Early Results of Transcatheter Arterial Embolization for Relief of Chronic Shoulder or Elbow Pain Associated with Tendinopathy Refractory to Conservative Treatment.

PURPOSE: To evaluate the effectiveness and safety of transcatheter arterial embolization to relieve pain associated with shoulder and elbow tendinopathy refractory to conservative treatment. MATERIALS AND METHODS: This study included 13 patients (15 cases) who underwent embolization between November 2015 and December 2016 to treat chronic shoulder pain (6 with rotator-cuff tendinopathy, 2 with calcific tendinitis) or elbow pain (7 with lateral epicondylitis) refractory to conservative treatment. Microspheres were used in the first 4 cases, and imipenem/cilastatin sodium was used in the remaining 11. Visual analog scale (VAS) score changes were recorded. Decrease in VAS score and degree of enhancement on digital subtraction angiography were compared. RESULTS: The technical and clinical success rates were 100% (15/15) and 73% (11/15), respectively. The mean VAS scores at baseline, 1 day, 1 week, 1 month, and 4 months after embolization were 6.1, 5.8, 5.1, 4.3, and 2.5, respectively (P < .05 after 1 wk). Pain improved in 9 of 10 cases (90%) with "evident" enhancement and 3 of 5 cases (60%) with no evident enhancement. The VAS scores in the evident enhancement group decreased more than those in patients with no evident enhancement (4.5 vs 1.8; P < .05). Forearm cutaneous erythema was noted in 1 patient treated with microspheres. CONCLUSIONS: Transcatheter arterial embolization may be an option for relieving pain associated with chronic shoulder and elbow tendinopathy refractory to conservative treatment. The degree of angiographic enhancement might be a possible factor affecting the degree of pain relief after embolization.

Does delaying surgery in immature adolescent idiopathic scoliosis patients with progressive curve, lead to addition of fusion levels?

PURPOSE: To analyze the changes in the curve extent, pattern and the fusion level in adolescent idiopathic scoliosis (AIS) patients who undergo delayed surgery instead of early surgery. METHODS: Thirty-five immature AIS patients whose radiographs demonstrated an initial primary curve of more than 40° with a subsequent increase of 10° before attaining skeletal maturity with brace were enrolled. The initial and the final radiographs taken before surgery were compared to assess the changes in curve extent, pattern and the fusion levels as recommended by King's, Lenke's and Suk's guidelines. RESULTS: The average age of 35 AIS patients was 12.7 ± 1.6 years. The time interval between initial and final radiography was 39.3 ± 20.2 months and the degree of progress of the primary curve was 13 ± 9.7°. Fusion levels changed in 33 (94.2%), 33 (94.2%) and 32 (91.4%) patients according to King's, Lenke's and Suk's guidelines, respectively. Curve pattern was changed in 2 (5.7%), 12 (34.3%) and 10 (28.6) patients by King's, Lenke's and Suk's guidelines. The mean number of levels requiring fusion increased from 9.4 ± 2.1 at initial visit to 11.1 ± 1.8 at the final follow-up using King's guidelines, 9.7 ± 2.2-11.6 ± 2.0 as per Lenke's guidelines and 9.1 ± 2.0-11.5 ± 2.3 when fusion was planned using Suk's guidelines (p < 0.001 in all guidelines). CONCLUSIONS: Delay of surgery in immature AIS patients whose Cobb's angle exceed 40° initially and showing subsequent progression of the curve, of more than 10° can lead to alterations in the curve pattern and the need for increase in fusion levels.

Effectiveness of Gelatin-Thrombin Matrix Sealants (Floseal®) on Postoperative Spinal Epidural Hematoma during Single-Level Lumbar Decompression Using Biportal Endoscopic Spine Surgery: Clinical and Magnetic Resonance Image Study.

BACKGROUND: Symptomatic postoperative spinal epidural hematoma (PSEH) is a devastating complication that could develop after lumbar decompression surgery. PSEH can also develop after biportal endoscopic spine surgery (BESS), one of the recently introduced minimally invasive spine surgery techniques. Gelatin-thrombin matrix sealant (GTMS) is commonly used to prevent PSEH. This study aimed at analyzing the clinical and radiological effects of GTMS use during BESS. METHODS: A total of 206 patients with spinal stenosis who underwent decompression by BESS through a posterior interlaminar approach from October 2015 to September 2018 were enrolled in this study. Postoperative magnetic resonance imaging (MRI) was performed in all patients for evaluation of PSEH. Patients in whom GTMS was not used during surgery were assigned to Group A, and those in whom GTMS was used were classified as Group B. In the clinical evaluation, the visual analog scale (VAS) of the leg and back, Oswestry Disability Index (ODI), and modified MacNab criteria were used. The incidence rate and degree of dural compression of PSEH on postoperative MRI were measured. RESULTS: The average age of the patients was 68.1 ± 11.2 (42-89) years. The overall incidence rate of PSEH was 20.9% (43/206). The incidence rates in Groups A and B were 26.4% and 13.6%, respectively, showing a significant difference (p = 0.023). The VAS-leg and ODI improvement was significantly different depending on the intraoperative use of GTMS. However, there was no statistically significant difference between the two groups in terms of the VAS-back improvement. Groups A and B showed "good" and "excellent" rates according to the modified MacNab criteria in 79.4% and 87.6% of patients, respectively, showing statistically significant difference (p = 0.049). In Group A, two patients underwent revision surgery due to PSEH, while none in Group B had such event. CONCLUSION: Intraoperative use of GTMS during BESS may be related to reduction in the occurrence rate of PSEH. Specifically, patients with GTMS appliance showed marked decrease in the occurrence of PSEH and had better clinical outcomes.

The biomechanical performance of bone block and soft-tissue posterior cruciate ligament graft fixation with interference screw and cross-pin techniques.

PURPOSE: The purpose of this study was to evaluate the biomechanical properties of 4 different graft fixation constructs on the tibial side of the posterior cruciate ligament with reconstruction by use of an Achilles tendon graft. METHODS: Biomechanical testing of 4 different fixation techniques was performed on 20 human cadaveric tibias and Achilles tendons. Cross-pin fixation with bone blocks (group A), interference screw fixation with bone blocks (group B), cross-pin fixation of soft tissue with backup fixation (group C), and interference screw fixation of soft tissue with backup fixation (group D) were tested. The tibia-graft fixation complex was cyclically loaded between 50 N and 250 N at 1 Hz for 1,000 cycles. After cycling, the amount of graft displacement was determined by measuring the change in grip-to-grip distance. The complex was then loaded to failure at 1 mm/s, and maximum failure load, stiffness, and mode of failure were determined. RESULTS: Group C had a higher maximum failure load and stiffness than groups A and B (P < .05 and P < .001, respectively) but poor results for displacement (P < .05 and P < .05, respectively). The failure modes were bone block fracture, graft laceration, or cross-pin fracture in the cross-pin groups and graft pullout in the interference screw groups. CONCLUSIONS: Our study suggests that maximum failure load and stiffness of hybrid fixation for Achilles tendon graft are comparable to those of both single calcaneal bone plug fixation methods that we studied. However, tendon graft displacement was significantly greater regardless of fixation method when compared with bone plug fixation. CLINICAL RELEVANCE: Hybrid fixation for soft-tissue graft on the tibial fixation site provides comparable biomechanical properties of bone-to-bone fixation.

Maggot debridement therapy for postsurgical wound infection in scoliosis: a case series in five patients.

STUDY DESIGN: Case series of 5 patients who developed resistant wound infection after scoliosis surgery. OBJECTIVE: To present maggot debridement therapy (MDT) as an effective alternative to the conventional treatment in postsurgical infection in scoliosis. SUMMARY OF BACKGROUND DATA: Numerous clinical reports have been published that describe outstanding effects of MDT, most notable on debridement, cleansing, disinfection, and healing of indolent wounds, many of which have previously failed to respond to conventional treatment. However, till date no reports have been found in the literature describing its use for the treatment of wound infection after scoliosis surgery, which has relatively longer and deeper wound. METHODS: A total of 5 patients (2 females and 3 males) who developed wound infection after scoliosis correction surgery were included in this study. All were operated for neuromuscular scoliosis using posterior approach with pedicle screw fixation. All developed deep wound infection within 2 to 6 weeks of surgery, which was resistant to all kinds of conventional therapy. MDT applied in all using prepared commercially available maggot bags, and dressing was changed twice a week till wound shows signs of healing. After confirming negative culture, MDT was stopped and routine dressings or secondary closure was done. During the treatment, wound appearance, size, and development of healing were observed. RESULTS: There were 1 patient with paralytic scoliosis and 4 with cerebral palsy. All wound healed completely within 5.2 ± 1.8 weeks of MDT or 8.8 ± 3.8 cycles of MDT. There was no recurrence on final follow-up of 21.6 ± 5.9 months. Wound size was also decreased from 24.2 ± 3.3 cm of pre-MDT to 11.8 ± 4.5 cm post-MDT showing 51.2% reduction in wound size. There was partial implant removal in 2 cases before MDT; however, no further implant extraction was needed in any case after MDT. Treatment was tolerated well by all patients without any obvious complications due to MDT. CONCLUSION: We would propose to use MDT for the treatment of wound infection after scoliosis surgery as an effective alternative to conventional treatment. In this way, implant extraction could be avoided without losing any correction.