AP3×ML3 reduction quality classification for femoral trochanteric fractures: validation for reliability focusing on positive medial cortical support.

INTRODUCTION: This study evaluated the validity of the AP3 × ML3 reduction quality classification, which applies the concept of positive medial cortical support. METHODS: A total of 120 trochanteric fractures classified as AO Foundation/Orthopedic Trauma Association 31A1 and A2 were retrospectively analyzed. The validity of the AP3 × ML3 classification was evaluated by comparison with the Baumgaertner reduction quality criteria. When using the AP3 × ML3 classification, reduction quality was divided into three classes based on the degree of anterior cortical contact between the proximal and distal fragments. Reduction quality was also divided into three classes when using the Baumgaertner criteria. The frequency of mechanical complications, including cut-out, delayed union, and excessive migration of the lag screw, was retrospectively assessed. Intra-observer and inter-observer reliability was assessed using the intraclass correlation coefficient (ICC). RESULTS: Mechanical complications included 4 cases of cutout (3.3%) and 1 of delayed union (0.8%). Mechanical complications occurred for all levels of reduction quality in both classifications, except for the acceptable of the Baumgaertner criteria. When reduction quality was rated as good, acceptable, and poor the incidence of mechanical complications was 2.5%, 5.7%, and 16%, respectively, under the AP3 × ML3 classification and 3.3%, 0%, and 15.0%, respectively, under the Baumgaertner criteria. The ICC was 0.80 for intra-observer reliability and 0.57 for inter-observer reliability when using the AP3 × ML3 classification and 0.85 and 0.34, respectively, when using the Baumgaertner criteria. CONCLUSION: The AP3 × ML3 classification was reliable and easy to use compared with the widely used Baumgaertner reduction quality criteria. Level of evidence 4.

Interscalene brachial plexus block for scapular and upper chest pain due to cervical radiculopathy: a randomized controlled clinical trial.

BACKGROUND: Animal experiments have shown that one of the pathways for pain originating from the cervical spine is the sympathetic trunk. However, there have been few reports regarding the cervical pain pathway and efficacy of interscalene brachial plexus block for upper limb, scapular and chest pain originating in the cervical spine in clinical cases. The purpose of the present study was to clarify the efficacy of interscalene brachial plexus block for upper limb, scapular and chest pain. METHODS: Patients (137 men and 223 women) who had cervical radicular pain were studied. The intensity of upper limb, scapular and chest pain was measured by using a VAS before injection and at 5 min and 7 days after injection. To evaluate the efficacy of interscalene brachial plexus block, patients with cervical radicular pain who had received NSAIDs for at least 2 weeks were randomized to interscalene brachial plexus block or control block groups. VAS scores were compared to assess the effects of injection and the pain pathway. RESULTS: The average VAS score for upper limb pain with or without scapular and chest pain was significantly reduced by interscalene brachial plexus block compared with control block at 5 min and 7 days after injection. After interscalene brachial plexus block, 89 patients reported symptoms of stellate ganglion block versus no patients after control block. Scapular and chest pain was significantly reduced in the patients with stellate ganglion block compared to those without stellate ganglion block. CONCLUSIONS: Interscalene brachial plexus block is useful for upper limb, scapular and chest pain due to disorders of the cervical spine. The scapular and chest pain pathway is more likely to be interrupted by an interscalene brachial plexus block that causes a stellate ganglion block compared to an interscalene brachial plexus block without stellate ganglion block.

Treatment of Capitellum Fracture with Chronic Radial Head Dislocation.

We encountered a case of capitellum fracture with radial head dislocation in which it was challenging to diagnose whether the dislocation was coincident with the fracture or this was chronic dislocation that presented before the fracture. Chronic radial head dislocation may be congenital or could occur in patients with untreated post-traumatic dislocation, although diagnosis is particularly challenging if the radial head dislocation is unilateral. Classical capitellum fracture involves anterosuperior bone fragment dislocation. However, in the present case, the bone fragment was present beneath the radial head, which suggests chronic radial head dislocation. When the bone fragment appears in a different position than usual, every effort should be made to understand the pathophysiology by reviewing the mechanism of onset, disease history, and imaging.

L5 Radiculopathy due to Foraminal Stenosis Accompanied With Vacuum Phenomena of the L5/S Disc on Radiography Images in Extension Position.

STUDY DESIGN: Retrospective study for L5 radiculopathy due to foraminal stenosis with vacuum phenomena (VP) at the L5/S disc. OBJECTIVE: To investigate the influence of the L5/S VP on L5 radiculopathy, due to L5/S foraminal stenosis. SUMMARY OF BACKGROUND DATA: Foraminal stenosis has often been detected via images. However, although this condition is well known, it is occasionally overlooked during diagnosis, because spinal nerve compression is not always visible on stationary images. METHODS: Patients who underwent lumbar spine surgery were examined to determine the presence of foraminal stenosis (n = 194). The presence of VP and the range of motion of the L5/S disc were assessed on radiography with the lumbar spine in the extended and flexed positions. The shapes of the L5/S foramina were confirmed using sagittal magnetic resonance imaging. Patients who showed VP were divided into 2 groups: patients with (group A) and without (group B) symptomatic foraminal stenosis. The relationship between the VP and symptomatic foraminal stenosis was examined. RESULTS: In total, 35 cases of VP at the L5/S disc were noted on lateral radiography. L5 radiculopathy due to L5/S foraminal stenosis was identified in 14 of these 35 cases. The ranges of L5/S angles were 10°â€Š±â€Š4° and 5°â€Š±â€Š3° in groups A and B, respectively, and these values were significantly different (P < 0.01). 11 (48%) of 23 L5/S foramina that showed VP of the L5/S disc and were completely occupied by a disc below the caudal edge of the vertebra had symptomatic foraminal stenosis. CONCLUSION: Our results indicated that VP, which showed a large range of motion angle between flexion and extension, triggered symptoms of foraminal stenosis at the L5/S disc. The dynamic motion of the VP should thus be considered for the diagnosis of L5/S foraminal stenosis. LEVEL OF EVIDENCE: 3.

Clinical outcome of percutaneous drainage for spondylodiscitis.

BACKGROUND: Although vertebral debridement with interbody fusion is a useful procedure for the treatment of spondylodiscitis, anterior interbody fusion (AIF) is risky to perform on patients in a poor condition since it is highly invasive. Percutaneous nucleotomy and drainage (PND) is less invasive than AIF, but there only have been few reports regarding the outcome. The purpose of this study was to test the efficacy of PND for spondylodiscitis. PATIENTS AND METHODS: To analyze the effectiveness of different surgical treatments, 111 patients with spondylodiscitis were studied retrospectively. The average durations from the start of treatment until the C-reactive protein fell below 1.0 mg/dL or below the baseline value, which was defined as "recovery time" in the present study, were compared among PND, AIF, and posterior decompression. RESULTS: PND was performed when conservative treatment has been done for average 2.0 ± 0.9 months. Of the 18 PND patients, 15 (83%) showed recovery; 63 (97%) of the 65 patients who had AIF showed recovery. There was no significant difference of the mean recovery time after PND and AIF. All 10 patients whithout methicillin-resistant Staphylococcus aureus (MRSA) recovered after PND, whereas 3 of 8 patients with MRSA did not recover after PND. Of the 3 unsuccessful PND cases, 1 later had AIF, and 1 repeated PND. One patient could not undergo additional surgery because of a poor general condition. CONCLUSIONS: Although the results of PND were inferior to AIF, PND is a useful next step after conservative treatment for patients in a poor condition. PND can be the initial procedure for spondylodiscitis before AIF if its limitations are understood.

Low parathyroid hormone levels in patients who underwent/would undergo hemodialysis result in bone graft failure after posterolateral fusion.

STUDY DESIGN: Case series. OBJECTIVE: To reveal the association between levels of parathyroid hormone (PTH) and outcome of bone fusion in patients who underwent/would undergo hemodialysis. SUMMARY OF BACKGROUND DATA: Among the different bone lesions observed in patients who underwent/would undergo hemodialysis, adynamic bone disease is regarded as a factor associated with bone graft failure because of severely reduced bone turnover. Although PTH levels reflect the pathological findings of bone lesions in patients who underwent/would undergo hemodialysis, the relationship between PTH levels and the outcome of bone fusion in patients who underwent/would undergo hemodialysis has not been investigated. METHODS: Patients who underwent/would undergo hemodialysis (n = 48) with lumbar spine lesion underwent posterolateral spinal fusion with instrumentation. The outcome of bone fusion was assessed radiographically 12 months after surgery, and sensitivity and specificity were determined using preoperative PTH levels as the standard. RESULTS: A significant difference in PTH levels was observed between the good fusion (mean, 235.4 pg/mL) and poor fusion (mean, 100.0 pg/mL) groups. The intersection of the sensitivity and specificity plots, generated using preoperative PTH levels, was 150 pg/mL, and the area under the receiver operating characteristic curve was 0.72. CONCLUSION: Low PTH levels are a risk factor for bone graft failure in patients who underwent/would undergo hemodialysis. Accordingly, PTH level can be a useful predictor of the outcome of bone fusion. LEVEL OF EVIDENCE: 4.