Hip avascular necrosis in a healthy pregnant woman: A case report and review of literature.

BACKGROUND: Hip pain during pregnancy is very common, but hip avascular necrosis represents a very rare entity. CASE REPORT: We report a rare case of a healthy30-year-old female patient pregnant with twins, that suffered right hip avascular necrosis in the peripartum period, her symptoms were initially neglected as a benign cause of hip pain, this led to aggressive treatment at a young age. DISCUSSION: With less than 100 cases reported in the literature, pregnancy is not a well-known risk factor for femoral head avascular necrosis and it should be differentiated from one of the more common hip pathologies in pregnancy which is the so-called "Pelvic pain syndrome" and transient osteoporosis of the hip. CONCLUSION: Having a high index of suspicion and low threshold for MRI imaging in a pregnant woman with hip pain is a must to prevent such complications.

Subperiosteal Schwannoma of the Mid-Tibia: A Cause of Long-Lasting Unexplained Pain.

Schwannomas are benign tumors affecting the nerve sheath. Their presence in the subperiosteal region is extremely rare. We report a case of a 66-year-old male patient with a 10-year history of unexplained pain of the anterior leg that turned out to be caused by a subperiosteal schwannoma of the mid-tibia. We believe this case report will increase surgeons' index of suspicion about this condition when dealing with cases of unexplained bony pain, consequently allowing for early diagnosis and better outcomes.

Low-Pressure Lumbar Provocation Discography According to Spine Intervention Society/International Association for the Study of Pain Standards Does Not Cause Acceleration of Disc Degeneration in Patients With Symptomatic Low Back Pain: A 7-Year Matched Cohort Study.

STUDY DESIGN: Retrospective matched cohort study. OBJECTIVE: To determine if low-pressure lumbar provocation discography (PD) results in long-term accelerated disc degeneration, internal disc disruption, or disc herniation in patients with symptomatic low back pain (LBP). SUMMARY OF BACKGROUND DATA: Study of subjects without clinically-significant LBP suggests that high-pressure PD may accelerate disc degeneration. METHODS: Consecutive patients with symptomatic LBP who underwent magnetic resonance imaging (MRI), PD, and repeat MRI more than 7 years later, but did not undergo subsequent spinal fusion surgery, were included. Punctured discs were matched (1:2 to 1:4) to corresponding discs in a control cohort by age, BMI, Pfirrmann score (±2), and presence of disc herniation; control cohort inclusion required MRIs for symptomatic LBP, separated by more than 7 years. The primary outcome of the study was a progression in Pfirrmann score category (I-II, III-IV, V). MRI disc-to-CSF T2 signal-intensity ratio, disc height, disc herniations, high intensity zones (HIZs), and Modic changes were assessed. RESULTS: Baseline and follow-up MRIs were available for 77 discs exposed to PD, and for 260 discs in the matched control cohort. There was no difference in the proportion of punctured discs that advanced in Pfirrmann score category in the PD group (17%, 95% CI 9-27%) compared with corresponding discs in the Control group (21%, 95% CI 17-27%), P = 0.3578, or in non-punctured discs in the PD group (35%, 95% CI 21-51%) compared with corresponding discs in the Control group (34%, 95% CI 27-42%), P = 0.1169. There were no differences in disc-to-CSF T2 signal-intensity ratio, presence of disc herniations, HIZs, or Modic changes following puncture in the PD versus matched cohort discs or in the non-punctured PD cohort discs versus corresponding control cohort discs (P > 0.05). CONCLUSION: Patients with symptomatic LBP who underwent low-pressure PD, but who did not undergo a subsequent spinal fusion surgery, developed disc degeneration and new disc herniations at a similar rate to corresponding discs in matched control patients. LEVEL OF EVIDENCE: 3.

Lumbar Spinous Process-Splitting Laminoplasty: A Novel Technique for Minimally Invasive Lumbar Decompression.

Minimally invasive posterior spinous process-splitting laminoplasty preserving the paraspinal musculature has been introduced to treat patients with lumbar spinal stenosis. Despite its theoretical advantage of limiting muscular trauma, additional efforts are required to evaluate patients' clinical and functional results following this procedure. Between 2010 and 2012, 37 patients underwent spinous process-splitting laminoplasty for lumbar stenosis at a mean age of 68 years (range, 36-87 years) and were followed for minimum of 1 year (mean, 1.3 years). There were 22 (59%) men and 15 (41%) women. Mean number of levels treated with a spinous process-splitting laminoplasty was 2.2 (range, 1-6 levels). Patients had statistically significant improvements in their scores for all self-reported outcomes, including visual analog scale (VAS) for back and leg pain, Oswestry Disability Index (ODI), and Short Form 36 (SF-36) components. Mean VAS significantly decreased by 4.4±3.2 points for back pain and 3.9±3.7 points for leg pain (P<.0001). Mean ODI significantly decreased by 17.5±19.1 points (P<.0001), and mean SF-36 significantly increased by 29±30.4 points (P=.0017) for the physical component and 21.8±25.6 points (P=.0062) for the mental health component. Four (10.8%) patients had a dural tear requiring repair (3 were intraoperative), 3 (8%) had an epidural hematoma requiring evacuation, 1 (2.7%) had an infection requiring irrigation and debridement, and 2 (5%) had additional decompression for symptom recurrence secondary to instability. Lumbar spinous process-splitting laminoplasty is a novel minimally invasive technique that provides adequate decompression for the neuronal elements and may avoid extensive paraspinal muscular damage associated with conventional laminectomy. Patients demonstrated significant improvements in pain and overall heath and function scores at a minimum 1-year follow-up. [Orthopedics.2016; 39(5):e950-e956.].

Perioperative complications in open versus percutaneous treatment of spinal fractures in patients with an ankylosed spine.

We compared open stabilization of vertebral fractures to percutaneous spinal fixation techniques in patients with a diagnosis of either ankylosing spondylitis (AS) or diffuse idiopathic skeletal hyperostosis (DISH). A retrospective review of patients known to have AS or DISH treated for spinal column fracture at a single institution between 1995 and 2011 was performed. Patients were analyzed by the type of fixation, divided into either a percutaneous group (PG) or an open group (OG). There were 41 patients identified with a spinal column fracture and history of AS or DISH who received surgical intervention. There were 17 (42%) patients with AS and 24 (58%) with DISH. Patients in the PG and OG cohorts presented with similar mechanisms of injury, Injury Severity Scale, number of vertebral fractures, number of additional injuries, and Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification scores. Mean operative time (254.76minutes versus 334.67minutes, p=0.040), estimated blood loss (166.8 versus 1240.36mL, p<0.001), blood transfusion volume (178.32 versus 848.69mL, p<0.001), and time to discharge (9.58 days versus 16.73 days, p=0.008) were significantly less in the PG cohort. The rate of blood transfusion (36% versus 87.5%, p=0.001) and complications (56% versus 87%, p=0.045) were significantly less in the PG cohort. Percutaneous stabilization of fractures in patients with AS or DISH was associated with lower blood loss, shorter operative times and decreased need for transfusion, shorter hospitalization time and a lower perioperative complication rate.

Modern techniques in the treatment of patients with metastatic spine disease.

The treatment of metastatic disease to the spine involves a comprehensive evaluation of the patient and an individualized treatment plan based on the tumor type and location, the extent of the disease, and the general medical condition of the patient. Careful consideration of these factors dictates the treatment options, which include surgery, radiation, chemotherapy, and/or palliative options. Patients with a good overall prognosis may be considered candidates for more aggressive surgical resections, such as en bloc resections, whereas those with a poor prognosis may benefit from less invasive piecemeal resections to decompress the spine and restore neurologic function while minimizing the morbidity associated with more invasive procedures. The goals of surgery are tailored to the overall prognosis and should be aimed at optimizing the quality of the patient's life.

Incidence of piriformis tendon preservation on the dislocation rate of total hip replacement following the posterior approach: a series of 226 cases.

BACKGROUND: Dislocation is a feared complication following total hip replacement (THR). While repairing the piriformis tendon after THR reduces dislocation, we analyze in this study the effect of piriformis tendon preservation on reducing the dislocation rate. MATERIAL AND METHODS: 226 THRs were done following the usual posterior approach and by the same surgeon. All patients received the same prosthetic design. All cases were primary THR. After reaching the external rotators, the piriformis muscle was identified and dissected on its inferior border from the gemellus superior and elevated by a retractor. Further stages were performed in the usual manner. Patients were followed up for a mean of 3 years. RESULTS: 226 THRs were done for 217 patients, 118 of whom were females and 99 were males with a mean age of 62. Nine patients received bilateral THRs. 112 procedures were performed on the right side and 114 on the left side. THR was performed in 70 cases following femoral neck fractures and in 156 cases due to osteoarthritis. No intraoperative or long-term complications were found while preserving the piriformis. Postoperative hip X-rays showed good positioning of both the femoral and acetabular components. No cases of dislocation were identified after a mean follow-up of 3 years. CONCLUSION: Preservation of the piriformis tendon during the postero-lateral approach in THR is a possible surgical technique that is easy to use and reproducible in both arthritic and traumatic conditions. It follows an anatomical intermuscular plan and permits full exposure of both the proximal femur and the acetabulum. Compared to the literature, preserving the piriformis tendon seems to be superior to repairing it in terms of dislocation of THR.

Position of the anterior branch of the axillary nerve in relation to the humeral bone length.

Many studies have attempted to define a safety zone for the axillary nerve in lateral approaches to the deltoid, but with varying results. The main objective of our study was to analyze the variations in the position of this nerve, especially in relation to the length of the humerus. Overall, 16 cadaveric shoulders were dissected. The distances between both the anterolateral edge of the acromin (anterior distance) and the lateral edge of the acromion (posterior distance) to the axillary nerve were measured; the length of the humerus was also measured. Correlation analysis was performed between each distance and the length of the humerus. The average anterior and posterior distance were 7.2 cm ± 0.84 cm and 7.9 cm ± 0.92 cm, respectively; the average length of the humerus was 30.7 cm ± 3.2 cm. A significantly high positive correlation was found between the length of the humerus and both anterior distance (P = .94), and posterior distance (P = .92). In shoulder surgery, prior measurement of the length of the humerus could predict the distance between the acromion and the axillary nerve, and determine its position.

Aneurysmal bone cyst of the lunate: case report.

Aneurysmal bone cysts rarely affect the carpus. We present a case of aneurysmal bone cyst affecting the lunate. Curettage and bone grafting of the lesion was successful, with no recurrence after 2 years of follow-up.

Secondary chondrosarcoma.

Secondary chondrosarcoma is a distinctive type of tumor that originates from a preexisting cartilaginous lesion. Most commonly, it is associated with solitary or multiple osteochondromas. A fraction of cases arises from other conditions, such as Maffucci syndrome and Ollier disease. A sudden increase in the size of the cartilaginous cap of an osteochondroma is a sign of malignant transformation to secondary chondrosarcoma. However, there is no strict cutoff in terms of thickness of the cartilaginous cap that can be regarded as being pathognomonic of malignancy. Most cases of secondary chondrosarcoma are low to intermediate grade. Distant metastasis is uncommon, and the prognosis is good for most patients. Overall survival at 5 years is approximately 90%. Surgical resection with wide margins is the best treatment option, but local recurrence remains a significant problem in approximately 10% to 20% of patients. Patients with secondary chondrosarcoma of the pelvis are especially at risk for local recurrence.

Fibula stress fracture mimicking a malignancy.

Stress fractures may be easily misdiagnosed as another entity, especially tumors, which may prompt very severe surgical treatment and sometimes amputation. The appropriate use of modern radiography may make the difference in proper diagnosis of stress fractures.

Malignant porocarcinoma of the nail fold: a tricky diagnosis.

Malignant eccrine porocarcinoma is a rare tumor of sweat glands with a high local recurrence rate and a tendency to metastatic spread. We present a case of a 77-year-old male patient that presented with a recurrent, periungual porocarcinoma mimicking onychomycosis and ingrown toe nail that was successfully treated by surgical excision. To our knowledge no such case has been described in this location in the English literature.