Spinal infection may occur due to iatrogenic causes. Its pathogenesis, clinical presentation, management, various imaging techniques, and its application in instrumented and noninstrumented spines are discussed. We provide an overview of the typical infection locations and its imaging correlates, such as spondylodiscitis, epidural and paravertebral abscesses, facet joint infection, and myelomeningitis. Iatrogenic spinal infection should be differentiated from postoperative fluid collections, such as hematoma, seroma, and pseudomeningocele.

This study analyses the accuracy of three-dimensional pre-operative planning and patient-specific guides for orthopaedic osteotomies. To this end, patient-specific guides were compared to the classical freehand method in an experimental setup with saw bones in two phases. In the first phase, the effect of guide design and oscillating versus reciprocating saws was analysed. The difference between target and performed cuts was quantified by the average distance deviation and average angular deviations in the sagittal and coronal planes for the different osteotomies. The results indicated that for one model osteotomy, the use of guides resulted in a more accurate cut when compared to the freehand technique. Reciprocating saws and slot guides improved accuracy in all planes, while oscillating saws and open guides lead to larger deviations from the planned cut. In the second phase, the accuracy of transfer of the planning to the surgical field with slot guides and a reciprocating saw was assessed and compared to the classical planning and freehand cutting method. The pre-operative plan was transferred with high accuracy. Three-dimensional-printed patient-specific guides improve the accuracy of osteotomies and bony resections in an experimental setup compared to conventional freehand methods. The improved accuracy is related to (1) a detailed and qualitative pre-operative plan and (2) an accurate transfer of the planning to the operation room with patient-specific guides by an accurate guidance of the surgical tools to perform the desired cuts.

PURPOSE To evaluate the long-term clinical results and the effectiveness of the anterior lumbar interbody fusion procedure. METHODS Between 1999 and 2005, 60 ALIFs were performed in 59 patients. Mean age was 41.1 years. Clinically, patients were evaluated at a mean follow-up of 9.5 years using the Visual Analogue Scale grading scale, the Oswestry Disability score and the SF-36 questionnaire. RESULTS Preoperative and postoperative clinical evaluation scores of 38 patients were available. Nineteen patients were lost to follow-up, and 2 patients died during the follow-up. The fusion rate was 84%. Mean preoperative VAS-score for back pain was 6.69 (±2.15) ; in the long term, the mean VAS-score was 4.95 (±2.95), which was a significant improvement. (p<0.01). The postoperative ODI-score was 36.11 (±22.32), while the preoperative ODI-score was 59.31 (±17.16), which demonstrates a significant improvement. According to the SF-36, mild to good results were observed. CONCLUSIONS The ALIF procedure can offer significant pain relief and improved function if a strict indication policy is followed.

Objective. In pursuance of thoroughly understanding and facilitating the evaluation of the radiological changes in the preloaded bone by Compliant Pre-Stress osseointegration (Compress Biomet, Warsaw, Indiana) a new staging method was created depicting four stages. Methods. Two cohorts (10 and 17 patients resp., not-receiving and receiving chemotherapy) were compared in terms of progression of osseointegration. Based on the changes at the bone-metal interface seen on röntgenorgrams four stages were defined: stage 0: immediate postoperative status, no ingrowth, or noncalcified callus; stage 1: early mineralization, calcified callus; stage 2: mature mineralization; and stage 3: hypertrophy at the level of the pins. Results. There were no significant differences between the two cohorts. Group 2, which was significantly younger than group 1 (p<0.001), presented a delayed initial rate of bone formation and reached stage 1 at 6 months instead of 3 months like group 1. The children from the group 2 demonstrated a visible rebound ingrowth. Conclusion. Despite the fact that the staging fails to demonstrate a statistical difference, it is rather simple and can be used for future studies.

The chick chorioallantoic membrane (CAM) assay was used to evaluate whether xenotransplanted sarcomas retain the histological characteristics and functional behavior of the original tumors. Metabolically active tumor tissue, identified by dynamic-contrast MRI, from 28 patients with a bone or soft-tissue tumors was applied to the CAM. Angiogenesis and graft and host behaviors were evaluated. The essential features and immunohistochemical characteristics of the original tumors were maintained, illustrating the diversity of sarcomas. Graft viability was inversely related to patient survival, but longer follow-up and more patients are needed to relate tumor graft behavior to natural history. We conclude that the CAM assay is a potential prognostic and predictive preclinical xenograft model for tumors that are difficult to culture in vitro, such as sarcomas; therefore, the use of the CAM assay may facilitate personalized medicine.

Anterior lumbar interbody fusion (ALIF) has increased in popularity because it has advantages over posterior fusion. Because there is disagreement about the stability of stand‐alone cage ALIF, some surgeons use various types of supplementary fixation, including anterior plates, pedicle screw systems and translaminar screws, to increase segmental stability. Many factors associated with both the cages and endplates influence the time of onset and extent of subsidence after use of stand‐alone cage ALIF. A large round cage with an adequate central opening is recommended to facilitate maximum contact with the periphery of the endplate. With regard to the relationship between radiographic fusion and recurrence of symptoms with the development of subsidence, most researchers have reported finding no correlation. Subsidence may be due to a process of bone incorporation between cages and endplates. Does subsidence or nonfusion really matter clinically? Further prospective, randomized controlled trials are very much needed to answer these questions.

Limb salvage is the gold standard to treat sarcoma patients, but bone stock should be retained for the future, as many of these patients are young and active. For this observational clinical study, 107 patients that presented with 108 malignant or locally aggressive benign bone tumours were treated by wide en-bloc resection of the affected bone, extracorporeal irradiation with 300 Gy to eradicate the tumour, and reimplantation of the bone as an orthotopic autograft. The irradiated bone was rigidly fixed to the remaining bone with classical intramedullary or extramedullary osteosynthesis material. We made a subdivision between intercalary, composite and osteoarticular grafts. The pelvis was considered a third separate entity, as it was considered both an intercalary and an osteoarticular graft when the acetabulum was involved. The incidence of local recurrence with the use of an orthotopic autograft comprised the primary endpoint of this study. Secondary endpoints: preservation of bone stock with graft healing and evaluation of factors that determine preservation. No local recurrences could be detected in the irradiated grafts. One local recurrence was detected in the surrounding soft tissue. At 5 years follow-up, graft healing occurred in 64% of cases, providing stable and lasting reconstruction. Eleven percent of the grafts had to be removed due to several incidents, but none could be proven significant. All patient subgroups displayed comparable results. Early infection appeared to be a significant determinant for the development of pseudarthrosis. Pelvic reconstructions showed a worse outcome. According to the results, guidelines for indications and surgical guidelines, such as rigid fixation and bridging of the graft, are proposed for using this technique. In general sarcoma resection, extracorporeal irradiation, and reimplantation provides a stable and lasting reconstruction with preservation of bone stock.

Vertebroplasty (VP) and kyphoplasty (KP) have been proven equally effective in providing pain relief in patients with vertebral compression fractures (VCF). Both have been reported to have multiple complications which, though rare, are potentially devastating. This literature review focuses on comparing the incidence of various types of complication of VP and KP. Local cement leakage and pulmonary cement embolism have been reported more commonly after VP than KP. It is questionable whether the relative risk of developing an adjacent level new fracture after VP is greater than after KP The relationship between a new VCF and each of these procedures has also not been clearly established. Although the majority of complications are clinically silent, their potential risks, which include a fatal outcome, should always be kept in mind by the practitioner.

We retrospectively reviewed 107 patients with 108 malignant or locally aggressive bone tumours treated between 1978 and 2009 by extracorporeal irradiation with 300 Gy to eradicate the tumour, and reimplantation of the bone as an orthotopic autograft. Patient subgroups were defined according to resection type. We describe the local recurrence rate, the graft infection rate and the factors affecting graft healing and graft survival. No local recurrences were detected in the irradiated grafts. At five-year follow-up, graft healing had occurred in 64% of patients, providing a stable and lasting reconstruction. For various reasons, 11% of grafts were removed, although no single factor was predictive of failure. All patient subgroups had comparable results. Early infection predicted the development of pseudarthrosis. Pelvic reconstructions had a worse graft survival. Rigid fixation and bridging of the graft appeared to be important technical points.

To analyse the long-term radiographic findings of intercalary, pure osteoarticular, and composite bone grafts in patients with primary bone sarcoma who were treated by reimplantation of the bone as an orthotopic autograft.

Detection of local recurrence after sarcoma resection can be impaired by metal implants locally, or by the patient ‘s general condition. Metal implants cause severe distortion and scattering of either MRI or CT data acquisition. Therefore the detection of local recurrences in proximity of heavy metal implants such as prostheses or osteosynthesis material can be difficult. Patient related conditions, e.g. renal insufficiency, allergy, claustrophobia, may completely prohibit the use of contrast media or even a scan itself. Ultrasound provides several advantages, and can be used for different indications in sarcoma patients. Patient related conditions prove no obstacle for this technique. Currently our indications are local follow-up after soft-tissue sarcoma resection and evaluation of regional lymph nodes, detection of local recurrence of bone sarcoma in proximity of metal implants, and amputation stump evaluation. We describe a patient study population of 103 patients. Seventeen had only diagnostic and staging ultrasound, four had an evaluation of their amputation stump, 24 were followed after resection of a soft-tissue sarcoma, and 58 were followed by this method after sarcoma resection and implantation of metallic implants. Evaluation modalities are described according to the indications. Results: We have detected nine local recurrences, and four patients with suspect lymph nodes had a biopsy of which half showed malignant tumour cells. Infection and inflammation around metallic implants can be evaluated, the technique also allowing placement of drains in infected seromas in irradiated regions. It should be emphasised that reliable results can only be achieved if a baseline ultrasound is performed, followed by subsequent studies at regular intervals.

The authors present two series of six and seven patients respectively, with a tumour of the proximal humerus, who were treated at two different institutions with a Delta type inverted shoulder prosthesis (DePuy International Ltd) after a Malawer type Ia or Ib resection. The rationale of using an inverted shoulder prosthesis is the aim to improve the functional outcome in rotator cuff deficient shoulders. This type of prosthesis medializes and lowers the centre of rotation, lengthens the lever arm of the deltoid muscle and improves its function. At one institution the resected part of the humerus was re-implanted after extracorporeal irradiation. It was fixed intramedullarly by cementation of the humeral prosthetic component to facilitate restoration of humeral height. This graft allowed reinsertion of muscles (deltoid, pectoralis, biceps) thus improving power generation postoperatively. The largest glenosphere, size 42, was routinely used to reconstruct the glenoid; this theoretically improves the functional outcome (increased external rotation) and stability. At the other institution no graft augmentation was used except in one patient. The height of the humeral prosthetic component was assessed after resection of the tumour by measurement of the resected part. The prosthetic stem was fitted in the remaining part of the humeral diaphysis, in three cases by cementation and in three cases by press-fit (hydroxyapatite coating). Muscle balance was appreciated intra-operatively. Stability of the prosthesis was directly related to the level of resection. Both techniques resulted in a minimum active abduction of 60 degrees, reaching 90 degrees or more in most patients. When compared to other results in the literature, this is a major functional improvement. The mean adjusted postoperative Constant score was 72.5% (range: 30-90%), and the mean MSTS score was 75.8% (range 36.7-96.7%).

Percutaneous vertebroplasty is increasingly used for the treatment of vertebral compression fractures. Local leakage of polymethylmethacrylate cement into the perivertebral space is a common complication, but important systemic effects have rarely been reported. The authors describe the case of a 52-year-old patient with central pulmonary embolism after percutaneous vertebroplasty of the eleventh thoracic vertebral body. The large cement embolus was removed from the right pulmonary artery with a hybrid technique combining an interventional catheter procedure with an open heart operation. The patient made an uneventful recovery. The authors review how appropriate arthroplasty techniques might minimize the risk of this dreadful complication.

We treated 15 patients suffering from an extracompartmental malignant pelvic tumour by resecting the affected part of the bone, irradiating it extracorporeally with 300 Gy, and reimplanting it after having removed the bulk of the lesion. Adjuvant therapies were used according to the type and extension of the tumour. Follow-up was an average of 4 years 6 months. Complications were seen in 13 patients. Most mechanical complications were related to the use of hip arthroplasties. Internal fixation of the graft failed in one case only, infection was seen in three cases, and seven patients died after local recurrence. Functional scores were fair. Although many complications were seen, this method remains our treatment of choice.