with the Sam Sling, but no statistically significant skin pressure differences were observed with any of the four devices (p > 0.05). The Sam Sling also had the least mean contact area (590 cm 2 ). In greater than 70% of the trials, including all four devices tested, skin pressures exceeded what has been shown to be pressure high enough to cause skin breakdown (9.3 kPa or 70 mm of Hg). Conclusions Application of commercially available pelvic binders as well as circumferential sheeting commonly results in mean skin pressures that are considered to be above the threshold for skin breakdown. We therefore recommend that these devices only be used acutely, and definitive fixation or external fixation should be performed early as patient physiology allows. There may be some advantage of use of a simple sheet given its low cost, versatility, and ability to alter contact surface area.

OBJECTIVES This study explored the relationships between negative affective states (depression and anxiety), physical/functional status, and emotional well-being during early treatment and later in recovery after orthopaedic trauma injury. DESIGN This was a secondary observational analysis from a randomized controlled study performed at a Level-1 trauma center. PATIENTS Patients with orthopaedic trauma (N = 101; 43.5 ± 16.4 years, 40.6% women) were followed from acute care to week 12 postdischarge. MAIN OUTCOME MEASURES Patient-reported outcomes measurement information system measures of Physical Function, Psychosocial Illness Impact-Positive and Satisfaction with Social Roles and Activities and the Beck Depression Inventory-II and the State-Trait Anxiety Inventory were administered during acute care and at weeks 2, 6, and 12. Secondary measures included hospital length of stay, adverse readmissions, injury severity, and surgery number. RESULTS At week 12, 20.9% and 35.3% of patients reported moderate-to-severe depression (Beck Depression Inventory-II score ≥20 points) and anxiety (State-Anxiety score ≥40 points), respectively. Depressed patients had greater length of stay, complex injuries, and more readmissions than those without. The study sample improved patient-reported outcomes measurement information system T-scores for Physical Function and Satisfaction with Social Roles and Activities by 40% and 22.8%, respectively (P < 0.0001), by week 12. Anxiety attenuated improvements in physical function. Both anxiety and depression were associated with lower Psychosocial Illness Impact-Positive scores by week 12. CONCLUSIONS Although significant improvements in patient-reported physical function and satisfaction scores occurred in all patients, patients with depression or anxiety likely require additional psychosocial support and resources during acute care to improve overall physical and emotional recovery after trauma. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background Diagnosing periprosthetic joint infection after total joint arthroplasty is often challenging. The alpha defensin test has been recently reported as a promising diagnostic test for periprosthetic joint infection. The goal of this study was to determine the diagnostic accuracy of alpha defensin testing. Methods One hundred and eighty-three synovial alpha defensin and synovial fluid C-reactive protein (CRP) tests performed in 183 patients undergoing evaluation for periprosthetic joint infection were reviewed. Results were compared with the Musculoskeletal Infection Society (MSIS) criteria for periprosthetic joint infection. Results Alpha defensin tests were performed prior to surgical treatment for infection, and 37 of these patients who had these tests were diagnosed by MSIS criteria as having infections. Among this group, the alpha defensin test had a sensitivity of 81.1% (95% confidence interval [CI], 64.8% to 92.0%) and a specificity of 95.9% (95% CI, 91.3% to 98.5%). There were 6 false-positive results, 4 of which were associated with metallosis. There were 7 false negatives, all of which were associated with either draining sinuses (n = 3) or low-virulence organisms (n = 4). A combined analysis of alpha defensin and synovial fluid CRP tests was performed in which a positive result was represented by a positive alpha defensin test and a positive synovial fluid CRP test (n = 28). Among this group, the sensitivity was calculated to be 73.0% (95% CI, 55.9% to 86.2%) and the specificity was calculated to be 99.3% (95% CI, 96.2% to 99.9%). An additional combined analysis was performed where a positive result was represented by a positive alpha defensin test or positive synovial fluid CRP test (n = 64). Among this group, the sensitivity was calculated to be 91.9% (95% CI, 78.1% to 98.3%) and the specificity was calculated to be 79.5% (95% CI, 72.0% to 85.7%). Conclusions Alpha defensin in combination with synovial fluid CRP demonstrates very high sensitivity for diagnosing periprosthetic joint infection, but may yield false-positive results in the presence of metallosis or false-negative results in the presence of low-virulence organisms. When both alpha defensin and synovial fluid CRP tests are positive, there is a very high specificity for diagnosing periprosthetic joint infection. Level of evidence Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Biomechanical cadaveric study. Trauma patients in the United States are immobilized on a rigid spine board, whereas in many other places vacuum mattresses are used with the proposed advantages of improved comfort and better immobilization of the spine. We sought to determine the amount of motion generated in an unstable cervical spine fracture with use of the vacuum mattress versus the spine board alone. Our hypothesis is that the vacuum mattress will better immobilize an unstable cervical fracture. Unstable subaxial cervical injuries were surgically created in five fresh whole human cadavers. The amount of motion at the injured motion segment during testing was measured using a Fastrak, three-dimensional, electromagnetic motion analysis device (Polhemus Inc., Colchester, VT). The measurements recorded in this investigation included maximum displacements during application and removal of the device, while tilting to 90 degrees, during a bed transfer, and a lift onto a gurney. Linear and angular displacements were compared using the Generalized Linear Model ANOVA for repeated measures for each of the 6 dependent variables (three planes of angulations and 3 axes of displacement). There was more motion in all six planes of motion during the application process with use of the spine board alone, and this was statistically significant for axial rotation (p = 0.011), axial distraction (p = 0.035), medial-lateral translation (p = 0.027), and anteroposterior translation (p = 0.026). During tilting there was more motion with just the spine board, but this was only statistically significant for anteroposterior translation (p = 0.033). With lifting onto the gurney there was more motion with the spine board in all planes with statistical significants, except lateral bending. During the removal process there was more motion with the spine board alone, and this was statistically significant for axial rotation (p = 0.035), lateral bending (0.044), and axial distraction (p = 0.023). There was more motion when using a spine board alone during typical maneuvers performed during early management of the spine injured patient as compared to the vacuum mattress. There may be benefit of use of the vacuum mattress versus the spine board alone in preventing motion at an unstable, subaxial cervical spine injury. Level of evidence: 2

Background As prehospital emergency rescuers prepare cervical spine-injured adult patients for immobilization and transport to hospital, it is essential that patients be placed in a favorable position. Previously, it was recommended that patients with cervical spine injuries be immobilized in a slightly flexed position using pads placed beneath the head. However, it is unknown how neck flexion created with pad placement affects the unstable spine. Objective To determine the effects of three different head positions on the alignment of unstable vertebral segments. Methods Five cadavers with a complete segmental instability at the C5 and C6 level were included in the study. The head was either placed directly on the ground (or spine board) or on foam pads. Three conditions were tested: no pad; pads 2.84 cm thick; and pads 4.26 cm thick. Pads were positioned beneath the head to determine their effect on spinal alignment. Anterior-posterior translation, flexion-extension motion, and axial displacement across the unstable segment were compared between conditions. Results Although statistical tests failed to identify any significant differences between pad conditions, some meaningful results were noted. In general, the “no pad” condition aligned the spine in a position that best replicated the intact spine. Conclusions Because the goal of emergency rescuers is to conserve whatever physiologic or structural integrity of the spinal cord and spinal column that remains, the outcome of this study suggests that this goal may be best achieved using the “no pad” condition. However, it is recommended that more research be conducted to confirm these preliminary findings.

Study design A gross anatomic and motion analysis study in cadavers. Objective Assess spinal motion in a cadaveric spinal fracture model and investigate the ability of external orthoses to control this motion. Summary of background data External orthoses are frequently prescribed for patients who have experienced burst fracture of the thoracolumbar spine. Despite the substantial expense involved, there is little data confirming their value. Methods A T12 burst fracture model was created in 5 lightly embalmed cadavers by resecting the anterior and middle columns of the T12 vertebra through a thoracolumbar anterior approach to the spine. An electromagnetic motion tracking and analysis system was used to track angular and linear displacement at the fracture during routine patient maneuvers. Several commonly used orthoses, including an extension brace and both an "off-the-shelf" and custom-molded thoracic-lumbar-sacral orthosis (TLSO), were applied to the cadavers and the affect on fracture site motion was assessed. Results Application of all 3 styles of brace resulted in angular motion of 8° to 12° in flexion-extension, 11° to 20° in axial rotation, and 8° to 10° of lateral bending. Brace application resulted in linear displacement of 29 to 46 mm in the medial-lateral plane, 21 to 23 mm in the axial plane, and 21 to 37 mm in the anterior-posterior plane. During logrolling maneuvers, TLSO style braces diminished angular motion, although residual motion in the range of 5° remained. TLSO style braces had little effect on linear translation. When placed in a seated position in bed, TLSO style braces diminished flexion and extension modestly, but did not influence lateral bending or linear translation. Extension style braces had no effect on fracture motion during any activity tested. Conclusion In a cadaver model of a burst fracture, there is surprising angular and linear motion at the fracture during common hospital activities. TLSO orthoses can decrease angular motion but do not effect translation at the fracture. An extension orthosis had no effect on motion at the spinal fracture site.

Background Safe and effective postoperative pain control remains an issue in complex spine surgery. Spinal narcotics have been used for decades but have not become commonplace because of safety or re-dosing concerns. An extended release epidural morphine (EREM) preparation has been used successfully in obstetric, abdominal, thoracic, and extremity surgery done with epidural anesthesia. This has not been studied in open spinal surgery. Methods Ninety-eight patients having complex posterior lumbar surgery were enrolled in a partially randomized clinical trial (PRCT) of low to moderate doses of EREM. Surgery included levels from L3 to S1 with procedures involving combinations of decompression, instrumented arthrodesis, and interbody grafting. The patients were randomized to receive either 10 or 15 mg of EREM through an epidural catheter placed under direct vision at the conclusion of surgery. Multiple safety measures were employed to prevent or detect respiratory depression. Postoperative pain scores, narcotic utilization, and adverse events were recorded. Results There were no significant differences between the two groups as to supplemental narcotic requirements, pain scores, or adverse events. There were no cases of respiratory depression. The epidural narcotic effect persisted from 3 to 36 hours after the injection. Conclusion By utilizing appropriate safety measures, EREM can be used safely for postoperative pain control in lumbar surgery patients. As there was no apparent advantage to the use of 15 mg, the lower 10 mg dose should be used.

Background: Smoking is associated with low back pain, intervertebral disc disease, inferior patient outcomes following surgical interventions, and increased rates of postoperative complications. The purpose of the present study was to examine the effect of smoking and smoking cessation on pain and disability in patients with painful spinal disorders. Methods: We examined a prospectively maintained database of records for 5333 patients with axial or radicular pain from a spinal disorder with regard to smoking history and the patient assessment of pain on four visual analog scales during the course of care. Confounding factors, including secondary gain, sex, age, and body mass index, were also examined. The mean duration of follow-up was eight months. Multivariate statistical analysis was performed with variables including smoking status, secondary gain status, sex, depression, and age as predictors of pain and disability. Results: Compared with patients who had never smoked, patients who were current smokers reported significantly greater pain in all visual analog scale pain ratings (p < 0.001). The mean improvement in reported pain over the course of care was significantly different between nonsmokers and current smokers (p

Background Most emergency transport protocols in the United States currently call for the use of a spine board (SB) to help immobilize the trauma patient. However, there are concerns that their use is associated with a risk of pressure ulcer development. An alternative device, the vacuum mattress splint (VMS) has been shown by previous investigations to be a viable alternative to the SB, but no single study has explicated the tissue-interface pressure in depth. Methods To determine if the VMS will exert less pressure on areas of the body susceptible to pressure ulcers than a SB we enrolled healthy subjects to lie on the devices in random order while pressure measurements were recorded. Sensors were placed underneath the occiput, scapulae, sacrum, and heels of each subject lying on each device. Three parameters were used to analyze differences between the two devices: 1) mean pressure of all active cells, 2) number of cells exceeding 9.3 kPa, and 3) maximal pressure (Pmax). Results In all regions, there was significant reduction in the mean pressure of all active cells in the VMS. In the number of cells exceeding 9.3 kPa, we saw a significant reduction in the sacrum and scapulae in the VMS, no difference in the occiput, and significantly more cells above this value in the heels of subjects on the VMS. Pmax was significantly reduced in all regions, and was less than half when examining the sacrum (104.3 vs. 41.8 kPa, p Conclusion This study does not exclude the possibility of pressure ulcer development in the VMS although there was a significant reduction in pressure in the parameters we measured in most areas. These results indicate that the VMS may reduce the incidence and severity of pressure ulcer development compared to the SB. Further prospective trials are needed to determine if these results will translate into better clinical outcomes.

One major concern regarding soft tissue allograft use in surgical procedures is the risk of disease transmission. Current techniques of tissue sterilization, such as irradiation have been shown to adversely affect the mechanical properties of soft tissues. Grafts processed using Biocleanse processing (a proprietary technique developed by Regeneration Technologies to sterilize human tissues) will have better biomechanical characteristics than tissues that have been irradiated. Fifteen pairs of cadaveric Achilles tendon allografts were obtained and separated into three groups of 10 each. Three treatment groups were: Biocleanse, Irradiated, and Control (untreated). Each specimen was tested to determine the biomechanical properties of the tissue. Specimens were cyclically preloaded and then loaded to failure in tension. During testing, load, displacement, and optical strain data were captured. Following testing, the cross sectional area of the tendons was determined. Tendons in the control group were found to have a higher extrinsic stiffness (slope of the load-deformation curve, p = .005), have a higher ultimate stress (force/cross sectional area, p = .006) and higher ultimate failure load (p = .003) than irradiated grafts. Biocleanse grafts were also found to be stiffer than irradiated grafts (p = .014) yet were not found to be statistically different from either irradiated or non-irradiated grafts in terms of load to failure. Biocleanse processing seems to be a viable alternative to irradiation for Achilles tendon allografts sterilization in terms of their biomechanical properties.

Background: Currently, up to 25% of patients with spinal cord injuries may experience neurologic deterioration during the initial management of their injuries. Therefore, more effective procedures need to be established for the transportation and care of these to reduce the risk of secondary neurologic damage. Here, we present more acceptable methods to minimize motion in the unstable spine during the management of patients with traumatic spine injuries. Methods: This review summarizes more than a decade of research aimed at evaluating different methods of caring for patients with spine trauma. Results: The most commonly utilized technique to transport spinal cord injured patients, the log rolling maneuver, produced more motion than placing a patient on a spine board, removing a spine board, performing continuous lateral therapy, and positioning a patient prone for surgery. Alternative maneuvers that produced less motion included the straddle lift and slide, 6 + lift and slide, scoop stretcher, mechanical kinetic therapy, mechanical transfers, and the use of the operating table to rotate the patient to the prone position for surgical stabilization. Conclusions: The log roll maneuver should be removed from the trauma response guidelines for patients with suspected spine injuries, as it creates significantly more motion in the unstable spine than the readily available alternatives. The only exception is the patient who is found prone, in which case the patient should then be log rolled directly on to the spine board utilizing a push technique.

Background Many studies have compared the restriction of motion that immobilization collars provide to the injured victim. No previous investigation has assessed the amount of motion that is generated during the fitting and removal process. The purpose of this study was to compare the three-dimensional motion generated when one-piece and two-piece cervical collars are applied and removed from cadavers intact and with unstable cervical spine injuries. Methods Five fresh, lightly embalmed cadavers were tested three times each with either a one-piece or two-piece cervical collar in the supine position. Testing was performed in the intact state, following creation of a global ligamentous instability at C5-C6. The amount of angular motion resulting from the collar application and removal was measured using a Fastrak, three-dimensional, electromagnetic motion analysis device (Polhemus Inc., Colchester, VT). The measurements recorded in this investigation included maximum values for flexion/extension, axial rotation, medial/lateral flexion, anterior/posterior displacement, axial distraction, and medial/lateral displacement at the level of instability. Results There was statistically more motion observed with application or removal of either collar following the creation of a global instability. During application, there was a statistically significant difference in flexion/extension between the one-piece (1.8 degrees) and two-piece (2.6 degrees) collars, p = 0.009. There was also a statistically significant difference in anterior/posterior translation between the one-piece (3.6 mm) and two-piece (3.4 mm) collars, p = 0.015. The maximum angulation and displacement during the application of either collar was 3.4 degrees and 4.4 mm. Statistical analysis revealed no significant differences between the one-piece and two-piece collars during the removal process. The maximum angulation and displacement during removal of either collar type was 1.6 degrees and 2.9 mm. Conclusions There were statistically significant differences in motion between the one-piece and two-piece collars during the application process, but it was only 1.2 degrees in flexion/extension and 0.2 mm in anterior/posterior translation. Overall, the greatest amount of angulation and displacement observed during collar application was 3.4 degrees and 4.4 mm. Although the exact amount of motion that could be deleterious to a cervical spine-injured patient is unknown, collars can be placed and removed with manual in-line stabilization without large displacements. Only trained practitioners should do so and with great care given that some motion in all planes does occur during the process.

Object The proper prehospital and inpatient management of patients with unstable spinal injuries is critical for prevention of secondary neurological compromise. The authors sought to analyze the amount of motion generated in the unstable thoracolumbar spine during various maneuvers and transfers that a trauma patient would typically be subjected to prior to definitive fixation. Methods Five fresh cadavers with surgically created unstable L-1 burst fractures were tested. The amount of angular motion between the T-12 and L-2 vertebral segments was measured using a 3D electromagnetic motion analysis device. A complete sequence of maneuvers and transfers was then performed that a patient would be expected to go through from the time of injury until surgical fixation. These maneuvers and transfers included spine board placement and removal, bed transfers, lateral therapy, and turning the patient prone onto the operating table. During each of these, the authors performed what they believed to be the most commonly used versus the best techniques for preventing undesirable motion at the injury level. Results When placing a spine board there was more motion in all 3 planes with the log-roll technique, and this difference reached statistical significance for axial rotation (p = 0.018) and lateral bending (p = 0.003). Using logrolling for spine board removal resulted in increased motion again, and this was statistically significant for flexion-extension (p = 0.014). During the bed transfer and lateral therapy, the log-roll technique resulted in more motion in all 3 planes (p ≤ 0.05). When turning the cadavers prone for surgery there was statistically more angular motion in each plane for manually turning the patient versus the Jackson table turn (p ≤ 0.01). The total motion was decreased by almost 50% in each plane when using an alternative to the log-roll techniques during the complete sequence (p ≤ 0.007). Conclusions Although it is unknown how much motion in the unstable spine is necessary to cause secondary neurological injury, the accepted tenet is to minimize motion as much as possible. This study has demonstrated the angular motion incurred by the unstable thoracolumbar spine as experienced by the typical trauma patient from the field to positioning in the operating room using the best and most commonly used techniques. As previously reported, using the log-roll technique consistently results in unwanted motion at the injured spinal segment.

OBJECTIVES To determine the effect of tibial plateau leveling osteotomy (TPLO) on patellar tendon angle (PTA) in dogs. STUDY DESIGN Cadaveric radiographic study. ANIMALS Pelvic limb pairs (n=5) obtained from skeletally mature dogs, weighing 22-36 kg. METHODS TPLO was performed using a radiolucent jig that allowed for plateau segment rotation to a tibial plateau angle (TPA) of 15 degrees, 6 degrees, and 0 degrees. Before, and at each of the prescribed rotations, PTA was measured by the tibial plateau (PTA(TP)) and common tangent (PTA(CT)) methods with the stifle positioned at 135 degrees of flexion. Linear regression analysis was performed to evaluate the correlation between TPA and PTA. RESULTS At a mean (+/-SD) TPA of 5.9+/-0.7 degrees, mean+/-SD PTA(TP) and PTA(CT) were 94.1+/-1.6 degrees and 86.8+/-2.5 degrees, respectively. A linear correlation was observed between TPA and PTA(TP) (r=0.85) and between TPA and PTA(CT) (r=0.61). Based on the regression equation of TPA and PTA(CT), a TPA of 12 degrees corresponded to a PTA(CT) of approximately 90 degrees. CONCLUSION TPLO to a TPA of 6 degrees reduces PTA to values similar to those recommended when performing tibial tuberosity advancement in dogs with cranial cruciate ligament insufficiency. CLINICAL RELEVANCE TPLO may neutralize tibial thrust by modifying PTA as well as decreasing TPA. TPLO to a TPA of 6 degrees may not be necessary to neutralize the cranial tibial thrust according to the plateau rotation based on PTA(CT) measurement.

Objective— To evaluate the biomechanical effects of 5 types of meniscal lesions on contact mechanics in the canine stifle. Study Design— Experimental study. Animals— Cadaveric canine stifles (n=12 pair). Methods— Medial meniscal lesions (radial, vertical longitudinal, nonreducible bucket handle, flap, and complex tears) were simulated in cadaveric stifles. A contact map was recorded from each tear type and contact area (CA) and peak contact pressure (PCP) from each tear type were compared. Results— A significant difference in PCP was detected between control and nonreducible bucket handle, flap, and complex tears. PCP increased by >45% in nonreducible bucket handle, flap, and complex meniscal tears when compared with control. No significant difference was found in PCP between control and radial and vertical longitudinal tears. No significant difference was found in CA between any of the meniscal conditions. Conclusions— Nonreducible bucket handle, flap, and complex tears cause a significant increase in PCP. Radial and vertical longitudinal tears had a minimal impact on the contact pressures of the medial compartment of the stifle. Clinical Relevance— Based on this ex vivo model, we support the clinical recommendation of debriding nonreducible bucket handle, flap, and complex tears because the injured portion of the meniscus no longer contributes significantly to the function of the meniscus. Radial and vertical longitudinal tears do not cause a change in contact mechanics allowing consideration of nonsurgical treatment and meniscal repair, respectively. Future experimental and clinical studies should aim to refine the treatment of specific meniscal injuries.

STUDY DESIGN A parallel group design with repeated measures using a cadaver model was employed. OBJECTIVE The purpose of this study was to evaluate and compare lumbar spine motion generated in the presence of spinal instabilities during common hospital moves using different transfer techniques. SUMMARY OF BACKGROUND DATA Up to 25% of spinal cord injuries may occur during initial management of the patient with a compromised spinal column, when multiple transfers between diagnostic locations and operating, recovery and hospital rooms are often required. Few studies have compared methods of moving patients with lumbar spinal column injuries in hospital settings. METHODS A global instability was created in 3 cadavers at L1 and sensors were attached to T12 and L2. A 3-dimensional electromagnetic tracking system (Liberty, Polhemus Inc) was used to measure flexion, lateral bending, and axial rotation while moving a cadaver from one bed to another to compare 2 transfer techniques used in hospitals: manual transfer and the On3, a motorized lateral transfer device (Hill-Rom, Batesville, IN). RESULTS Significant increases in lumbar angulations (P

A study of spine biomechanics in a cadaver model.To quantify motion in multiple axes created by transfer methods from stretcher to operating table in the prone position in a cervical global instability model.Patients with an unstable cervical spine remain at high risk for further secondary injury until their spine is adequately surgically stabilized. Previous studies have revealed that collars have significant, but limited benefit in preventing cervical motion when manually transferring patients. The literature proposes multiple methods of patient transfer, although no one method has been universally adopted. To date, no study has effectively evaluated the relationship between spine motion and various patient transfer methods to an operating room table for prone positioning.A global instability was surgically created at C5-6 in 4 fresh cadavers with no history of spine pathology. All cadavers were tested both with and without a rigid cervical collar in the intact and unstable state. Three headrest permutations were evaluated Mayfield (SM USA Inc), Prone View (Dupaco, Oceanside, CA), and Foam Pillow (OSI, Union City, CA). A trained group of medical staff performed each of 2 transfer methods: the "manual" and the "Jackson table" transfer. The manual technique entailed performing a standard rotation of the supine patient on a stretcher to the prone position on the operating room table with in-line manual cervical stabilization. The "Jackson" technique involved sliding the supine patient to the Jackson table (OSI, Union City, CA) with manual in-line cervical stabilization, securing them to the table, then initiating the table's lock and turn mechanism and rotating them into a prone position. An electromagnetic tracking device captured angular motion between the C5 and C6 vertebral segments. Repeated measures statistical analysis was performed to evaluate the following conditions: collar use (2 levels), headrest (3 levels), and turning technique (2 levels).For all measures, there was significantly more cervical spine motion during manual prone positioning compared with using the Jackson table. The use of a collar provided a slight reduction in motion in all the planes of movement; however, this was only significantly different from the no collar condition in axial rotation. Differences in gross motion between the headrest type were observed in lateral bending (Foam PillowProne View, P=0.045), medial lateral translation (Foam PillowMayfield, P=0.032), and anterior posterior translation (Prone ViewMayfield, P=0.030).The data suggest that the manual transfer technique produces 2 to 3 times more cervical spine angular motion than the Jackson table method of transfer. The use of a collar provides significant benefit in limiting spine motion that is only observed in axial rotation. Choice of headrest does have a significant effect on the amount of motion allowed during turning, with the Foam Pillow and Prone View generally providing more effective stabilization compared with the Mayfield.

Functional outcomes of three surgical treatments for massive rotator cuff repairs were compared. Surgery was performed by a single surgeon (T.W.W.) on 38 patients (mean age: 62.5 years). The surgeon decided which procedure to use for each patient based on tissue quality, ability to mobilize the torn rotator cuff, and degree of tension after the repair was attempted. Twenty-one patients underwent complete repair, 11 underwent partial repair, and 6 had debridement alone. Results were evaluated using the Shoulder Pain and Disability Index and by measuring range of motion and strength. The mean Shoulder Pain and Disability Index score for all patients postoperatively was 25, with subindices averaging 10 for pain and 15 for function. For the subgroups, Shoulder Pain and Disability Index scores for pain and function, were 8 and 10 for complete repair, 11 and 19 for partial repair, and 14 and 24 for debridement alone, respectively. Active external rotation was significantly better (P = .008) postoperatively in patients who had a complete repair compared to debridement alone.

BACKGROUND: The main comorbidities associated with spinal cord injury patients are secondary to immobilization. Kinetic bed therapy is used currently to reduce the complications associated with immobilization, but the effect on the unstable spine has not been quantified. The purpose of this study was to compare the motion in the cervical and thoracolumbar spine when cadavers with spinal instabilities are log rolled (LR) on a standard hospital bed or rotated on a RotoRest kinetic treatment table (KTT). METHODS: Cervical and lumbar instabilities were created surgically in three embalmed cadavers. An electromagnetic tracking device was used to measure the three-dimensional segmental motion generated at C5 to C6 and T12 to L2 during LR and KTT treatments. RESULTS: In both the cervical and lumbar spine, significantly more motion was observed during LR than KTT treatment. CONCLUSIONS: We found that in cadavers with severely unstable cervical spine, rotation using a KTT produced less flexion and lateral bending than the LR. Also, in cadavers with severely unstable lumbar spine, treatment with the KTT produced less axial rotation than the LR. Currently, we think that the best way to immobilize the spine while still allowing therapeutic motion is through the use of a KTT. Language: en

Background Endotracheal intubation is not always an option for unconscious trauma patients. Prehospital personnel are then faced with the dilemma of maintaining an adequate airway without risking deleterious movement of a potentially unstable cervical spine. To address these two concerns various alternatives to the classical recovery position have been developed. This study aims to determine the amount of motion induced by the recovery position, two versions of the HAINES (High Arm IN Endangered Spine) position, and the novel lateral trauma position (LTP). Method We surgically created global cervical instability between the C5 and C6 vertebrae in five fresh cadavers. We measured the rotational and translational (linear) range of motion during the different maneuvers using an electromagnetic tracking device and compared the results using a general linear mixed model (GLMM) for regression. Results In the recovery position, the range of motion for lateral bending was 11.9°. While both HAINES positions caused a similar range of motion, the motion caused by the LTP was 2.6° less (P = 0.037). The linear axial range of motion in the recovery position was 13.0 mm. In comparison, the HAINES 1 and 2 positions showed significantly less motion (−5.8 and −4.6 mm, respectively), while the LTP did not (−4.0 mm, P = 0.067). Conclusion Our results indicate that in unconscious trauma patients, the LTP or one of the two HAINES techniques is preferable to the standard recovery position in cases of an unstable cervical spine injury.

Background A patient with a suspected cervical spine injury may be at risk for secondary neurologic injury when initially placed and repositioned to the center of the spine board. Objectives We sought to determine which centering adjustment best limits cervical spine movement and minimizes the chance for secondary injury. Methods Using five lightly embalmed cadaveric specimens with a created global instability at C5–C6, motion sensors were anchored to the anterior surface of the vertebral bodies. Three repositioning methods were used to center the cadavers on the spine board: horizontal slide, diagonal slide, and V-adjustment. An electromagnetic tracking device measured angular (degrees) and translation (millimeters) motions at the C5–C6 level during each of the three centering adjustments. The dependent variables were angular motion (flexion-extension, axial rotation, lateral flexion) and translational displacement (anteroposterior, axial, and medial-lateral). Results The nonuniform condition produced significantly less flexion-extension than the uniform condition ( p = 0.048). The horizontal slide adjustment produced less cervical flexion-extension ( p = 0.015), lateral bending ( p = 0.003), and axial rotation ( p = 0.034) than the V-adjustment. Similarly, translation was significantly less with the horizontal adjustment than with the V-adjustment; medial-lateral ( p = 0.017), axial ( p p = 0.006). Conclusions Of the three adjustments, our team found that horizontal slide was also easier to complete than the other methods. The horizontal slide best limited cervical spine motion and may be the most helpful for minimizing secondary injury based on the study findings.

This study determined in a prospective manner if arthroscopic shoulder capsular release can decrease the duration of adhesive capsulitis symptoms when compared with a nonoperative home therapy program. Patients randomized to the operative group underwent arthroscopic capsular release and manipulation of the shoulder. Immediately after surgery they began the same stretching program as the nonoperative group, which consisted of terminal range of motion low-grade stretches twice daily for at least 15 minutes per session for 3 months. Twenty-six patients granted consent for the study (final analyses included 10 operative and 7 nonoperative). There were no statistical differences between the groups regarding gender, age (operative mean age, 51.5 ± 11.1 years; nonoperative mean age, 52.0 ± 6.8 years) or treatment outcome. This prospective, randomized study, which compared arthroscopic capsular release to a gentle home stretching program, demonstrated both treatment options to be effective treatment modalities.

Background context Pedicle screws have been shown to be superior to hooks in the lumbar spine, but few studies have addressed their use in the thoracic spine. Purpose The objective of this study was to biomechanically evaluate the pullout strength of pedicle screws in the thoracic spine and compare them to laminar hooks. Study desing/setting Twelve vertebrae (T1–T12) were harvested from each of five embalmed human cadavers (n=60). The age of the donors averaged 83+8.5 years. After bone mineral density had been measured in the vertebrae (mean=0.47 g/cm3), spines were disarticulated. Some pedicles were damaged during disarticulation or preparation for testing, so that 100 out of a possible 120 pullout tests were performed. Methods Each vertebra was secured using a custom-made jig, and a posteriorly directed force was applied to either the screw or the claw. Constructs were ramped to failure at 3 mm/min using a Mini Bionix II materials testing machine (MTS, Eden Prairie, MN). Results Pedicle claws had an average pullout strength of 577 N, whereas the pullout strength of pedicle screws averaged 309 N. Hooks installed using the claw method in the thoracic spine had an overwhelming advantage in pullout strength versus pedicle screws. Even in extremely osteoporotic bone, the claw withstood 88% greater pullout load. Conclusion The results of this study indicate that hooks should be considered when supplemental instrumentation is required in thoracic vertebrae, especially in osteoporotic bone.

Objective: In the process of anterior cervical fusion, little is known about the biomechanics of anterior cervical screw pullout. In this study, three different aspects of cervical screw fixation were evaluated: self-tapping (ST) versus self-drilling (SD) screws, the effect of screw geometry (length, diameter, thread pitch), and the use of rescue screws. Methods: Nine screws consisting of different diameters, lengths, and thread pitch (cancellous and cortical) were tested in peak pullout force in an artificial bone model using an MTS 858 Mini Bionix test system. Rescue screws (4.5 mm) were then inserted in the failed holes of 4.0-mm screws and extracted to determine their holding strength. Results: Length of screws and thread pitch both had a significant effect on the pullout force. Each 1 mm of increased screw length translates to 16 N of increased force to pullout in the foam bone model. Pullout strength did not vary significantly according to screw diameter or between SD and ST screws. However, the SD screw has an advantage because it can decrease the length of surgery. A decrease in pullout force of between 43% and 70% was found when using rescue screws. Conclusions: In situations in which the use of rescue/salvage screws is required, the surgeon should anticipate a significant decrease in the holding force compared with the original screw. Future directions for research include an evaluation of pullout force for screw and plate constructs.

The purpose of this study was to compare the outcomes of 2 treatments for unstable distal radius fractures: open reduction internal fixation (ORIF) through a volar approach with a fixed-angle implant and a standard external fixation (EF) method.This study included patients with comminuted unstable intra-articular and extra-articular distal radius fractures treated by a single surgeon. Data were gathered retrospectively on 11 patients treated with EF who had been followed up for an average of 47 months (range, 12-84 mo). Prospective data were gathered on 21 patients who were treated with ORIF through a volar approach with a fixed-angle implant. Follow-up evaluation for this group averaged 17 months (range, 12-24 mo). The 2 groups were compared for range of motion (ROM), strength, and functional outcome as measured by the Patient Rated Wrist Evaluation (PRWE) and the Disability of the Arm, Shoulder, and Hand Questionnaire (DASH). Fracture reduction was evaluated from radiographs taken at the last follow-up visit and compared between groups.The mean passive wrist ROM at the final follow-up evaluation in EF patients was 59 degrees extension and 57 degrees flexion, compared with 63 degrees extension and 64 degrees flexion in patients treated with ORIF. Passive pronation/supination arc of motion was similar for the 2 groups, as were the DASH and PRWE scores. Grip strength as a percentage of the opposite wrist was significantly greater in the external fixation group, a possible consequence of longer follow-up evaluation. Final radiographic measurements for the EF group averaged 5 degrees volar tilt and 25 degrees radial inclination, with 2.2-mm ulnar-positive variance. The ORIF with volar plating group averaged 10 degrees volar tilt and 22 degrees radial inclination, with .5-mm ulnar-negative variance. Radial length and volar tilt were significantly greater for the ORIF group. The average final intra-articular step-off was significantly different, with 1.4-mm step-off in the EF group and .4 mm in the ORIF group.The use of ORIF with a volar fixed-angle implant resulted in stable fixation of the distal articular fragments, allowing early postsurgical wrist motion. The PRWE and DASH scores for the groups were equivalent, whereas intra-articular step-off, volar tilt, and radial length were better in the ORIF group. There were few complications, implant removal was not necessary, and early postsurgical wrist ROM was initiated without loss of reduction.

Much of the work describing support of the medial longitudinal arch has focused on the plantar fascia and the extrinsic muscles. There is little research concerning the function of intrinsic muscles in the maintenance of the medial longitudinal arch. Ten healthy volunteer adults served as subjects for this study, which was approved by the University Investigational Review Board. The height of the navicular tubercle above the floor was measured in both feet while subjects were seated with the foot in a subtalar neutral position and then when standing in a relaxed calcaneal stance. Subtalar neutral was found by palpating for talar congruency. Recordings of muscle activity from the abductor hallucis muscle were performed while the subjects maintained a maximal voluntary contraction in a supine position by plantarflexing their great toes. An injection of lidocaine (1% with epinephrine) was then administered by a Board-certified orthopedic surgeon in the region of the tibial nerve, posterior and inferior to the medial malleolus. Measurements were repeated and compared by using a paired t test. After the nerve block, the muscle activity was 26.8% of the control condition (P = .011). This corresponded with an increase in navicular drop of 3.8 mm. (P = .022). The observation that navicular drop increased when the activity of the intrinsic muscles decreased indicates that the intrinsic pedal muscles play an important role in support of the medial longitudinal arch.

Controversy exists regarding obesity-related injury severity and clinical outcomes after orthopedic trauma.The purposes of this study were to expand our understanding of the effect of morbid obesity on perioperative and acute care outcomes after acetabular fracture.This was a retrospective review of patients with acetabular fracture after trauma. Non-morbidly obese (BMI35 kg/m(2)) and morbidly obese (BMI ≥ 35 kg/m(2); N = 81). Injury severity scores and Glasgow Coma Scale scores (GCS) were collected. Perioperative and acute care outcomes were positioning and operative time, extra fractures, estimated blood loss, complications, hospital charges, ventilator days, transfusions, length of stay (LOS) and discharge destination. Positioning and operative times were longer in morbidly obese patients (p0.05). No other differences existed between groups.Orthopedic trauma surgeons and care teams can expect similar acute care outcomes in morbidly obese and non-morbidly obese patients with acetabular fracture.

Introduction Bedrest is often used for temporary management, as well as definitive treatment, for many spinal injuries. Under such circumstances patients cannot remain flat for extended periods due to possible skin breakdown, blood clots, or pulmonary complications. Kinetic therapy beds are often used in the critical care setting, although this is felt to be unsafe for turning patients with spine fractures. We sought to evaluate whether a kinetic therapy bed would cause as much spinal motion at an unstable cervical injury as occurs during manual log-rolling on a standard intensive care unit bed. Methods Unstable C5–C6 ligamentous injuries were surgically created in 15 fresh, whole cadavers. Sensors were affixed to C5 and C6 posteriorly and electromagnetic motion tracking analysis performed. In all cases a cervical collar was applied by an orthotist after creation of the injury. The amount of angular motion and linear displacement that occurred at this injured level was measured during manual log-rolling and patient turning using a kinetic therapy bed. For statistical analysis, the range of motion for angles about each axis and displacement in each direction was analyzed by multivariate analysis of variance with repeated measures. Results When comparing manual log-rolling and kinetic bed therapy, significantly more angular motion was created by the log-roll manoeuvre in flexion–extension ( p = 0.03) and lateral bending ( p = 0.01). There was no significant difference in axial rotation between the two methods ( p = 0.80). There were no significant differences demonstrated in medial–lateral and anterior–posterior translation. There was almost two times the axial displacement between manual log-rolling and the kinetic therapy bed and this reached statistical significance ( p = 0.05). Conclusion There is less motion at an unstable cervical injury in flexion–extension, lateral bending, and axial displacement when turning a patient using a kinetic therapy bed as opposed to traditional manual log-rolling. It may be preferable to use a kinetic therapy bed rather than manual log-rolling for patients with cervical spine injuries to decrease unwanted spinal motion. In addition, it may be easier and less physically demanding on nursing staff that must regularly turn the patient if manual log-rolling is implemented.

Fourteen patients (17 shoulders) were identified who had been treated by one surgeon from 1992 to 2008 for symptomatic shoulder osteonecrosis using proximal humerus core decompression with fibular allograft strut placement. Pre- and postoperative radiographs were available, along with active range of motion and postoperative function: SPADI, ASES, SF-12. Two patients (two shoulders) were lost to follow-up. Radiographs were staged using the Cruess classification system as eight precollapse (stages I and II) (mean age 44 years) and six postcollapse shoulders (stages III and IV) (mean age 30 years). Groups had similar preoperative and postoperative flexion, external rotation, and functional scores. Two stage II shoulders and one stage IV shoulder were subsequently converted to hemiarthroplasty. This minimally invasive surgical technique could expand indications for strut grafting and joint salvage to treatment of patients with advanced osteonecrosis.

Excessive spinal motion generated during multiple bed transfers of patients with unstable spine injuries may contribute to neurological deterioration.To evaluate spinal motion in a cadaveric model of global spinal instability during hospital bed transfers using several commonly used techniques.A motion analysis and evaluation of hospital bed transfer techniques in a cadaveric model of C5-C6 and T12-L2 global spinal instability. Setting/outcome measures: Global instability at C5-C6 and T12-L2 was created. The motion in three planes was measured in both the cervical and lumbar spine during each bed transfer via electromagnetic motion detection devices. Comparisons between transfers performed using an air-assisted lateral transfer device, manual transfer, a rolling board, and a sliding board were made based on the maximum range of motion observed.Significantly less lateral bending at C5-C6 was observed in air-assisted device transfers when compared with the two other boards. Air-assisted device transfers produced significantly less axial rotation at T12-L2 than the rolling board, and manual transfers produced significantly less thoracolumbar rotation than both the rolling and sliding boards. No other significant differences were observed in cervical or lumbar motion. Motion versus time plots indicated that the log roll maneuvers performed during rolling board and sliding board transfers contributed most of the observed motion.Each transfer technique produced substantial motion. Transfer techniques that do not include the logroll maneuver can significantly decrease some components of cervical and lumbar motion. Thus, some spinal motion can be reduced through selection of transfer technique.

Context: Two methods have been proposed to transfer an individual in the prone position to a spine board. Researchers do not know which method provides the best immobilization. Objective: To determine if motion produced in the unstable cervical spine differs between 2 prone logrolling techniques and to evaluate the effect of equipment on the motion produced during prone logrolling. Design: Crossover study. Setting: Laboratory. Patients or Other Participants: Tests were performed on 5 fresh cadavers (3 men, 2 women; age = 83 ± 8 years, mass = 61.2 ± 14.1 kg). Main Outcome Measure(s): Three-dimensional motions were recorded during 2 prone logroll protocols (pull, push) in cadavers with an unstable cervical spine. Three equipment conditions were evaluated: football shoulder pads and helmet, rigid cervical collar, and no equipment. The mean range of motion was calculated for each test condition. Results: The pull technique produced 16% more motion than the push technique in the lateral-bending angulation direction (F1,4 = 19.922, P = .01, η2 = 0.833). Whereas the collar-only condition and, to a lesser extent, the football-shoulder-pads-and-helmet condition demonstrated trends toward providing more stability than the no-equipment condition, we found no differences among equipment conditions. We noted an interaction between technique and equipment, with the pull maneuver performed without equipment producing more anteroposterior motion than the push maneuver in any of the equipment conditions. Conclusions: We saw a slight difference in the motion measured during the 2 prone logrolling techniques tested, with less lateral-bending and anteroposterior motion produced with the logroll push than the pull technique. Therefore, we recommend adopting the push technique as the preferred spine-boarding maneuver when a patient is found in the prone position. Researchers should continue to seek improved methods for performing prone spine-board transfers to further decrease the motion produced in the unstable spine.

Although it is essential to maintain a secure airway in a trauma patient, it is also critical to protect the potentially injured cervical spine. It has previously been suggested that the jaw thrust maneuver be used in place of the head tilt-chin lift in the suspected spine-injured patient.We sought to examine whether the jaw thrust was in fact safer to use in the setting of an unstable upper cervical spine injury.Unstable, dissociative C1-C2 injuries were surgically created in nine fresh, lightly embalmed human cadaver specimens. An electromagnetic motion analysis device was used to assess the amount of angular and linear motion with sensors placed above and below the injured segment. Measurements were recorded during execution of the two airway maneuvers. Trials were performed both with and without a cervical immobilization collar in place.There was almost twice as much angular motion in all planes when performing a head tilt-chin lift as compared with the jaw thrust, and this was statistically significant (p.013). In addition, there was more displacement at the injured level with a head tilt-chin lift as compared with the jaw thrust. This was statistically significant for axial displacement and anteroposterior translation (p=.003 for both), and approached significance for mediolateral translation (p=.056).The jaw thrust maneuver results in less motion at an unstable C1-C2 injury as compared with the head tilt-chin lift maneuver. We therefore recommend the use of the jaw thrust to improve airway patency in the trauma patient with suspected cervical spine injury.

Objective Most trauma centers place pelvic binders on unstable pelvic fractures for acute management and control of hemorrhage. It has been proposed that the binders be placed at the level of the greater trochanters of the femur. Our hypothesis was that application of the T-POD at this site would provide better immobilization of an unstable pelvic injury than a more cephalad location. Methods Unstable pelvic injuries (OTA type 61-C1) were surgically created in 9 fresh whole human cadavers. Electromagnetic sensors were affixed to the intact and injured sides of the pelvis. A Fastrak, three-dimensional electromagnetic motion analysis device was used to determine the angular motion occurring at the fractured sites. Maximum displacements for sagittal, coronal, and axial rotation were recorded during application of the binder, while performing bed transfers, while logrolling, and elevating the head of the bed. The T-POD device was placed either over the greater trochanters or at the level of the anterior superior iliac spine as per manufacturer's recommendations. Results There were no significant differences in the amount of motion produced during application of the T-POD at either location. There was less motion observed in all planes of motion during all maneuvers when the T-POD was placed at the level of the greater trochanters versus anterior superior iliac spine. During bed transfers, this was statistically significant in all planes. This was statistically significant while logrolling in the axial plane and the coronal plane during head of bed elevation. Conclusions We advocate the placement of pelvic binder devices at the level of the greater trochanters for improved control of the fracture in an unstable pelvic injury. This may result in improved control of hemorrhage, better access to the abdomen, and greater patient comfort.

BACKGROUND Most institutions treating pelvic fractures use some method of acute mechanical stabilization. This typically involves use of pelvic binders or circumferential sheeting, and/or external fixation. The comparative value of these different modalities is controversial. We hypothesized that an external fixator would provide more stability to an unstable pelvic injury than a commercially available binder device (trauma pelvic orthotic device [T-POD]). METHODS Unstable pelvic injuries (Tile C) were surgically created in five fresh whole human cadavers. Electromagnetic sensors were placed on the same position of each hemipelvis. The amount of angular motion during testing was measured using a Fastrak, three-dimensional, electromagnetic motion analysis device. Maximum displacements were recorded during application of the stabilizing devices, bed transfer, logrolling, and head-of-bed elevation. External fixation frames were constructed by placing two 5.0-mm half pins into the iliac crest and then connected them with a 10-mm curved bar. The T-POD device was placed at the level of the greater trochanters as per manufacturer's recommendations. RESULTS While logrolling the patient and performing bed transfers, the T-POD conferred more stability in all planes of motion, although this did not reach statistical significance. During elevation of the head of the bed, the T-POD allowed less motion in the sagittal and coronal planes but permitted equivalent motion in axial rotation. These differences were not statistically significant. CONCLUSION There were no significant differences in stability conferred by an external fixator or a T-POD for unstable pelvic injuries. We advocate acute, temporary stabilization of pelvic injuries with a binder device and early conversion to internal fixation when the patient's medical condition allows.

Biomechanical cadaveric study.We sought to analyze the amount of motion generated in the unstable cervical spine during various maneuvers and transfers that a trauma patient would typically be subjected to prior to definitive fixation, using 2 different protocols.From the time of injury until the spine is adequately stabilized in the operating room, every step in management of the spine-injured patient can result in secondary injury to the spinal cord.The amount of angular motion between C5 and C6, after a surgically created unstable injury, was measured using an electromagnetic motion analysis device (Polhemus Inc., Colchester, VT). A total sequence of maneuvers and transfers was then performed that a patient would be expected to go through from the time of injury until surgical fixation. This included spine board placement and removal, bed transfers, lateral therapy, and turning the patient prone onto the operating table. During each of these, we performed what has been shown to be the best and commonly used (log-roll) techniques.During bed transfers and the turn prone for surgery, there was statistically more angular motion in each plane for traditional transfer with the spine board and manually turning the patient prone as commonly done (P0.01). During spine board placement, there was more motion in all 3 planes with log-rolling, and this reached statistical significance for axial rotation (P = 0.015) and lateral bending (P = 0.004). There was more motion during board removal with log-rolling in all 3 planes. This was statistically significant for lateral bending (P = 0.009) and approached significance in flexion-extension (P = 0.058) and axial rotation (P = 0.058). During lateral therapy, there was statistically more motion in flexion-extension and lateral bending with the manual log-roll technique (P0.001). The total motion was decreased by more than 50% in each plane when using an alternative to log-roll techniques during the total sequence (P0.006).We have demonstrated the total angular motion incurred to the unstable cervical spine as experienced by the typical trauma patient from the field to stabilization in the operating room using the best compared with the most commonly used techniques. As previously reported, using log-roll techniques consistently results in unwanted motion at the injured spinal segment.

Total shoulder arthroplasty (TSA) is commonly performed for arthritic conditions of the shoulder. The outcome after TSA is generally good, but there are several modes of failure, with one of the more common reasons being glenoid loosening. One possible cause for glenoid loosening is inadequate cementation technique. The purpose of this study was to evaluate the incidence of lucent lines on the first postoperative radiograph using 2 different cementation techniques.One hundred consecutive patients had a pegged glenoid placed with 1 of 2 different cementation techniques. In 26 consecutive patients, the pegged glenoid component was cemented with a traditional minimal manual pressurization technique, whereas 74 underwent a contemporary 3-step pressurization cementation technique before implant insertion. The first postoperative radiograph was evaluated using the system of Lazarus et al, looking at the frequency of lucent lines. The radiographs were deidentified and were randomized and evaluated by 2 independent observers on 3 separate occasions.The Kruskal-Wallis test showed significant differences between grades of radiolucent lines for pressurized versus unpressurized cementation techniques. There were significantly (P.05) fewer lucent lines identified in the group that underwent contemporary 3-step pressurization as opposed to the group that underwent minimal manual pressurization. Intraobserver reliability and interobserver reliability with Cronbach α coefficients were good.The 3-step pressurized cementation technique resulted in a low incidence of radiolucent lines around the glenoid implant in patients undergoing TSA.Level II, Prospective Cohort, Treatment Study.

After spine board immobilization of the trauma victim and transport to the hospital, the patient is removed from the spine board as soon as practical. Current Advanced Trauma Life Support's recommendations are to log roll the patient 90 degrees, remove the spine board, inspect and palpate the back, and then log roll back to supine position. There are several publications showing unacceptable motion in an unstable spine when log rolling.Cervical spine motion was evaluated during spine board removal. A C5 to C6 instability was surgically created in cadavers. A three-dimensional electromagnetic tracking system was used to assess motion between C5 and C6. The log roll was compared with a lift-and-slide technique. Throughout the log roll procedure, manual inline cervical stabilization was provided by a trained individual in a series of trials. In other trials, the lift-and-slide technique was used. In the final stage, the amount of motion generated was assessed when the spine board removal techniques were completed by experienced and novice persons in maintaining inline stabilization of the head and neck.Motion between C5 and C6 was reduced during the lift-and-slide technique in five of six parameters. The reduction was statistically significant in four parameters. When performing the log roll, motion was not reduced with increased head holder experience.Spine boards can be removed using a lift-and-slide maneuver with less motion and potentially less risk to the patient's long-term neurologic function than expected using the log roll.

Hemiarthroplasty was the treatment of choice for rotator cuff tear arthropathy (CTA) before the introduction of the reverse total shoulder arthroplasty (RTSA). The purpose of this study was to compare our outcomes for hemiarthroplasty with those for RTSA.The records of patients with the diagnosis of CTA who had received either a hemiarthroplasty or RTSA from 1997 to 2007 were reviewed. A minimum of 2 years' follow-up was required. Active shoulder elevation, external rotation, internal rotation, and Shoulder Pain and Disability Index (SPADI) scores were obtained. Statistical analysis was performed comparing function, pain, and range of motion of hemiarthroplasty patients with RTSA patients.We identified 56 shoulder arthroplasties in 50 patients with a minimum of 2 years' follow-up. There were 20 hemiarthroplasties and 36 RTSAs performed. The mean follow-up was 4.4 years (range, 2-12 years) in the hemiarthroplasty group and 3 years (range, 2-5 years) in the RTSA group. The mean age in the hemiarthroplasty group was 64 years versus 72 years in the RTSA group (P.05). SPADI scores improved in both groups. However, after follow-up of 2 years or greater, the mean SPADI scores were significantly better (lower) in the RTSA group (34) than in the hemiarthroplasty group (58) (P = .005). Active elevation was significantly better in the RTSA group at all postoperative time periods. The complication rate for both groups was 25%.RTSA performs better than hemiarthroplasty in terms of pain relief, function, and active elevation at 2-year follow-up.

SummaryObjective: To evaluate the integrity of the cranial tibial artery after performing the tibial plateau levelling osteotomy (TPLO) with or without soft tissue dissection and protection with gauze sponges.Study design: Experimental cadaveric study.Animals: Ten dogs weighing 28 to 35 kg.Methods: Ten pairs of normal pelvic limbs were divided randomly into two groups in which a TPLO was performed with or without soft tissue protection with gauze sponges respectively. Angiography was used to evaluate the integrity of the cranial tibial artery after TPLO in each group. Contrast angiography was performed for each group: 1) before TPLO [Control] 2) after TPLO [Osteotomy] and 3) after intentional laceration of the cranial tibial artery [Arteriotomy]. A ‘yes or no’ was used to score contrast extravasation. The area of extravasated contrast was also calculated on the radiographs. A Mann-Whitney test and an ANOVA with repeated measures were completed to assess the score and the area, respectively, for each of the surgical treatments (Control, Osteotomy, and Arteriotomy) between the conditions of dissection with respect to the cranial tibial artery. A value of p Results: The differences between the two groups (with and without protection) for scores and areas of leakage were not significant (p >0.05). However, significant differences were noted between Control and Arteriotomy (p 0.05).Conclusions and clinical relevance: A TPLO without protection of the cranial tibial artery can be performed without increased risk of arterial trauma.

Background Cervical orthoses are commonly used for extrication, transportation, and definitive immobilization for cervical trauma patients. Various designs have been tested frequently in young, healthy individuals. To date, no one has reported the effectiveness of collar immobilization in the presence of an unstable mid-cervical spine. Study Objectives To determine the extent to which cervical orthoses immobilize the cervical spine in a cadaveric model with and without a spinal instability. Methods This study used a repeated-measures design to quantify motion on multiple axes. Five lightly embalmed cadavers with no history of cervical pathology were used. An electromagnetic motion-tracking system captured segmental motion at C5–C6 while the spine was maneuvered through the range of motion in each plane. Testing was carried out in intact conditions after a global instability was created at C5–C6. Three collar conditions were tested: a one-piece extraction collar (Ambu Inc., Linthicum, MD), a two-piece collar (Aspen Sierra, Aspen Medical Products, Irvine, CA), and no collar. Gardner-Wells tongs were affixed to the skull and used to apply motion in flexion-extension, lateral bending, and rotation. Statistical analysis was carried out to evaluate the conditions: collar use by instability (3 × 2). Results Neither the one- nor the two-piece collar was effective at significantly reducing segmental motion in the stable or unstable condition. There was dramatically more motion in the unstable state, as would be expected. Conclusion Although using a cervical collar is better than no immobilization, collars do not effectively reduce motion in an unstable cervical spine cadaver model. Further study is needed to develop other immobilization techniques that will adequately immobilize an injured, unstable cervical spine.

STUDY DESIGN.: Cadaveric biomechanical study. OBJECTIVE.: To quantify spinal motion created by transfer methods from supine to prone position in a cadaveric C1-C2 global instability model. SUMMARY OF BACKGROUND DATA.: Patients who have sustained a spinal cord injury remain at high risk for further secondary injury until their spine is adequately stabilized. To date, no study has evaluated the effect of patient transfer methods from supine to prone position in the operating room, on atlantoaxial cervical spine motion. METHODS.: A global instability was surgically created at the C1-C2 level in 4 fresh cadavers. Two transfer protocols were tested on each cadaver. The log-roll technique entailed performing a standard 180 degrees log-roll rotation of the supine patient from a stretcher to the prone position onto the operating room Jackson table (OSI, Union City, CA). The "Jackson technique" involved sliding the supine patient to the Jackson table, securing them to the table, and then rotating them into a prone position. An electromagnetic tracking device registered motion between the C1 and C2 vertebral segments. Three different head holding devices (Mayfield, Prone view, and blue foam pillow) were also compared for their ability to restrict C1-C2 motion. Six motion parameters were tracked. Repeated measures statistical analysis was performed to evaluate angular and translational motion. RESULTS.: For 6 of 6 measures of angulation and translation, manual log-roll prone positioning generated significantly more C1-C2 motion than the Jackson table turning technique. Out of 6 motion parameters, 5 were statistically significant (P < 0.001-0.005). There was minimal difference in C1-C2 motion generated when comparing all 3 head holding devices. CONCLUSION.: The data demonstrate that manual log-roll technique generated significantly more C1-C2 motion compared to the Jackson table technique. Choice of headrest has a minimal effect on the amount of motion generated during patient transfer, except that the Mayfield device demonstrates a slight trend toward increased C1-C2 motion.