Medial and lateral exostoses of the distal phalanx of the hallux: A potentially painful bunion-like structure. Part 1: Incidence and clinical application.

BACKGROUND: Exostoses at the base of the distal phalanx of the great toe are usually asymptomatic. The literature has not generally considered them as the origin of a possible problem resulting from a pressure conflict between hallux and shoe (medial aspect) or second toe (lateral aspect) nor a potential complication of surgical correction of hallux valgus deformity. No studies, to our knowledge, have evaluated its possible correlation with other foot disorders. When one of these neglected exostoses became painful after surgical correction of hallux valgus, we decided to start a study to determine their possible origin, prevalence in daily practice and histo-pathological morphology. METHODS: Two hundred and fifty-four feet of patients (average age 41.7y.) were enrolled in the study from January 2007 to June 2009. Dorsoplantar weight-bearing radiographs were used to analyze the presence of exostoses and their correlation with the distal phalanx morphology, metatarsal formula (or transverse plane orientation of the metatarsal heads parabola) and hallux valgus angles. Patients were classified according to their age and main symptom for consultation. Four exostoses removed from cadaver feet were also analyzed microscopically. RESULTS: Osseous excrescences arising on the medial or lateral aspect at the proximal part of the terminal phalanx of the hallux were observed in 132 feet (51.9%). Thirty-five feet out of these 132 (13.7%) had exostoses on both sides of the phalanx.A statistically significant positive correlation was found between the presence of a medial exostosis of the phalanx and the severity of HVA. Patients with higher IPH and asymmetry angles have a lower prevalence of medial exostoses (p<0.05). Amongst the different morphologies of the second phalanx, exostoses were most likely found in the standard form. CONCLUSIONS: Prevalence of exostoses at the base of the distal phalanx is high (51.9% of the studied feet). Histological findings would suggest that these exostoses could be considered a mechanical reactive process, produced by a chronic irritation by shoes. We encourage surgeons to be aware of its potential clinical implications. Direct resection is very simple and the most appropriate treatment for symptomatic cases.

Ongoing and cumulative pregnancy rate after cleavage-stage versus blastocyst-stage embryo transfer using vitrification for cryopreservation: impact of age on the results.

PURPOSE: To determine if blastocyst transfer increases the ongoing and cumulative pregnancy rates, compared with day 3 embryo transfer, in women of all ages when at least 4 zygotes are obtained. METHODS: Prospective study including patients undergoing a first IVF/ICSI treatment and assigned to cleavage stage (n = 46) or blastocyst (n = 58) embryo transfer. Supernumerary embryos were vitrified and patients failing to achieve an ongoing pregnancy after fresh embryo transfer would go through cryopreserved cycles. The main outcome measure was the ongoing pregnancy rate after the fresh IVF/ICSI transfer and the cumulative ongoing pregnancy rate. Results were also analyzed according to age (under 35 and 35 or older). RESULTS: A majority of patients (96.6 %) had a blastocyst transfer when at least 4 zygotes were obtained. The ongoing pregnancy rate was significantly higher in the day-5 group compared with the day-3 group (43.1 % vs. 24 %, p = 0.041). The cumulative ongoing pregnancy rate was higher (but not significantly) with blastocyst than with cleavage stage embryos (56.8 % vs. 43.4 %, p = 0.174). When analysed by age, patients 35 or older showed significantly higher ongoing pregnancy rate (48.4 % vs. 19.3 %, p = 0.016) and cumulative ongoing pregnancy rate (58 % vs. 25.8 %, p = 0.01) in the day-5 group compared to the day-3 group, while no such differences were observed in women under 35. CONCLUSIONS: Blastocyst transfer can be suggested whenever there are at least 4 zygotes. While there are no differences in women under 35, the benefit of this option over cleavage stage transfer could be significant in women 35 or older.

Iliac bone Candida albicans osteomyelitis in a patient with iliac crest bone autograft: a case report and review of the literature.

Candida osteomyelitis is a well recognized but infrequent entity. We describe an interesting case of iliac bone C. albicans osteomyelitis as a result of a surgical trauma of an iliac bone for the auto-grafting of a fracture in the lumbar spine. The peri-operative acquisition of Candida was by the inoculation of a yeast colonizing the skin. Remarkably, several risk factors described for Candida infection and candidemia were absent. The patient also presented with a local fistula. The iliac crest was the only bone affected and local pain was the only symptom present in our case. Diagnosis was made by multiple-specimen biopsy obtained by surgery. Treatment with fluconazole was successful.

Vitrification can modify embryo cleavage stage after warming. Should we change endometrial preparation?

PURPOSE: Studies have shown that embryo metabolism and cell cleavage after warming vitrified embryos is faster than after thawing frozen embryos. We study vitrified embryo transfer (VET) results depending on the developmental stage of warmed embryos and the duration of progesterone treatment before embryo transfer. METHODS: We designed a prospective study, patients were randomized in two groups, starting progesterone three (D + 3) or four days (D + 4) before embryo transfer. We recruited 88 patients with embryos vitrified on day 3. RESULTS: We didn't find statitistical differences in pregnancy rate when we transferred embryos in D + 3 vs D + 4 (38.2 % vs 40.5 % p ≥ 0.05). The day after warming, 54.6 % of embryos had developed to morula or early blastocyst, 32.4 % to cleavage stage and 13 % didn't cleave. Transfers were with morula/blastocysts stage embryos (52.1 %; n:37), cleavage stage embryos (18.3 %; n:13) or mixed (29.6 %; n:21). Implantation rate was significantly higher in morula/blastocyst stage than in cleavage stage or mixed transfers (44 %, 22 % and 16.3 %; p = 0.011). Pregnancy and implantation rates were significantly higher in morula/blastocyst transfers on D + 4 than on D + 3 (68.7 % and 64.7 % vs 33.3 %, and 33.3 %, p = 0.033 and p = 0.034). CONCLUSIONS: Our findings suggest that a majority of embryos will develop to morula/blastocyst stage after warming. VET results with morula/blastocysts, and after four days of progesterone supplementation, are better than with cleavage stage embryos.

The dimensions of the posterior arch of C2 for instrumented screw fixation. A radiological study in the Spanish population.

BACKGROUND: To describe the feasibility of the posterior arch of C2 accepting two crossing screws in the Spanish population. METHODS: One hundred and fifty patients who underwent a routine neck CT scan for non-cervical pathology were enrolled. Submillimeter slices (thickness 0.7 mm) every 0.4 mm were performed with a 64 multi-detector CT scan, which allows isometric measurements. We measured the length and height of the cortical and cancellous (endomedullar) region of the lamina and the spinous process, inclination, maximal screw length and spinolaminar angle. RESULTS: The average (standard deviation) measurements of the lamina were: width of the left cortical 7.2 (1.5) mm, right cortical 6.9 (1.3) mm, width of the cancellous part of the left lamina 4.8 (1.5) mm, right side 4.6 (1.4) mm. The mean left cortical height was 13.0 (1.5) mm and 13.1 (1.6) mm for the right. The mean height of the cancellous part was 9.0 mm for both sides. The average measurements of the spinous process were: cortical length 15.7 (3.5) mm, endomedullar length 12.5 (3.9) mm; cortical height 11.9 (2.2) mm, endomedullar height 8.4 (2.1) mm; spinolaminar angle 49º (4); the maximum screw length 3.18 cm, and the inclination angle 143º. CONCLUSION: A CT scan with submillimeter slices is necessary in order to avoid malpositioning of the screws. The outer cortical measurements are 2 to 4 mm bigger than the endomedullar ones. Taking into account the dimensions of the spinous process, 24% of the population would not be candidates for this crossing screw technique.

[Bilateral hip fracture in a patient with Down syndrome]. / Fractura bilateral de cadera en un paciente con síndrome de Down.

There are few published data available about simultaneous bilateral hip fractures. We present the case of a 56-year-old man with Down syndrome and Alzheimer-like dementia with simultaneous bilateral hip fracture. A bilateral partial hip cemented arthroplasty was performed on this patient. The aim was to avoid the partial burden that could be caused by ostheosynthesis, due to the patient's lack of cooperation arising from his mental deterioration and his problems realizing everyday activities. He was able to walk unaided with complete autonomy until his death fourth years later. In our experience, one stage surgery for bilateral hip prosthesis is safe and provides good results in patients with severe mental impairment.

Cervicobrachialgia and pancoast tumor: value of standard anteroposterior cervical radiographs in early diagnosis.

Ten patients diagnosed with Pancoast tumor were studied retrospectively. The definitive diagnosis was made between 2 and 24 months after the onset of pain. Pain localization was hard to pinpoint; some patients reported pain in four different sites (neck, shoulder, arm, and scapula). Five patients had previously been diagnosed with degenerative, inflammatory, or infectious diseases of the cervical spine or shoulder. In the remaining five patients, the diagnosis was made during the first clinical visit. In three patients, an orthopedic surgeon made the diagnosis by viewing a standard anteroposterior (AP) cervical radiograph. The radiographic evidence arousing suspicion of a Pancoast tumor was the lack of pulmonary air at the top of the affected lung. Furthermore, a parallel study was conducted on 100 consecutive patients seeking treatment for neck pain. By examining the AP radiographs of their cervical spines, the third rib and the top of both lungs were observed in all cases. This study stresses the value of standard AP cervical radiographs in the diagnosis of Pancoast tumor.

[Synovial cyst in the lumbar facet joint. A rare cause of lumbar-sciatic pain]. / Quiste sinovial en articulación interapofisaria lumbar. Una causa infrecuente de lumbociática.

Synovial cysts of the facet joints are uncommon lesions which may be asymptomatic or present as low back pain, with or without radicular symptoms. They are considered to be secondary to trauma or degenerative joint disease, and they occur more frequently in patients with spondylolisthesis. Diagnosis is normally achieved with computed tomography or magnetic resonance, which show a cystic lesion located laterally adjacent to the facet joint. We review the literature and report a patient who presented with first sacral nerve root symptoms attributable to a ganglion cyst of the left L5 S1 facet joint. Treatment was curative and consisted in excision of the cyst.

[Cauda equina syndrome due to giant disc herniation]. / Síndrome de cauda equina por hernia discal gigante.

In cases of acute or progressive development in a few hours of bilateral sciatica, severe foot and occasional quadriceps weakness and/or retention or incontinence of urine with perineal hypalgesia or anesthesia, acute compression of the cauda equina should be suspected, which is usually due to a lumbar disc herniation. Cauda equina syndrome requires emergency spinal surgery. To identify and confirm this syndrome by MR, Ismanoatory. Early surgical decompression must be achieved. Decompression within 24-48 hours significantly improves the neurological and urological outcome. We present the case of a patient who had previously been treated for low back pain who developed a cauda equina syndrome a few days later.

[Non-tuberculous infections of the spine]. / Infecciones no tuberculosas del raquis.

Non tuberculous spondylodiscitis of the rachis is an uncommon entity that affects boys and male adults with greater frequency. The zone with higher incidence of affection is the lumbar region. Usually the causal germ travels through the hematogenous via from an extrarachidial infectious area. Clinical manifestations begin with an acute segmentary rachialgia and paravertebral muscular contracture while presenting fever. In special cases of little boys or when having radiated pain, the presenting form could be confusing. There is always a vertebral rigidity when performing the physical exam and an increase of the globular sedimentation rate. A septic leukocytal formula is not always present. Between the onset of symptoms and the appearance of radiologic alterations (decrease in the height of the disc, erosion and vertebral destruction, reactive bone neo-formation) there is a variable two to eight weeks latency period. Scintigraphy with Tc99 and Ga67 and CAT scan are very important when facing definite diagnosis. To be able to reach a bacteriological diagnosis, we employ puncture-aspiration of the disc. The isolated germ in most cases is staphylococcus aureus. The most complex differential diagnosis is with tuberculous spondylodiscitis. The evolution is favorable if the treatment is initiated early and if it is adequate (antibiotic therapy and immobilization). If this is not done, recurrences and chronicity of the infection can occur, as well as orthopaedic (Kyphosis) and neurological complications.

[Congenital malformations of the atlas: classification and clinical significance]. / Malformaciones congénitas del atlas: clasificación y repercusión clínica.

A classification of congenital anomalies of atlas is proposed in order to make a systematic approach to its radiological diagnosis. Atlas is divided in four areas (posterior arch, union of posterior arch and articulation, articulation and anterior arch) for isolated malformations and two more for occipito-atloid and atlo-axoid anomalies. The common anomalies and its possible clinical relevance in each area are described.

[Use of bone allografts in the surgical repair of tibial plateau fractures]. / Empleo de aloinjerto óseo en la reparación quirúrgica de fracturas del platillo tibial.

The number of indications of the allografts is increasing in bone and joint pathology treatment. With this good alternative, it is possible to avoid the morbidity sometimes observed in patients in which autograft is used. We present 6 cases of fractures of the external tibial plateau type B3 (AO classification) treated using bone allograft (a piece of femoral head) as a support of the tibial plateau after to get a proper reduction of the fractures. In all the cases we got good results in the support function of the allograft as in consolidation, with no complication.

[Surgical treatment of vertebral metastasis]. / Tratamiento quirúrgico de las metástasis vertebrales.

Spinal metastases may cause pain and neurologic dysfunction secondary to bone destruction and spinal cord compression. The new oncology therapy have prolonged life expectancy of many patients with different primary tumors. The treatment of metastases is frequently necessary to enhance quality of life. We reviewed 121 patients with spinal metastases of different primary tumors operated between 1982 and 1995. We employed different approach and instrumentation depending on particular case, metastases location and life expectancy. We analysed primary tumor location, spinal pain, neurologic function, pre and post surgical treatment, complications and development. Spinal stabilization and cord decompression gives excellent results for pain relief, neurological improvement and quality of life, always helping to medical treatment of a patient with metastatic disease.

[Cervical spondylodiscitis]. / Espondilodiscitis cervicales.

Eighty patients were treated for spondylodiscitis with the cervical spine involved in nine cases. Conservative treatment was applied in seven cases with Minerva jacket and antibiotics, and surgical treatment was applied in severe, rapidly, progressive, complicated cases and in patients with involvement of nervous system (two cases). The good and satisfactory results in both group were similar. These results show that when the indications are properly established, both conservative and operative methods have satisfactory results.

[Epiphyseal osteoid osteoma]. / Osteoma osteoide epifisario.

Three more cases of osteoid osteoma located in epiphysis are presented. All of them had special features, as a reactive synovitis due to the proximity of the lesion to the joint and the lower movility arch of these joints. The x-ray was essential for the diagnosis and definitive treatment was surgical resection.

[Allografts in extensive spinal arthrodesis]. / Aloinjertos en artrodesis vertebrales extensas.

Surgery of spinal deformities and vertebral tumors often requires extensive arthrodesis, with the difficulty of obtaining sufficient autogenous bone graft (particularly in children and cases of paralytic deformities) and the necessity of a second incision, thus lengthening the operation and eventual increase of the morbidity. We present 52 patients who suffered from vertebral tumours, fractures or spinal deformities and underwent spinal arthrodesis surgery. Femoral head allografts were used as cancellous bone graft to add to the amount obtained from the arthrodesis bed itself (posterior structures). In three occasions, femoral head grafts shaped as a strut were also used as intersomatic bone graft, being implanted via a costotansversectomy. The only complication was the appearance of seromas of spontaneous resorption in the first 15 cases (thereafter repeated cleaning of the bone graft avoided this problem). In our experience, bone grafts facilitate the carrying out of shorter surgical operations but can also avoid having to recourse the further incisions without reducing the possibility of obtaining a successful arthrodesis.

[Radiologic evaluation of idiopathic congenital clubfoot and its clinical correlation in Codivilla's surgical technique]. / Valoración radiológica del pie zambo congénito idiopático y su correlación clínica en la operación de Codivilla.

Thirty-seven patients (52 idiopathic clubfeet) were treated with Codivilla's technique between 1971 and 1985. Radiological measurements and clinical evaluation before and after surgery were performed; a correlation was carried out between these evaluations and personal satisfaction. The results were rated as follows: poor in 4 feet (7.7%), fair in 18 feet (34.6%), good in 24 feet (46.2%) and excellent in 6 feet (11.5%) with a total percentage of satisfactory results amounting to 57.7%. Our conclusion is that when the indications are properly established, Codivilla's technique is a good procedure to correct clubfoot.

[Histiocytosis X]. / Histiocitosis X.

We make a clinical and bibliographical review in diagnosis and treatment of Histiocytosis X, who includes three components: Eosinophylic granuloma, Hand-Schüller-Christian disease and Letterer-Siwe syndrome. We had 28 cases, with an average age of 11.8 years. Eighteen (64%) were males and 10 (36%) females. Seventeen were solitary lesions and 8 had multiple skeletal lesions. Three patients had generalized disease: 2 with Hand-Schüller-Christian disease and 1 with Letterer-Siwe syndrome. The femur lesion was frequently observed among the solitary lesions and the cranium involvement in the multiple skeletal lesions. The total number of lesions was 47. The treatment depended on the location, the clinical manifestations and the number of lesions. The patients with solitary lesions (17) were treated with curettage and bone grafting in 6 cases, segmental resection in 3 cases, only curettage in 3, radiotherapy in one and 4 patients didn't receive treatment. The patients with multiple lesions (8), were treated surgically (4 cases), only radiation therapy (2 patients), with surgery and radiotherapy (1) and one patient had no treatment. The generalized disease was treated with surgery of the main lesion depending in the clinical manifestations and chemotherapy and radiotherapy. The prognosis was good in almost all the patients and we observed regression of the disease even without specific treatment. The case of acute generalized disease died due to systemic complications.

[The influence of age on the end-results of the total surgical replacement of the hip]. / Influencia de la edad en el resultado de la cirugía sustitutiva total de la cadera.

A revision of the first 700 total hip prostheses (operated on in the period 1969-1980) is carried out with the purpose to establish the influence of the age on the evolution of the arthroplasty. The results are very satisfactory but it is younger patients that complications related to loosening are more frequent. This fact can be explained by a longer period of evolution and a major prosthetic stress in these patients. By this reason, we do not use actually cement to fix the implants in those patients younger than sixty.

[Congenital synostoses of the tarsus. Concept, classification, diagnosis and therapeutic approach]. / Sinostosis congénitas del tarso. Concepto, clasificación, diagnóstico y planteamiento terapéutico.

The incidence of congenital tarsal coalition is about 1%. It is recognized as the main etiology of painful, rigid flatfoot in the pediatric population. Talonavicular (50%) and talocalcaneal (40%) coalition are the most common presentation. We must suspect a tarsal coalition in a child with mechanical pain and shoes deformity. Rigid and painful planovalgus deformity are found in physical exam which led to describe in the pass this entity as peroneal spastic flatfoot. Lateral and oblique (35 degrees-45 degrees) radiographs must be practice to observe the coalition. The presence of a beak in the head of the talus or a half moon condensation image as the result of the superposition of the talus over the calcaneus are commonly described. CT-scan is also useful to delineate the size of the coalition and its location. Resection of the bar is the surgical treatment of choice. Excision of the coalition and interposition of fat or a graft must be tried in young patients in order to preserve foot biomechanical properties and to avoid long term problems associated with arthrodesis. Triple arthrodesis or subtalar arthrodesis must be used in older patients with degenerative signs in radiographs or in those cases of multiple coalition or if resection has failed.