One frantic evening on nightfloat as a PGY-2, Dr. Glotzbecker was confused by the issue of thromboembolic chemoprophylaxis for postoperative spine patients. From there, he developed a multi-part investigation in this topic to identify the prevalence of thromboembolic disease and epidural hematomas in postoperative spine patients and to determine the optimal time to start chemoprophylaxis in these patients. His initial endeavors started with online questionnaire to 193 orthopaedic and neurosurgical spine surgeons established in clinical practices in spine trauma and/or spine tumor surgery. From this questionnaire, he gathered that there was no clear consensus regarding the optimal timing to initiate post-operative chemoprophylaxis. Moreover, their opinions regarding the risk of postoperative epidural hematoma and DVT’s were also widely varied. From pooled analysis of systematic review of the literature, he estimated overall rate of DVT and PE in postoperative spine patients to be 2.7% and 0.2%, respectively. These numbers were obtained from widely varying prophylaxis regimens and surveillance methods. In addition, he gathered that overall incidence of postoperative epidural hematoma with and without LMWH prophylaxis were 0.2% and 0.4%, respectively. Despite lack of strong evidence based practice, the authors from literature recommended the routine use of pneumatic sequential compression devices (PSCD) and thromboembolic deterrent stockings (TEDS) for any spinal procedure. For higher risk patients, defined by previous thromboembolic event, advanced malignancy, significant neurological deficit or anterior spine approaches, chemical prophylaxis and/or IVC filter may be considered. In sum, Dr. Glotzbecker concluded that there are currently insufficient data in literature for a definitive position statement on chemoprophylaxis against thromboembolic disease in spine patients. His thesis highlighted the need for rigorous, prospective evaluation of TE risk after spine surgery.

Dr. Kevin McGuire congratulated Dr. Glotzbecker on tremendous amount of work. He highlighted the different views of postoperative DVT’s in joint surgeons and spine surgeons. The subsequent discussion questioned whether the current surveillance method is sufficient. Dr. Thornhill commented that the sources of the pulmonary embolus may not always be from the lower extremity. Dr. Glotzbecker agreed and commented that a fair number of DVT’s in the pelvis can be missed with current surveillance methods.

Hailed as “dead-bone sandwich,” treatment of bicondylar tibial plateau fractures has been a challenge for orthopaedic surgeons for years. Current classification systems are based on plain films and the standard of treatment has been lateral locking plates. Dr. Weaver looked at bicondylar tibial plateau fractures on CT scans and investigated the different fracture patterns and the role for dual plating in treatment of these fractures. He studied 140 patients and evaluated their preoperative CT scans which revealed 47% had single large medial fragment with articular surface intact, 14% had medial articular fracture line with a non-coronal component and 39% had coronal fracture through the medial articular surface. He looked at post-op plain films immediately postop to assess angular alignment and again at the time of union to assess loss of reduction. Of the 129 patients that were treated with lateral locked plating alone and 11 patient with coronal fracture of the medial condyle that underwent dual plating, he demonstrated that the presence of medial coronal fractures line resulted in fractures healing in more varus (2° [-4.5-13°) vs. 0.5° [-2.0 – 3.5°]]. In addition, patient with coronal fracture lines treated with dual plating had significantly less loss of reduction.

Dr. Rodriguez congratulated Dr. Weaver for tackling the difficult topic of “dead-bone sandwich” and commended him for classifying and quantifying the different fracture patterns on CT and their optimal surgical treatment. Dr. Thornhill, in his interest in total knee arthroplasty, asked what incision or incisions were used for dual plating. To his dismay, Dr. Weaver answered, separate medial and lateral incisions.

Dr. Kathryn Grannatt investigated the Galeazzi semitendinosus tenodesis for patellofemoral instability in skeletally immature patients. She retrospectively analyzed a population of skeletally immature patients who underwent semitendinosus tenodesis for patellofemoral instability with minimum of 1 year follow-up. Condition-specific outcome and function were determined using the IKDC score, the Kujala Score, and the Marx Activity Scale. Twenty-eight patients (34 knees) were included in the study, and follow-up averaged 65 months (range 18 to 217 months). Thirteen knees required subsequent surgery, and 15 knees had at least one episode of recurrent patellar subluxation or dislocation. Dr. Grannatt found a failure rate, which included those cases requiring revision surgery or those with recurrent patellar dislocation or subluxation, of 82.4% (28 of 34 knees). The overall satisfaction with the surgery was 6.4 for those who failed treatment and 9.5 for those without recurrent instability. Dr. Grannatt concluded that semitendinosus tenodesis for patellofemoral instability in skeletally immature patients appears safe but carries a high failure rate. She further concluded that consideration should be given to more anatomic contemporary patellofemoral ligament reconstruction procedures in skeletally immature patients. Dr. Kramer noted that the population studied presents a very challenging problem and that Galeazzi semitendinosus tenodesis may be a successful temporizing procedure until skeletal maturity when an osseous procedure may be performed.