[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.

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.

Effect of brightness in the evaluation of lumbar pedicular screws position: clinical study.

Artifact may lead to confusion when evaluating postoperative CT scans of lumbar pedicle screws. The aim of our study was to develop a specific metal artifact reduction image protocol, in order to reduce metal artifact caused by titanium pedicular screw in patients undergoing lumbar pathology by lumbar fusion. Therefore, the reduction in metal artifacts in lumbar pedicle screws allows surgeons to do an accurate diagnosis of the exact placement of inserted pedicle screws, minimizes false reexploration, and maximizes proper and prompt treatment of misplaced screw. In a first step, we performed a retrospective study of 103 titanium alloy pedicle screws in patients undergoing a lumbar instrumented fusion for treatment for degenerative disease. CT scan was performed postoperatively evaluating the possible overdimension caused by artifact. In a second step, a prospective study was performed using a 64-slice multidetector-row computed tomography (MDCT) in 104 titanium alloy pedicle screws in patients undergoing a lumbar instrumented fusion for treatment for degenerative disease. Our results show that on the group of sequential CT scan, mean overdimension (on each side) due to brightness was 1.045 mm (SD 0.45). On the group of 64-slice multichannel CT, mean overdimension (on each side) due to brightness was 0.005 mm at the proximal part of the screw and 0.025 mm at the distal part of the screw. The results observed suggest that beam-hardening artifacts caused by the screw on CT after lumbar fusion are dramatically reduced by using specific metal artifact reduction image protocol in a 64-slice MDCT.

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.

[Lack of correlation between plantar arthrosis of the first metatarsal joint and sesamoids and pain in patients after hallux valgus surgery]. / Falta de correlación entre artrosis plantar del primer metatarsiano y sesamoideos y dolor en pacientes intervenidos de hallux valgus.

OBJECTIVES: To determine the relationship between osteoarthritis in the plantar region of the first metatarsophalangeal joint of the foot and patient pain after hallux valgus surgery. MATERIAL AND METHODS: A total of 28 patients undergoing hallux valgus surgery were examined. The patients were examined for pain in the plantar region of the metatarsophalangeal joint (sesamoid bones area), by looking into their medical records and by means of palpation during the physical exam. X-rays were taken to look for metatarsophalangeal arthritis, and PASA and sesamoid displacement were measured. During the surgical procedure, the metatarsal head was macroscopically assessed for arthritis according to the ICRS Score. RESULTS: Of the 28 patients, 18 had no pain, 7 had mild pain (VAS 1-3) and 3 had moderate pain (VAS 4-6). Macroscopically, all the patients had some degree of plantar osteoarthritis. Only 5 patients had radiological signs of metatarsophalangeal arthritis. There was no correlation (P=.44) between pain and plantar osteoarthritis. There was a mild but non-significant correlation between PASA and osteoarthritis (P=.06). There was a weak but significant correlation between patient age and arthritis (P=.04). CONCLUSION: Osteoarthritis in the plantar aspect of the first metatarsal head does not correlate with patient symptoms or with pain intensity in patients undergoing hallux valgus surgery.

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.

[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.

[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.

[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.

[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.

Lumbosacral arthrodesis using pedicular screws and ringed rods.

Sixty-one patients who had lumbar instability and chronic low back pain or deformity from nontraumatic lumbar pathologies were studied. In all of them a posterior lumbosacral fusion with CUN (Clinic of the University of Navarre) pedicle rod fixation was used. The mean follow-up period was 36 months (range 26-46 months). The consolidation rate was evaluated according to plain and functional radiographs, and a clinical evaluation was made using an analogue pain scale. The rate of fusion was 93.5%. Neurological complications occurred in 3.3%. The incidence of screw failure was 2.3% of all the screws. No other implant failure occurred. The patients rated their clinical results as 'excellent' in 33.8% of the cases, 'good' in 42.2%, 'fair' in 16.9% and 'poor' in 6.7%. CUN instrumentation is a versatile internal fixation system that has been shown to provide satisfactory stability. Furthermore, the clinical results are comparable to those reported in studies in which the most common hardwares were used.

Congenital absence of the pedicles and the neural arch of L2.

Congenital pedicle abnormalities are rare. Unilateral aplastic and hypoplastic lumbar pedicles have been reported, but these were usually discovered incidentally and did not need surgical treatment. We present a case of absence of both pedicles and the neural arch of L2, with associated kyphoscoliosis with neurological involvement, that needed a two-stage corrective surgery. An L1-L4 fusion was achieved with relief of the symptoms.

[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.

Avascular necrosis of the distal fibular epiphysis: a new condition?

A 5-year-old boy was seen because of a right ankle sprain; radiographs showed a marginal anterior avulsion of the distal fibular epiphysis. After plaster immobilization, the patient continued with pain and subjective instability. New radiographs showed a lytic area in the same zone of the avulsion with surrounding sclerosis and a detached bone fragment. Biopsy showed bone necrosis. Two years later, without any traumatic event, the patient began to have a similar pain in the left ankle. Radiographs showed fragmentation of the anterior portion of the distal fibular epiphysis with surrounding sclerosis. Surgical treatment was performed by curettage and cancellous bone grafting; biopsy showed connective tissue, mucoid degeneration, and necrotic bone. After excluding any general disease, we believe that this bone necrosis could be considered an epiphyseal idiopathic avascular necrosis in children.

Ewing's tumor of the spine: report on seven cases including one with a 10-year follow-up.

This study analyzed the cases of seven patients who completed the Treatment Protocol of the University Clinic of Navarre for Ewing's tumor of the spine between 1982 and 1993. The surgical procedures aimed at gaining local control and recovering the neurological deficit are discussed. Poor results in the survival rate can be expected, as shown by the clinical study. Only two patients are alive, including one who is free of disease more than 10 years after surgery.

Apical hemifacetectomy of the first sacral vertebra in the treatment of an osteoid osteoma.

We present the surgical technique of apical hemifacetectomy, which is useful for performing selective resection of lesions located in the upper articular processes avoiding facet joint instability. This surgical technique was used in a 20-year-old patient to remove an osteoid osteoma deeply located in the S1 articular process.

Union after multiple anterior cervical fusion. 21 cases followed for 1-6 years.

With a mean follow-up of 3 (1-6) years, we report on 21 patients who underwent multiple level cervical fusion, using autologous iliac crest grafts. Dissectomies were performed in 14 patients and corpectomies in another 7. Instrumentation was used in all patients with corpectomies and in 2 patients who underwent 2-level and 3-level dissectomies. Non-union occurred in 1 patient at 1 level. Graft displacement requiring reoperation was observed in 2 patients with massive corpectomies, in 1 of them as a consequence of trauma. In both patients complete bony fusion was obtained after reoperation and no other complications were observed. We conclude that the success rate with multiple-level fusion is comparable to that of single-level fusion when adequate fixation is achieved.

Lumbosacral arthrodesis with louis technique. Review of 186 cases.

A retrospective study was carried out of 186 patients surgically treated by lumbosacral arthrodesis using Louis plates from 1981 to 1989 with an average follow-up of 7.2 years (range 3-11). The average age of the patients was 42.2 years (range 11-71). The indication for surgery was a herniated disc and segmentary instability in 29% (54 patients), spondylolysis or spondylolisthesis in 26.3% (49 patients), arthrosis in 11.3% (21 patients), instability (narrowing of the disc space and zygapophyseal hypertrophy) and stenosis in 5.9% (11 patients), tumour in 5.4% (10 patients), fractures in 0.5% (1 patient) and combinations of the above in 21.5% (40 patients who mainly had a herniated disc and associated spinal stenosis). Iliac crest autograft was used in 33 cases (17.7%), bank allograft in 5 (2.6%), and in the other 148 patients the graft was obtained from the arthrodesis bed. After follow-up we observed loosening of the screws in 20 patients and screw rupture in 10. We only documented 2 cases of pseudarthrosis using dynamic X-radiography. We conclude that the Louis plate is a simple method that leads to lumbosacral arthrodesis with a low rate of pseudoarthrosis.

Eosinophilic granuloma of the spine with and without vertebra plana: long-term follow-up of six cases.

Vertebral eosinophilic granuloma is a rare condition frequently associated with vertebra plana. In this paper we present six patients with eosinophilic granuloma of the spine; three were without vertebra plana, which represents a diagnostic problem. The mean follow-up was 9 years, (range 2 to 23) and the mean age was 10.8 years at diagnosis. All complained of pain with no neurological deficit. The lesions were located on the vertebral bodies of C4, T9, T10, L1, L2, and L5, respectively. Histologic confirmation of diagnosis was obtained in all patients, two by puncture and four by open biopsy. The patients with vertebra plana (T10, L1, and L5, respectively) were treated conservatively. Long-term follow-up demonstrated total healing of the vertebral body in two and partial rebuilding 8 years after diagnosis in one. Patients without vertebra plana (C4, T9, and L2, respectively) underwent curettage and bone grafting. In the patient with T9 location, a T8-10 anterior arthrodesis with autogenous rib graft was performed. The outcome was satisfactory in all.

[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.