Prospective Study of Posterior Lumbar Interbody Fusion With Either Interbody Graft or Interbody Cage in the Treatment of Degenerative Spondylolisthesis.

STUDY DESIGN: A prospective study of 2 different fusion techniques for the treatment of single-level degenerative spondylolisthesis. OBJECTIVE: To determine whether the addition of an intervertebral cage improves the clinical outcome and fusion rate of patients undergoing posterior lumbar interbody fusion (PLIF) after decompression for degenerative spondylolisthesis. SUMMARY OF BACKGROUND DATA: The surgical approach that should be used for degenerative spondylolisthesis is a controversial issue. Decompression and PLIF with an interbody cage is widely used. Theoretical advantages in favor of PLIF include anterior column support, indirect foraminal decompression, restoration of lordosis, and reduction of the slip via ligamentotaxis. Despite numerous publications, the scientific support for the PLIF method is, however, weak. MATERIALS AND METHODS: A prospective study was carried out including 59 patients with degenerative spondylolisthesis. Average age of patients was 66 years: 34 males and 25 females. Patients were divided into 2 treatment groups: group 1-32 patients with PLIF with interbody graft and group 2-27 patients with PLIF with cage. Minimum 2-year follow-up. Outcomes were assessed by measuring preoperative and postoperative lordotic angles. SF-12 physical and mental health scores were recorded along with visual analogue scores for pain. Complications were also recorded. RESULTS: No significant difference in the postoperative lordotic angles was achieved between the 2 techniques. Nonsignificant difference in the clinical outcomes between both the techniques. CONCLUSIONS: We have found the use of a cage to achieve lumbar interbody fusion in the treatment of degenerative lumbar spondylolisthesis does not confer any significant advantages in terms of restoration of lumbar lordosis, improvement in clinical symptoms, or relief of pain postoperatively.

Deep soft tissue leiomyoma mimicking fibromatosis in a 5-year-old male.

Leiomyomas of the deep soft tissue in the extremities of children are very rare. These benign soft tissue tumors occur more frequently in adults between the fourth and sixth decades of age. Women are more commonly affected than men, with the uterus the most common location. We present a rare case of deep soft tissue leiomyoma in the foot of a 5-year-old male. The tumor was misdiagnosed as a desmoid-type fibromatosis from the findings of both magnetic resonance imaging and needle biopsy. The unusual age of presentation, atypical location, and failure of magnetic resonance imaging and ultrasound-guided needle biopsy in diagnosing the lesion make the case interesting. The case also highlights the importance of treating such patients at specialist tertiary centers with a multidisciplinary setting.

Free fibular graft reconstruction following resection of chondrosarcoma in the first metacarpal.

Chondrosarcoma is most frequently present in the pelvis and long bones and rarely seen in the bones of the hand. Traditionally the treatment of choice for involvment of the hand is ray amputation, however this causes significant functional deficit if there is thumb involvement. There are limited cases in literature of resection of thumb chondrosarcoma with restoration of function. We present a case of high grade chondrosarcoma of the first metacarpal treated with resection and free fibular graft reconstruction. We report excellent functional outcome with this procedure.

Avulsion fracture of the anterior superior iliac spine: misdiagnosis of a bone tumour.

Avulsion fractures of the anterior superior iliac spine are rare. This injury is usually seen in adolescents, as an avulsion fracture of the apophyses, a result of sudden vigorous contraction or repetitive contraction of the sartorius and tensor fasciae latae muscles. Treatment for this injury is usually conservative; however, surgical management has been reported in those with significant displacement. We present a 14 year old male patient who was referred to our unit for biopsy of a possible pathological fracture of his right ilium. The authors feel it is essential to understand the importance of ruling out a bone tumour, if the possibility has been raised, before managing a suspected fracture. If there is any doubt, the case should be referred to an appropriate sarcoma unit for review prior to any intervention.

Atypical tibial tuberosity fracture in an adolescent.

Avulsion fractures of the tibial tuberosity are typically sustained by adolescent males during sporting activities. Tibial tuberosity avulsions with simultaneous proximal tibial epiphyseal fractures are rare injuries. We present an unusual case of Ogden type IIIA avulsion fracture of tibial tuberosity with a Salter Harris type IV posterior fracture of proximal tibial epiphysis in a 13-year-old boy. We believe that the patient sustained the tibial tuberosity avulsion during the take-off phase of a jump while playing basketball due to sudden violent contraction of the quadriceps as the knee was extending. This was then followed by the posterior Salter Harris type IV fracture of proximal tibial physis as he landed on his leg with enormous forces passing through the knee. Although standard radiographs were helpful in diagnosing the complex fracture pattern, precise configuration was only established by computed tomography (CT) scan. The scan also excluded well-recognized concomitant injuries including ligament and meniscal injuries. Unlike other reported cases, our patient did not have compartment syndrome. Anatomic reduction and stabilization with a partially threaded transepiphyseal cannulated screw and a metaphyseal screw followed by early mobilization ensured an excellent recovery by the patient.Our case highlights the importance of vigilance and a high index of suspicion for coexisting fractures or soft tissue injuries when treating avulsion fractures of tibial tuberosity. A CT scan is justified in such patients to recognize complex fracture configurations, and surgical treatment should be directed appropriately to both the fractures followed by early rehabilitation. Patients with such injuries warrant close monitoring for compartment syndrome during the perioperative period.

Angioleiomyoma of the knee: case series and an unusual cause of knee pain.

We present a consecutive series of five patients with angioleiomyoma, a rare benign soft tissue tumor around the knee. Between 2005 and 2010, five patients with histopathologically confirmed diagnosis of angioleiomyoma of the knee underwent surgical excision. All five patients were Afro-caribbean in origin. The presenting feature was burning medial knee pain localized to a tender hyperesthetic swelling around the knee. The mean age of presentation was 45 years (range, 42 to 51 years), and the mean duration of symptom was 34 months (range, 12 to 96 months). Although magnetic resonance imaging (MRI) scans were helpful in locating and delineating the tumors, true diagnosis was established only by histopathology. All patients underwent surgical excision with complete resolution of symptoms. No recurrences were seen at an average follow-up of 16 months (range, 3 to 24 months). The treatment of these tumors, especially around the knee, is frequently delayed due to their late presentation and lack of awareness of this clinical condition. We recommend a high index of suspicion in patients, especially of Afro-caribbean origin, presenting with painful hyperesthetic subcutaneous swelling around the knee. Early investigation by MRI expedites the diagnosis, and surgical excision results in complete resolution of symptoms.

Giant cell tumours of tendon sheath of hand: causes and strategies to prevent recurrence.

Giant cell tumours of tendon sheath of hand present a surgical dilemma due to their high incidence of local recurrence. We present a case series of 46 patients with 47 histologically confirmed giant cell tumours of tendon sheath over a ten-year period from 1998 to 2008. The mean follow-up was 47 months (range 25-124 months). We identified tumours with bony erosions and piecemeal resections as predictors of recurrence. Our recurrence rate of 9% was at the lower end of spectrum of previously published reports (range 7%-44%). We recommend "en-masse" excision of these tumours. All the patients with suspicion of these tumours should have preoperative radiographs to identify erosions. A thorough curettage of the bone should be done in cases with osseous erosion to prevent recurrence. Patients with these risk factors should be followed up annually for five years and be warned about recurrence.

Intra-neural Ewing's sarcoma of the upper limb mimicking a peripheral nerve tumour. A report of 2 cases.

Ewing's sarcoma is a malignant round cell tumour of bone commonly affecting children and young adults. Intra-neural Ewings is very rare form of extraosseous Ewing's sarcoma (EES), posing diagnostic and therapeutic challenges. We report two cases of intra-neural EES presenting with elbow pain and swelling, mimicking an upper limb peripheral nerve sheath tumour. Following a CT guided biopsy to confirm diagnosis, the patients were treated with a combination of surgical resection, chemotherapy and radiotherapy. These cases highlight the potential diagnostic challenges as their presentation can be misleading due to the non-specificity of symptoms. These are highly aggressive tumours with the propensity to metastasize. We review importance of collective radiological and immunohistochemical analysis followed by early, aggressive multimodal treatment within a multidisciplinary setting. This provides the best prognosis in the context of upper limb peripheral nerve tumours.