Tibial intraneural ganglion cysts at the superior tibiofibular joint treated with joint resection alone: a proof of concept.

BACKGROUND: Intraneural ganglion cysts involving the tibial nerve are rare. Recent evidence has supported an articular (synovial) theory to explain the joint-related origin of these cysts; however, optimal operative treatment for cysts originating from the STFJ remains poorly understood. Therefore, we present a novel strategy: addressing the joint itself without addressing the articular branch and/or the cyst. METHODS: Records of patients with tibial intraneural ganglion cysts with a connection to the STFJ who were treated with a joint resection alone at a single academic institution were reviewed. The clinicoradiographic features, operative intervention, and postoperative course were recorded. RESULTS: We identified a consecutive series of 7 patients. These patients (4/7 male, 57%) were 43 (range 34-61) years of age and all presented with symptoms of neuropathy. The patients underwent resection of the synovial surfaces of the STFJ without disconnection of the articular branch or decompression of the cyst. Postoperatively, three patients regained partial motor function (43%, n=7), although four patients noted continued sensory abnormality (57%, 4/7). All six patients with postoperative MRIs had some evidence of regression of the cyst. CONCLUSIONS: This novel surgical technique serves as a proof of concept-highlighting the fact that treating the primary source (the joint origin) can be effective in eliminating the secondary problem (the cyst itself). While this study shows that this simplified approach can be employed in select cases, we believe that superior results (faster, fuller recovery) can be achieved with combinations of disconnecting the articular branch, decompressing the cyst, and/or resecting the joint.

Does complete regression of intraneural ganglion cysts occur without surgery?

PURPOSE: The dynamic nature of intraneural ganglion cysts, including spontaneous expansion and regression, has been described. However, whether these cysts can regress completely in the absence of surgical management has important therapeutic implications. Therefore, we aim to review the literature for cyst regression without surgical intervention. METHODS: We reviewed our database of 970 intraneural ganglion cysts in the literature to search for evidence of complete regression based on strict radiologic confirmation, either spontaneously, or after percutaneous cyst aspiration or steroid injection. RESULTS: We did not find any examples of complete regression without surgical treatment that met inclusion criteria. Spontaneous regression was reported in four cases; however, only two cases had follow-up imaging, both of which demonstrated residual cysts. Nineteen cases of percutaneous intervention were found in the literature, 13 of which reported clinical improvement following aspiration/steroid injection; however, only seven cases had available imaging. Only two cases reported complete resolution of cyst on MR imaging at follow-up, but reinterpretation found residual intraneural cyst in both cases. CONCLUSION: We believe that pathology (structural abnormalities and/or increased joint fluid) always exists at the joint origin of intraneural ganglion cysts which persist even with regression of the cyst. The persistence of a capsular abnormality or defect can lead to recurrence of the cyst in the future, and while imaging may show dramatic decreases in cyst size, truly focused assessment of images will show a tiny focus of persistent intraneural cyst at the joint origin. Thus, expectant management or percutaneous intervention may lead to regression, but not complete resolution, of intraneural ganglion cysts.

Can Topical Vancomycin Prevent Periprosthetic Joint Infection in Hip and Knee Arthroplasty? A Systematic Review.

BACKGROUND: Periprosthetic joint infection (PJI) after hip and knee arthroplasty is a leading cause of revision surgery, inferior function, complications, and death. The administration of topical, intrawound vancomycin (vancomycin powder) has appeared promising in some studies, but others have found it ineffective in reducing infection risk; for that reason, a high-quality systematic review of the best-available evidence is needed. QUESTIONS/PURPOSES: In this systematic review, we asked: (1) Does topical vancomycin (vancomycin powder) reduce PJI risk in hip and knee arthroplasty? (2) Does topical vancomycin lead to an increased risk of complications after hip and knee arthroplasty? METHODS: A search of Embase, MEDLINE, and PubMed databases as of June 2020 was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Studies comparing topical vancomycin in addition to standard infection prevention regimens (such as routine perioperative intravenous antibiotics) with standard regimens only in primary hip and knee arthroplasty were identified. Patients 18 years or older with a minimum follow-up of 3 months were included. No restrictions on maximal loss to follow-up or PJI definition were imposed. Studies were excluded if they included patients with a history of septic arthritis, used an antibiotic other than vancomycin or a different route of administration for the intervention, performed additional interventions that differed between groups, or omitted a control group. A total of 2408 studies were screened, resulting in nine eligible studies reviewing 3371 patients who received topical vancomycin (vancomycin powder) during a primary THA or TKA and 2884 patients who did not receive it. Groups were comparable with respect to duration of follow-up and loss to follow-up when reported. Study quality was assessed using the Newcastle-Ottawa scale, showing moderate-to-high quality for the included studies. The risks of PJI and overall complications in the topical vancomycin group were compared with those in the control group. RESULTS: One of nine studies found a lower risk of PJI after primary THA or TKA, while eight did not, with odds ratios that broadly bracketed the line of no difference (range of odds ratios across the nine studies 0.09 to 1.97). In the six studies where overall complications could be compared between topical vancomycin and control groups in primary THA or TKA, there was no difference in overall complication risks with vancomycin (range of ORs across the six studies 0.48 to 0.94); however, we caution that these studies were underpowered to detect differences in the types of uncommon complications associated with vancomycin use (such as allergy, ototoxicity, and nephrotoxicity). CONCLUSION: In the absence of clear evidence of efficacy, and without a sufficiently large evidence base reporting on safety-related endpoints, topical vancomycin (vancomycin powder) should not be used in routine primary THA and TKA. Adequately powered, multicenter, prospective trials demonstrating clear reductions in infection risk and large registry-driven audits of safety-related endpoints are required before the widespread use of topical vancomycin can be recommended. LEVEL OF EVIDENCE: Level III, therapeutic study.

Understanding the role of total knee arthroplasty for primary treatment of tibial plateau fracture: a systematic review of the literature.

BACKGROUND: Surgical fixation of tibial plateau fracture in elderly patients with open reduction and internal fixation (ORIF) provides inferior outcomes compared with younger patients. Primary total knee arthroplasty (TKA) may be of benefit in elderly patients with a combination of osteoporotic bone and metaphyseal comminution. However, there continues to be conflicting evidence on the use of TKA for primary treatment of tibial plateau fracture. This systematic review was performed to quantify the outcomes and perioperative complication rates of TKA for primary treatment of tibial plateau fracture. MATERIALS AND METHODS: A comprehensive search of MEDLINE, Embase, and PubMed databases from inception through March 2018 was performed in accordance with PRISMA guidelines. Two reviewers independently screened papers for inclusion and identified studies featuring perioperative complications and outcomes of primary TKA for tibial plateau fracture. Weighted means and standard deviations are presented for each outcome. RESULTS: Seven articles (105 patients) were eligible for inclusion. All-cause mortality was 4.75 ± 4.85%. The total complication rate was 15.2 ± 17.3%. Regarding outcomes, Knee Society scores were most commonly reported. The average Knee Society Knee Score was 85.6 ± 5.5, while the average Knee Society Function Score was 64.6 ± 13.7. Average range of motion at final follow-up was 107.5 ± 10.0°. CONCLUSIONS: Primary TKA for select tibial plateau fractures has acceptable clinical outcomes but does not appear to be superior to ORIF. It may be appropriate to treat certain geriatric patients with TKA to allow for early mobilization and reduce the need for reoperation. Other factors may need to be considered in deciding the optimal treatment. LEVEL OF EVIDENCE: Level III.

Superficial radial intraneural ganglion cysts at the wrist.

Superficial radial intraneural ganglion cysts are rare. Only nine previous cases have been described. We provide two examples with a wrist joint connection and review the literature to provide further support for the unifying articular (synovial) theory for the pathogenesis and treatment of intraneural ganglia.

Satisfactory Results of the Exeter Revision Femoral Stem Used for Primary Total Hip Arthroplasty.

BACKGROUND: The Exeter cemented femoral stem has demonstrated excellent clinical and radiographic outcomes as well as long-term survivorship free from aseptic loosening. A shorter revision stem (125 mm) with a 44 offset became available for the purpose of cement-in-cement revision situations. In certain cases, this shorter revision stem may be used for various primary total hip arthroplasties (THAs) where the standard length stem would require distally reaming the femoral canal. We sought to report on the early to midterm results of this specific stem when used for primary THA regarding (1) clinical and radiographic outcomes, (2) complications, and (3) survivorship. METHODS: Twenty-nine patients (33 hips) underwent a hybrid THA using the smaller revision Exeter cemented femoral stem. Twenty-five patients (28 hips) had at least 2 years of follow-up and were assessed for clinical and radiographic outcomes. All 33 hips were included in the analysis of complications and survivorship. The Kaplan-Meier survivorship was performed using revision for all causes and for aseptic loosening as the end points. RESULTS: The average clinical follow-up was 4 years (range, 2-7). Harris Hip Scores improved from a mean preoperative value of 56 (range, 23-96) to 90 (range, 51-100) at the latest follow-up. All patients demonstrated superior cement mantles with no signs of loosening. One patient suffered a B2 periprosthetic fracture and 1 patient experienced 2 episodes of instability. The 5-year Kaplan-Meier survivorship was 96.7% for all causes of revision and was 100% using aseptic loosening as the end point. CONCLUSION: The shorter Exeter revision cemented femoral stem has favorable early to midterm clinical and radiographic outcomes when used for primary THA with a low complication rate and is a viable option in patients with narrow femoral canals where uncemented stem fixation is not desired.

Survivorship of Metaphyseal Sleeves in Revision Total Knee Arthroplasty.

BACKGROUND: Metaphyseal fixation has promising early results in providing component stability and fixation in revision total knee arthroplasty (TKA). However, there are limited studies on midterm results of metaphyseal sleeves. We analyzed complications, rerevisions, and survivorship free of revision for aseptic loosening of metaphyseal sleeves in revision TKA. METHODS: Two hundred eighty patients with 393 metaphyseal sleeves (144 femoral, 249 tibial) implanted during revision TKA from 2006-2014 were reviewed. Sleeves were most commonly cemented (55% femoral, 72% tibial). Mean follow-up was 3 years, mean age was 66 years, and mean body mass index was 34 kg/m2. Indications for revision TKA included 2-stage reimplantation for deep infection (37%), aseptic loosening of the tibia (14%), femur (12%), or both components (9%), and instability (14%). RESULTS: There was a 12% rate of perioperative complications, most commonly intraoperative fracture (6.5%). Eight sleeves (2.5%) required removal: 6 (2%) during component resection for deep infection (all were well-fixed at removal) as well as 1 (0.8%) femoral sleeve and 1 (0.8%) tibial sleeve for aseptic loosening. Five-year survivorship free of revision for aseptic loosening was 96% and 99.5% for femoral and tibial sleeves, respectively. Level of constraint, bone loss, sleeve and/or stem fixation, and revision indication did not significantly affect outcomes. CONCLUSION: Metaphyseal sleeve fixation to enhance component stability during revision TKA has a 5-year survivorship free of revision for aseptic loosening of 96% and 99.5% in femoral and tibial sleeves, respectively. Both cemented and cementless sleeve fixation provides reliable durability at intermediate follow-up.

The mechanism underlying combined medial and lateral plantar and tibial intraneural ganglia in the tarsal tunnel.

Intraneural ganglion cysts in the tarsal tunnel are rare. We present a patient who had an intraneural ganglion cyst involving the medial and lateral plantar and distal tibial nerves. Magnetic resonance imaging revealed evidence to support the joint-related (i.e., subtalar) origin of the cyst. Careful reinterpretation of the imaging supported a phasic mechanism (i.e., cross-over) to explain the interrelated pathogenesis of the intraneural cyst within the three nerves. This mechanism is analogous to that described for the prototypes-the peroneal, tibial and sciatic nerves in the knee region-and can be generalized to other nerves in the foot and ankle region. We believe that understanding the pathogenesis sheds light on the effective treatment.

Subparaneurial ganglion cysts of the fibular and tibial nerves: A new variant of intraneural ganglion cysts.

Over the last decade, the mechanism of formation of intraneural ganglion cysts has been established through a meticulous review of clinical findings and correlation with patterns produced on magnetic resonance imaging (MRI). Pathognomonic imaging patterns distinguish these rare lesions from the more common extraneural variants in almost all cases. In this report, we present a new pattern of cyst occurrence in the subparaneurial compartment of the nerve and provide potential anatomic explanations for its pathogenesis. Using an anatomic framework of connective tissue compartments of the nerve, we reviewed 63 (56 fibular and seven tibial) intraneural ganglion cysts in the knee region evaluated at our institution and all reports with MRI in the world's literature for evidence of cyst occurrence in the subparaneurial compartment. We identified six cases (five in the common fibular nerve and one in the tibial nerve) at our institution that had MR evidence of cyst in the subparaneurial compartment with a new complex lobulated pattern. All cases had articular branch connections to the superior tibiofibular joint, which at operation were resected along with the joints. Follow-up revealed complete recovery in all instances and no clinical or radiological signs of recurrence. Three cases out of 80 in the literature exhibited the new complex lobulated MRI pattern. We present a new pattern of intraneural ganglion cyst occurrence in a potential space that surrounds peripheral nerves--the subparaneurial compartment. We believe that the unifying articular theory applies to the pathogenesis and management of these rare variants.

Recurrent intraneural ganglion cysts: Pathoanatomic patterns and treatment implications.

The etiology of intraneural ganglion cysts has been poorly understood. This has resulted in the development of multiple surgical treatment strategies and a high recurrence rate. We sought to analyze these recurrences in order to provide a pathoanatomic explanation and staging classification for intraneural cyst recurrence. An expanded literature search was performed to identify frequencies and patterns in cases of intraneural ganglion cyst recurrences following primary surgery. Two univariate analyses were completed to identify associations between the type of revision surgery and repeat cyst recurrences. The expanded literature search found an 11% recurrence rate following primary surgery, including 64 recurrences following isolated cyst decompression (Group 1); six after articular branch resection (Group 2); and none following surgical procedures that addressed the joint (Group 3). Eight cases did not specify the type of primary surgery. In group 1, forty-eight of the recurrences (75%) were in the parent nerve, three involved only the articular branch, and one travelled along the articular branch in a different distal direction without involving the main parent nerve. In group 2, only one case (17%) recurred/persisted within the parent nerve, one recurred within a persistent articular branch, and one formed within a persistent articular branch and travelled in a different distal direction. Intraneural recurrences most commonly occur following surgical procedures that only target the main parent nerve. We provide proven or theoretical explanations for all identified cases of intraneural recurrences for an occult or persistent articular branch pathway.

The etiology and management of cystic adventitial disease.

BACKGROUND: Cystic adventitial disease (CAD) is a rare condition that affects arteries and veins. The etiology remains controversial and several treatment methods have been described. By understanding the pathogenesis of CAD, we can improve the surgical treatment, reduce recurrence rates, and improve patient outcomes. The objective of this study was to perform a systematic review of the world's literature. METHODS: We searched across multiple scientific databases and cross-referenced each article to collect the world's literature on CAD. Studies included were those that reported a case or case series of CAD. Each article was analyzed for site of CAD, patient demographic data, type of imaging, surgical management, presence of a joint connection on imaging or at surgery, and recurrences. A regression analysis was used to identify risk factors for cyst recurrence. RESULTS: We identified 503 reports (724 patients), which were included in our analysis. The most common vessel affected was the popliteal artery with 587 cysts. The mean age was 46 (range, 5-80) years with a male-to-female ratio of approximately 4:1. Magnetic resonance imaging (MRI) or angiography was performed for 182 cysts and conventional angiography was the most advanced imaging modality used in 355 patients who did not receive a MRI or computed tomography scan as part of their assessment. Multiple types of surgical interventions were reported with the most common being cyst resection and saphenous vein graft reconstruction (204 cases). There were 122 joint connections (17%) identified. Sixty-five patients (9%) developed at least one cyst recurrence or persistence. Percutaneous surgery (aspiration or angioplasty) was found to be a risk factor for cyst recurrence (odds ratio, 13.7; 95% confidence interval, 6.5-29.0; P < .0001). Because of the rarity of this condition, publications were limited to level IV evidence consisting of case series and case reports. Several reports had short or no follow-up and few patients had postoperative MRI. These limitations likely underestimate the true rate of cyst recurrence or persistence. CONCLUSIONS: This article provides a comprehensive review of the world's literature on CAD, which can serve as a baseline for future studies. When analyzed in the context of the literature, this systematic review supplies further evidence that CAD adheres to the articular (synovial) theory. We believe that knowledge of these joint connections can simplify treatment, reduce recurrence rates, and improve patient outcomes.

Evidence to support that adventitial cysts, analogous to intraneural ganglion cysts, are also joint-connected.

Cystic adventitial disease (CAD) is a rare condition in which cyst is found within a vessel, typically producing symptoms of vascular compromise. Most commonly located in the popliteal artery near the knee, it has been reported in arteries and veins throughout the body. Its pathogenesis has been poorly understood and various surgical approaches have been recommended. We extrapolated some recent information about a similar condition, intraneural ganglion cyst affecting the deep fibular (peroneal) nerve, to the prototype, CAD of the popliteal artery. In intraneural ganglion cysts affecting the deep fibular nerve we have shown that an articular (neural) branch is the conduit between the superior tibiofibular joint and the main parent nerve for which epineurial dissection of joint fluid can occur. We hypothesized that the same principles would apply to CAD and that an articular (vascular) branch would be the conduit from the knee joint leading to dissection to the main parent vessel. We reviewed five patients with CAD of the popliteal artery in whom MRIs were available: two treated by the primary author well familiar with the proposed articular theory, and three treated by others at our institution, less familiar with it. We then reviewed the literature critically to assess for additional evidence to support our articular (synovial) theory and an anatomic explanation. In the two cases treated by the primary author a joint connection was identified on high resolution MRI prospectively and intraoperatively through the middle genicular artery (MGA); postoperatively in these cases there was no recurrence. In the other three cases, a joint connection was not identified on imaging or at operation. Reinterpretation of these cases revealed a joint connection through the MGA in the one patient who had preoperative imaging and subclinical persistence/recurrence in the two patients who underwent postoperative MRIs done for other reasons. Our review of the literature and imaging studies revealed unrecognized joint connections in CAD to the knee and other joints as well as evidence that the MGA is the conduit in cases of CAD of the popliteal artery. We believe that adventitial cysts originate in neighboring joints and dissect within articular (vascular) branches. In our opinion, the unifying articular theory and the principles introduced for intraneural ganglion cysts apply equally to common and rare sites of adventitial cysts.

Tibial intraneural ganglion cysts arising from the tibiofemoral joint: illustrative cases.

BACKGROUND: Intraneural cysts involving the tibial nerve in the knee region (popliteal fossa) are rare. According to the articular (synovial) theory, which posits a joint origin for this pathology, these cysts originate from either the superior tibiofibular joint (STFJ) or the tibiofemoral (knee) joint. As tibial intraneural cysts arising from the tibiofemoral joint remain poorly understood, the authors present 2 illustrative cases and a review of the world's literature on all tibial intraneural ganglion cysts in the knee region. OBSERVATIONS: Fourteen cases of tibial intraneural ganglion cysts arising from the tibiofemoral joint were identified in the literature. Different articular branch patterns were demonstrated, which could be explained by the varied, rich articular branch innervation at the knee. Favorable outcomes were observed in cases in which the articular branch had been disconnected and the cyst drained and were comparable to the outcomes seen in tibial intraneural ganglion cysts with an STFJ origin. LESSONS: Tibial intraneural cysts in the knee region can be subdivided by their joint of origin: the STFJ or the tibiofemoral joint. Those arising from the tibiofemoral joint originate from different areas of the joint and propagate in predictable patterns, with favorable outcomes following surgical intervention when the joint connection is identified and treated. The origin of tibial intraneural cysts from the tibiofemoral joint are more complex than those originating from the STFJ but seem to have similar propagation patterns and outcomes.

Management of posttraumatic radioulnar synostosis.

Posttraumatic radioulnar synostosis is a rare complication following fracture of the forearm and elbow. Risk factors for synostosis are related to the initial injury and surgical management of the fracture. Typically, patients present with complete loss of active and passive forearm pronation and supination. Evidence of bridging heterotopic bone between the radius and ulna can be seen on plain radiographs. Although nonsurgical management is sufficient in some cases, surgical excision is typically required. The timing of surgical intervention remains controversial. However, early resection between 6 and 12 months after the initial injury can be performed safely in patients with radiographic evidence of bony maturation. Surgical management consists of complete resection of the synostosis with optional interposition of biologic or synthetic materials to restore forearm rotation. A low recurrence rate can be achieved following primary radioulnar synostosis excision without the need for routine adjuvant prophylaxis.

Sprengel deformity: pathogenesis and management.

Sprengel deformity (ie, congenital elevation of the scapula) is a rare clinical entity. However, it is the most common congenital anomaly of the shoulder. Sprengel deformity is caused by abnormal descent of the scapula during embryonic development. Sprengel deformity is associated with cosmetic deformity and decreased shoulder function. Diagnostic confusion with limited scoliosis can be dangerous to the patient because it may delay proper treatment of other abnormalities that may be present with even mild cases. Sprengel deformity is commonly linked to a variety of conditions, including Klippel-Feil syndrome, scoliosis, and rib anomalies. Nonsurgical management can be considered for mild cases. Surgical management is typically warranted for more severe cases, with the goal of improving cosmesis and function. Surgical techniques are centered on resection of the protruding portion of the scapula and inferior translation of the scapula. Recent long-term studies indicate that patients treated surgically maintain improved shoulder function and appearance.

Primary perivascular epithelioid cell neoplasm (PEComa) of bone: report of two cases and review of the literature.

Primary perivascular epithelioid cell neoplasms (PEComas) of bone are rare mesenchymal tumors. Histologically, they are composed predominantly of perivascular epithelioid cells and have the capacity to metastasize. PEComas have been reported within intra-abdominal and intra-pelvic organs. To the best of our knowledge, only seven primary PEComas of bone have been described in the English literature. We present two cases of PEComa of bone, one arising from the distal fibula and one from the acetabulum. Both were treated by surgical excision and one also received adjuvant chemotherapy.

A new procedure for tibial spine avulsion fracture fixation.

Several techniques have been described to repair tibial spine avulsion fractures. Most of these methods use either internal fixation with a screw or suture fixation over a tibial tunnel bone bridge. This article presents a new technique for the surgical management of tibial spine avulsion fractures. The technique involves the creation of a suture mattress to compress and reduce the tibial spine into its fracture bed. The advantages of this technique are that it creates four points of fixation, aids with reduction, and allows for compression of the tibial spine fragment anatomically in its fracture bed. Level of evidence V.

Long-term follow-up and metal ion trend of patients with metal-on-metal total hip arthroplasty.

PURPOSE: Long-term studies are required to support the use of metal-on-metal (MoM) bearings in total hip arthroplasty (THA) given the concern about systemic metal ion release and reports of adverse local soft tissue reactions. The purpose of this study was to report the seven to 13-year clinical, radiographic, and metal ion results in patients following MoM THA. METHODS: We studied 163 prostheses after second-generation MoM THA between July 1997 and November 2003. Cobalt and chromium metal ions were collected using whole and analysed by inductively-coupled plasma-mass spectrometry. RESULTS: The mean follow-up was 8.87 years (range, 7-13 years). Four hips (2.5 %) were revised. The Kaplan-Meier survivorship was 91.3 % for revision for all causes, and 97.5 % when excluding the hips revised for a manufacturer's defect. Median whole blood cobalt levels peaked at a value of 2.87 µg/L at four years (p < 0.0001 vs. pre-operative) and subsequently decreased to 2.0 µg/L after nine years (p = 0.002 vs. four years). Median chromium levels maximally increased up to 0.75 µg/L after five years (p < 0.0001 vs. pre-operative) and tended to decrease thereafter to values of 0.56 µg/L after seven years. CONCLUSIONS: This seven to 13-year follow-up study indicates that the clinical and radiological results following MoM THA are satisfactory with low revision rates. Cobalt and chromium ion levels peaked at four and five years, respectively, and gradually decreased thereafter.