Improvement of Life After PVCR in Complete Paraplegic Patients with Posttraumatic Severe Kyphosis.

AIM: To determine the effect of posterior vertebral column resection (PVCR) in patients with paraplegia by using the American Spinal Injury Association (ASIA) score and Scoliosis Research Society (SRS)-22 questionnaire. MATERIAL AND METHODS: Twelve patients with posttraumatic paraplegia and severe angular kyphosis ( > 60?) had undergone PVCR between 6-24 months after the trauma for severe pain, persistent vertebral instability and difficulty in adherence to rehabilitation. ASIA scores and SRS-22 questionnaire results obtained in the preoperative and postoperative periods, and the last control were statistically compared to assess the presence of any change. RESULTS: The average age of twelve patients included in this study was 35.6 ± 10.2 (21-51) years. Female/male ratio was 2/10 (20.0%). The mean follow-up duration was 50.3 ± 17.6 (24-86) months. None of the patients had additional changes in neuromonitoring records during surgery. The mean preoperative kyphotic angle of the patients was 66.58° ± 7.1? (60?-82?) which decreased to 7.0? ± 5.4? in the postoperative period (p < 0.05). The mean ASIA score, which was 43.3 ± 5.1 preoperatively, increased to 44.4 ± 4.4 in the postoperative period. The SRS-22 score, which was 2.4 ± 0.3 in the preoperative period, increased to 4.2 ± 0.4 in the early postoperative period. This increase was found to be statistically significant (p < 0.05). The SRS-22 score was 4.1 ± 0.4 at last follow-up and was not statistically different from the early postoperative value (p > 0.05). CONCLUSION: In the light of these data, it can be stated that PVCR is a safe and reliable procedure in paraplegic patients with rigid posttraumatic kyphosis and increases patient satisfaction.

The implications of the glenoid angles and rotator cuff status in patients with osteoarthritis undergoing shoulder arthroplasty.

BACKGROUND: The success of shoulder arthroplasty, both reverse and anatomical, depends on correcting the underlying glenoid deformity especially in patients with an osteoarthritis. We hypothesized that the distribution of glenoid version and especially inclination are underestimated in the shoulder arthritis population, and also that superior glenoid inclination can be detected through 3-dimensional (3D) software program of computed tomography (CT) to a greater proportion in patients with rotator cuff insufficiency, but also in patients with osteoarthritis with an intact rotator cuff. Because of the influence of rotator cuff imbalance on secondary glenoid wear the values of the critical shoulder angle (CSA) and the fatty infiltration of the rotator cuff are further analyzed. The aim of our study is to determine; 1) the distribution of glenoid inclination and version; 2) the relationship between glenoid inclination, version, the critical shoulder angle (CSA) to the status of the rotator cuff; 3) the proportion of patients with both an intact rotator cuff and a superior inclination greater than 10°. METHODS: A total of 231 shoulders were evaluated with X-ray images, 3-dimentional (3D) software program of computed tomography (CT), and magnetic resonance imaging. The cohort was divided into 3 groups according to their inclination angles and also grouped as intact-rotator cuff and torn-cuff group. RESULTS: The median (min/max) values for the 231 shoulders were 8° (- 23°/56°) for the inclination angle, - 11°(- 55°/23°) for the version angle, and 31.5°(17.6°/61.6°) for the CSA. The majority of the glenoids were found to show posterior-superior erosion. Glenoid inclination angle and CSA were significantly higher in torn-cuff group when compared with intact-cuff group (P < 0.001, both). The rotator cuff tears were statistically significant in high inclination group than low inclination group and no inclination group (p < 0.001). In the high inclination group, 41 of 105 (39%) shoulders had an intact rotator cuff, in about 18% of all shoulders. CONCLUSION: Our findings show that 3D evaluation of glenoid inclination is mandatory for preoperative planning of shoulder replacement in order to properly assess superior inclination and that reverse shoulder arthroplasty may be considered more frequently than as previously expected, even when the rotator cuff is intact. LEVEL OF EVIDENCE: Level III.

Radiofrequency Thermocoagulation of the Ganglion Impar for Coccydynia Management: Long-Term Effects.

OBJECTIVE: To investigate the short- and long-term effects of ganglion impar radiofrequency thermocoagulation (RFT) treatment in patients with chronic coccydynia. METHODS: We retrospectively analyzed the medical records of patients who underwent RFT of the ganglion impar between 2009 and 2011. Pain intensity visual numeric scale (VNS) scores and Euroqol 5D (EQ-5D) index scores were recorded pre-intervention and post-intervention at the first, sixth, and twelfth months. The differences between pre-procedural VNS scores and post-procedural VNS scores at the first, sixth, and twelfth months were evaluated. The success of the intervention was recorded as the percentage difference between the pre-intervention VNS scores and post-intervention VNS scores at the first, sixth, and twelfth months. RESULTS: The mean age of the patients, including 11 females (55%) and 8 males (45%), was 48.7 ± 14.3 years. The average follow-up duration was 17.3 ± 2.9 months. Statistically significant differences were observed between the pre- and post-procedure VNS scores (P < 0.0001). Improvements in VNS scores were correlated with improvements in EQ-5D index scores. Mid-term (sixth month) and long-term (twelfth month) evaluations after the intervention revealed that 67.4% and 61.1% of the patients had successful outcomes, respectively. CONCLUSION: Our data suggested that RFT of the ganglion impar in patients with chronic coccydynia resulted in effective outcomes, and patients who responded to RFT had significantly lower post-RFT pain scores.

Sudden motor and sensorial loss due to retroperitoneal hematoma during postoperative periods: a case report / Súbita perda sensitiva e motora devido a hematoma retroperitoneal durante os períodos de pós-operatório: relato de caso

Abstract A 68 year-old male patient was hospitalized for radical prostatectomy. He had no abnormal medical history including neurological deficit before the operation. Prior to general anesthesia, an epidural catheter was inserted in the L3-4 interspace for intraoperative and postoperative analgesia. After surgery for nine hours, he developed confusion and flaccid paralysis of bilateral lower extremities occurred. No pathology was detected from cranial computed tomography and diffusion magnetic resonance imaging no pathology was detected. His thoracic/lumbar magnetic resonance imaging. Intraabdominal pressure was shown to be 25 mmHg, and abdominal ultrasonography revealed progression in the inflammation/edema/hematoma in the perirenal region. The Bromage score was back to 1 in the right foot on the 24th hour and in the left foot on the 26th hour. Paraplegia developed in patients after epidural infusion might be caused by potentiated local anesthetic effect due to retroperitoneal hematoma and/or elevated intra-abdominal pressure.

Resumo Paciente do sexo masculino, 68 anos, hospitalizado para prostatectomia radical. O paciente não tinha história médica anormal, inclusive nem déficit neurológico, antes da operação. Antes da anestesia geral, um cateter peridural foi inserido no espaço intermédio L3-4 para analgesia no intra e pós-operatório. Após a cirurgia, que durou nove horas, o paciente desenvolveu confusão e paralisia flácida bilateral dos membros inferiores. Tomografia computadorizada de crânio e imagem de difusão por ressonância magnética não detectaram lesão. Os achados nas imagens de ressonância magnética torácica/lombar eram normais. A pressão intra-abdominal era de 25 mmHg e o ultrassom abdominal revelou progressão de inflamação/edema/hematoma na região perirrenal. O escore de Bromage voltou a 1 no pé direito na 24a hora e no pé esquerdo na 26a hora. A paraplegia desenvolvida nos pacientes após a infusão epidural pode ter sido causada por um efeito potencializado do anestésico local devido a hematoma retroperitoneal e/ou pressão intra-abdominal elevada.

[Sudden motor and sensorial loss due to retroperitoneal hematoma during postoperative periods: a case report]. / Súbita perda sensitiva e motora devido a hematoma retroperitoneal durante os períodos de pós­operatório: relato de caso.

A 68 year-old male patient was hospitalized for radical prostatectomy. He had no abnormal medical history including neurological deficit before the operation. Prior to general anesthesia, an epidural catheter was inserted in the L3-4 interspace for intraoperative and postoperative analgesia. After surgery for nine hours, he developed confusion and flaccid paralysis of bilateral lower extremities occurred. No pathology was detected from cranial computed tomography and diffusion magnetic resonance imaging no pathology was detected. His thoracic/lumbar magnetic resonance imaging. Intraabdominal pressure was shown to be 25mmHg, and abdominal ultrasonography revealed progression in the inflammation/edema/hematoma in the perirenal region. The Bromage score was back to 1 in the right foot on the 24th hour and in the left foot on the 26th hour. Paraplegia developed in patients after epidural infusion might be caused by potentiated local anesthetic effect due to retroperitoneal hematoma and/or elevated intra-abdominal pressure.

Comparison of Anteromedial and Transtibial ACL Reconstruction Using Expandable Fixation.

The influence of anatomical or nonanatomical femoral tunnel position on tunnel widening and clinical outcomes in patients undergoing anterior cruciate ligament (ACL) reconstruction is not fully understood. This retrospective study examined the influence of tunnel width and placement on anterior knee stability and clinical outcomes after ACL reconstruction using the AperFix System (Cayenne Medical Inc, Scottsdale, Arizona), a direct expandable fixation technique with autologous hamstring grafts. The records of 80 patients (79 men and 1 woman) who underwent ACL reconstruction were evaluated. In 38 patients, anatomical femoral tunnel placement was performed via an accessory medial portal (anteromedial group); in the remaining 42 patients, the femoral tunnel was positioned nonanatomically using a transtibial technique (transtibial group). Mean follow-up was 40.7 months (range, 27-60 months). Postoperative knee kinetics were measured, and clinical outcomes were assessed using International Knee Documentation Committee, Lysholm, and Tegner scores. Femoral tunnel widening was measured by comparing postoperative radiographs with final follow-up radiographs. Femoral tunnel width was significantly greater (P<.001) and anterior knee translation was significantly higher (P=.01) in the transtibial group. Lysholm and Tegner scores were not significantly different (P>.05) between the 2 groups. These findings suggest that femoral tunnel widening is associated with increased anterior joint laxity when a direct fixation technique is used for ACL reconstruction, particularly in nonanatomically positioned femoral tunnels. Anatomical femoral tunnel placement provides better anterior stability and less tunnel widening than transtibial tunnel placement; however, these benefits did not produce a detectable advantage in clinical outcomes measures. [Orthopedics. 2017; 40(3):e532-e537.].

Changes in posterior tibial slope angle in patients undergoing open-wedge high tibial osteotomy for varus gonarthrosis.

PURPOSE: In this study, postoperative changes in the posterior tibial slope angle and clinical outcomes following open-wedge high tibial osteotomy were evaluated. METHODS: This study included 39 knees (18 left, 21 right) of 35 patients (three male, 32 female; median age, 53 years; age range 37-64 years) with symptomatic isolated medial joint osteoarthritis who underwent open-wedge high tibial osteotomy and fixation with a Puddu plate. The patients were clinically assessed according to the Lysholm knee score, a visual analogue pain scale, and a patient satisfaction questionnaire. Radiological assessment was made according to the changes in the posterior tibial slope angle and the correlation between these changes and clinical signs. The median follow-up period was 11 years (range 7-14 years). RESULTS: Significant improvements were observed in the preoperative and postoperative clinical scores of the Lysholm knee scale, visual analogue pain scale, and patient satisfaction questionnaire (p < 0.05). Radiological assessment showed that the posterior tibial slope angle was significantly higher during the postoperative and follow-up periods (p  0.05). There was no correlation between the postoperative Lysholm scores and the increase in the posterior tibial slope angle (p = n.s.). CONCLUSIONS: We conclude that both the conventional Puddu plate design and its anteromedial plate placement are what increase the tibial slope after an opening-wedge proximal tibial osteotomy. Therefore, current new plate design may help preserve the posterior tibial slope angle. LEVEL OF EVIDENCE: IV.

Need for Bone Grafts in the Surgical Treatment of Displaced Intra-Articular Calcaneal Fractures.

Controversy is ongoing regarding the use of bone grafts to fill cavities that occur with collapse of the posterior facet in the joint and for repair of the calcaneal height with plating. The present study included 40 patients with 43 displaced intra-articular calcaneal fractures treated with open reduction and internal fixation from March 2009 to November 2013. In the present case-control study, the patients were separated into 2 groups: group A received an allograft (20 patients, 22 calcaneal fractures) and group B did not (20 patients, 21 calcaneal fractures). The calcaneal height and Böhler's angle were compared between the 2 groups. The final outcomes for all patients were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle hindfoot scale score and compared between the 2 groups. No significant differences were observed between the groups with regard to the basic demographic variables (p > .05). Using Sanders classification, 8 (18%) were type 2, 19 (44%) were type 3, and 16 (37%) were type 4 fractures. The comparisons between the 2 groups showed a loss of Böhler's angle and loss of calcaneal height that was significantly greater in group B (p < .001). No significant differences were observed between the 2 groups in the AOFAS ankle hindfoot scale scores (p > .05). In conclusion, although no differences were found in the clinical results between the 2 groups, more satisfactory radiologic results were obtained in group A, in which bone grafts were used.

Is the presence of linear fracture a predictor of delayed posterior fossa epidural hematoma?

BACKGROUND: Though traumatic posterior fossa epidural hematoma (PFEDH) is rare, the associated rates of morbidity and mortality are higher than those of supratentorial epidural hematoma (SEDH). Signs and symptoms may be silent and slow, but rapid deterioration may set in, resulting in death. With the more frequent use of computed tomography (CT), early diagnosis can be achieved in patients with cranial fractures who have suffered traumatic injury to the posterior fossa. However, some hematomas appear insignificant or are absent on initial tomography scans, and can only be detected by serial CT scans. These are called delayed epidural hematomas (EDHs). The association of EDHs in the supratentorial-infratentorial compartments with linear fracture and delayed EDH (DEDH) was presently investigated. METHODS: A total of 212 patients with SEDH and 22 with PFEDH diagnosed and treated in Göztepe Training and Research Hospital Neurosurgery Clinic between 1995 and 2005 were included. Of the PFEDH patients, 21 underwent surgery, and 1 was followed with conservative treatment. In this group, 4 patients underwent surgery for delayed posterior fossa epidural hematoma (DPFEDH). RESULTS: Mean age of patients with PFEDH was 12 years, and that of the patients with SEDH was 18 years. Classification made according to localization on cranial CT, in order of increasing frequency, revealed of EDHs that were parietal (27%), temporal (16%), and located in the posterior fossa regions (approximately 8%). Fracture line was detected on direct radiographs in 48% of SEDHs and 68% of PFEDHs. Incidence of DPFEDH in the infratentorial compartment was statistically significantly higher than incidence in the supratentorial compartment (p=0.007). Review of the entire EDH series revealed that the likelihood of DEDH development in the infratentorial compartment was 10.27 times higher in patients with linear fractures than in patients with supratentorial fractures (p<0.05). CONCLUSION: DPFEDH, combined with clinical deterioration, can be fatal. Accurate diagnosis and selection of surgery modality can be lifesaving. The high risk of EDH development in patients with a fracture line in the posterior fossa on direct radiographs should be kept in mind. These patients should be kept under close observation, and serial CT scans should be conducted when necessary.

Endobutton Fixation Technique for Multifragmented Coronoid Fractures.

Coronoid fractures commonly occur in a part of unstable elbow fractures. Stable coronoid fracture fixation is important for early elbow motion. It may be difficult to fix multifragmented coronoid process fractures with loose capsular attachment. Thus, we demonstrated the endobutton suspensory technique to fix the anterior coronoidal fragments due to its suspensory effect providing capsular attachment. This technique allows stable fixation to the small multifragmented coronoid fractures with early range of motion.

Atypical Presentation of an Epidural Hematoma in a Patient Receiving Rivaroxaban After Total Hip Arthroplasty.

The authors report a case of a 69-year-old woman who presented with a spontaneous spinal epidural hematoma (SSEH) 10 days after a total hip arthroplasty. The patient had been receiving 10 mg/d of rivaroxaban for 5 days for venous thromboembolism prophylaxis. She had a sudden onset of severe neck pain, followed by quadriplegia below C4. A dorsal SSEH was revealed by computed tomography. While preparing for the emergency evacuation of the SSEH, the neurological symptoms resolved spontaneously in 4 hours. The 1-month follow-up magnetic resonance imaging confirmed that the SSEH had completely resolved. The pathogenesis of SSEH is unclear, but anticoagulant therapy is a known risk factor. It is a relatively rare disorder. Only 1 case of SSEH has been reported, and that patient was receiving a nonsteroidal anti-inflammatory drug besides rivaroxaban, which is another known risk factor for bleeding disorders. [Orthopedics. 2016; 39(3):e558-e560.].

Review of management of unstable elbow fractures.

Stable and painless elbow motion is essential for activities of daily living. The elbow joint is the second most commonly dislocated joint in adults. The goals of treatment are to perform a stable fixation of all fractures, to achieve concentric and stable reduction of the elbow and to provide early motion. The treatment modality for complex elbow instability is almost always surgical. The treatment objectives are anatomic reduction, stable fixation, and early rehabilitation of the elbow. The common complications of these unstable fractures include recurrent instability, stiffness, myositis ossifications, heterotopic calcification, and neurovascular dysfunction. We analyzed the management of complex elbow fractures and instabilities on the basis of recent literature and suggested possible guidelines for the treatment in this paper. In conclusion, recognition of the injury pattern and restoration of the joint stability are the prerequisites for any successful treatment of an unstable elbow injury.

Acral melanoma with satellitosis, disguised as a longstanding diabetic ulcer: a great mimicry.

Acral lentiginous melanoma affects the palms, soles, and nail apparatus. Around 3-15% of all cutaneous melanomas are located on the foot and have a poorer prognosis than melanoma elsewhere. Possible reasons for this prognostic difference may be omitting this area during routine skin check by both the patient and the physicians, in addition to misdiagnosis of melanoma as other benign skin lesions. We describe here an elderly female patient treated for a non-healing foot ulcer interpreted as a diabetic ulcer, which after 2 years was diagnosed as acral melanoma with satellitosis. Histopathological examination of the amputated distal phalanx revealed an advanced stage melanoma with 1·2 cm Breslow thickness and of Clark level 5. Dermoscopy of the bluish papulonodules scattered on the dorsal foot showed characteristic findings described for metastasis of skin melanoma. This case underlines the importance of considering skin malignancies in case of chronic, non-healing ulcers in diabetic patients. Furthermore, we point out the critical significance of skin examination as a whole, and dermoscopy being an important tool in the diagnosis of melanoma and/or cutaneous melanoma metastasis.

Simultaneous bilateral ganglion cysts of the anterior cruciate ligaments.

Intra-articular ganglion cysts of the anterior cruciate ligament (ACL) are rare, and bilateral ganglion cysts are even rarer. These cysts may cause intermittent or chronic nonspecific knee discomfort. Although three cases of bilateral ganglion cysts have been reported in the literature, the knees were not simultaneously affected in those cases. Herein, we report the case of a 56-year-old woman who presented with simultaneous bilateral ganglion cysts of the ACL that were symptomatic. She was successfully treated with arthroscopic resection and debridement. We also present a brief review of the literature, highlighting the aetiology, diagnosis and management of ganglion cysts of the ACL. To the best of our knowledge, this is the first report of simultaneous bilateral intra-articular ganglion cysts of the ACL.