Lightning Podiums: Smorgasboard - Room 802B

Presented by: F. Altaf

Author(s):

L. Wilson(1), F. Altaf(2), P. Tyler(3), R. Dhawan(4)

(1) Wellington Hospital, Spinal Unit, London, United Kingdom
(2) Royal National Orthopaedic Hospital, Spinal Surgery, Stanmore, United Kingdom
(3) Royal National Orthopaedic Hospital, Radiology, Stanmore, United Kingdom
(4) Wellington Hospital, Radiology, London, United Kingdom

Abstract

Objective: This study evaluates the clinical and radiological outcomes following the Percutaneous internal fixation of incomplete pars inter-articularis fractures using a Titanium compression screw.

Method: 19 consecutive patients [2 female, 17 male] aged 15-31 [mean 21.4 years] were operated on between April 2010 - July 2016. The fractures were unilateral in 16 patients and bilateral in 3 patients. The mean duration of symptoms pre-operatively was 15.7 months, with three patients undergoing surgery acutely due to severe symptoms at between 1-4 months, and one at 9 months due to deteriorating pain despite 6 months of rest. The other 15 patients failed one or more cycles of conservative management, with the return of symptoms once they re-engaged with their sport. All but one patient was either an Academy or a Professional sportsman. The sports were Cricket [6 Academy, 7 Professional, all fast bowlers], Football [2 Academy, 1 Professional] and Athletics [2 Professional]. The operations were performed with the patients prone on a radiolucent table using fluoroscopic screening in three planes [AP, Lateral, and Oblique circa 30º]. A 1.5cm incision was made below the corresponding spinous process in the midline, enabling access to both sides if required. A Jamshedi needle was docked onto the inferior surface of the lamina, and once the correct orientation was established, a guide wire was drilled across the fracture site and the position checked with an intra-operative CT. Once the wire was correctly sited a drill and tap prepared the channel for the compression screw. Post-operatively the patients were mobilised with a simple corset and discharged within 24 hours, with a customised rehabilitation program starting at 2 weeks post-operation. In one patient the intra-operative CT failed, and the following day a CT showed an asymptomatic transgression of the lateral recess with the screw thread, which was revised.

Results: The patients have now been followed-up for between 1-7 years. A CT scan was performed at between 3-6 months post-operation, and all but one case showed excellent evidence of healing. The single case showed an area of lysis around the screw at the fracture site, but no distal or proximal loosening. The screw was removed and the screw channel was prepared with a high-speed burr and grafted. The cavity and fracture healed by 5 months. All 10 Professional Sportsmen/women resumed their previous level of sport at between 4-6 months. This includes 4 Internationals who continue to represent their country at Cricket [1], Soccer [1] and Athletics [2]. Three of the 6 Academy Cricketers have now become Professionals, 1 remains in the Academy, and 2 have moved on to Grade level Cricket. Two soccer players remain at the Academy level, and the only non-Sportsman in the series remains asymptomatic at 7 years.

Conclusion: Sportsmen/women who have persistent symptoms from incomplete Pars Interarticularis fractures after a cycle of conservative treatment, should consider percutaneous internal fixation rather than undergo prolonged or repeated cycles of conservative treatment. Percutaneous Internal fixation can reliably achieve fracture healing with minimal soft tissue damage, allowing the athlete to maintain fitness during the recovery period, and once healing is established they can rapidly return to full function.