Interventional and multimodal pain rehabilitation in a child with meralgia paresthetica.

Meralgia paresthetica is a chronic pain syndrome that is extremely rare in the pediatric population. It is manifested by hypesthesia or pain in the distribution of the lateral femoral cutaneous nerve (LFCN) and is typically caused by entrapment as the nerve passes deep to the inguinal ligament. This sensory mononeuropathy is rare in children and diagnosis is typically delayed, often leading to prolonged functional impairment and unnecessary medical testing. A 9-year-old girl presented to the pain clinic with a 6-week history of right anterolateral thigh pain first noticed after a nontraumatic cheerleading practice. Comprehensive laboratory and radiographic evaluation by multiple prior specialists revealed no clear nociceptive source of pain. History and examination were consistent with a diagnosis of idiopathic, compressive meralgia paresthetica. Conservative management including physical therapy was followed for 2 weeks with only mild improvement noted. To facilitate physical therapy, an ultrasound-guided LFCN block was performed which confirmed the diagnosis by providing complete analgesia. The patient reported overall 25% improvement from multimodal therapy at another 2 weeks. A second LFCN block was performed with complete resolution of symptoms and restoration of function. The patient remains pain-free and has returned to walking, running, and competitive sports. The primary goal of pediatric chronic pain management, regardless of pain etiology, is early restoration of function to avoid prolonged absence from school, sports, or other productive activities and limit the psychological burden of chronic disease.

The future of spinal cord stereotaxy.

The spinal cord is an integral part of central nervous system, therefore it can be expected that spinal cord has the same properties as the brain. Movement activity is realized by the activation of individual motoneurons of various spinal cord segments under the influence of analytical function of the spinal cord. When a hypothesis is accepted that the mentioned large volume of spinal cord white matter represents the entire length of neuronal network, an idea can be established that the activated motoneurons project through their reticular processes to this connecting network forming a synthetic picture of this movement and after fluent continuity the entire act of movement. Therefore, neuronal network plays the role of dynamic memory.The perspective of spinal cord stereotaxy in functional neurosurgery hypothetically enables a recognition and understanding of how brain and spinal cord communicate in movement performance (Fig. 2, Ref. 6).

[Reflection on the physiological mechanisms of movements controlled by the spinal cord-brain interaction]. / Uvaha o fyziologickém mechanizmu pohybové reakce uskutecnované míchou na podnety z mozku.

The process of communication between brain and spinal cord remains unclear. Therefore an attempt supported by spinal cord stereotaxy was made to disclose the physiological mechanism underlying the cooperation between brain and spine as generated by the spinal cord. The initializing stimulus was the discovery of motoneuron location in all spinal cord segments providing the organic substrate for spinal cord stereotaxy. What remained to be clarified were the anatomical structures of spinal cord, participating in the feedback between brain and spinal cord. Therefore two possible hypotheses were proposed by the authors. One is closely related to the analytic-synthetic mechanism of real object and thoughts depiction in the memory of the brain and in the form of concrete ideas forming the basis for concrete thinking. In the case of spinal cord, another more probable mechanism should be considered: The process of analysis and synthesis between the participating spinal motoneurons. The mutual neuronal connections in the spinal cord are capable of depicting the movement pattern and the movement is transferred by means of the described spinal cord pathways to the memory of the brain as a concrete movement idea. From here the ideas are transferred according to the individual needs backwards by means of another described spinal cord pathways back to the spinal cord and the spinal cord is the final effector. The process of thinking is the physiological correlate of technical software, but in the form of abstract thinking it is transferred to the form of abstract thinking.

Considerations on physiological mechanisms of spinal cord movement performance according to cerebral stimuli.

The process of communication between brain and spinal cord remains unclear. Therefore an attempt supported by spinal cord stereotaxy was made to disclose the physiological mechanisms underlying the cooperation between the brain and spine as generated by the spinal cord. The initializing stimulus was the discovery of motoneuron location in all spinal cord segments providing an organic substrate for spinal cord stereotaxy. What remains to be clarified are the anatomical structures of spinal cord, participating in the feedback between brain and spinal cord. Therefore two possible hypotheses were proposed by the authors. One of them is closely related to the analytical synthetical mechanism of real objects and thoughts depiction in the memory of the brain and in form of concrete ideas it forms the basis for concrete thinking. In case of spinal cord another more probable mechanism should be considered: the process of analysis and synthesis between the participating spinal motoneurons. The mutual neuronal spinal cord connections are capable of depicting the movement pattern, and the movement is transferred by means of the described spinal cord pathways to the memory of the brain as a concrete movement idea. From here the ideas are transferred according to the individual needs backwards by means of another described spinal cord pathway back to the spinal cord, and the spinal cord is the final effector. The process of thinking is the physiological correlation of technical software, but in form of abstract thinking it is transferred to the form of abstract thinking. (Fig. 3, Ref 7). Full Text (Free, PDF) www.bmj.sk.

Periprosthetic total joint infections: staging, treatment, and outcomes.

Forty-three patients having 49 treatment protocols for periprosthetic total joint infections were staged prospectively, using an osteomyelitis classification system designed to stratify treatment selection according to patient risk factors. Implant salvage was possible in 66% of the infections treated within 30 days of the surgical procedure or within 14 days of symptom onset after a late, septic event. After debridement and implant removal, 88% of the patients with long-standing, refractory infections now have infection-free, functional reconstructions; 64% of these patients have a new, total joint replacement at the original site of treatment. All of the treatment failures, deaths, and amputations occurred in the high-risk patient cohorts prospectively identified within the staging system. Infection duration and the condition of the host are the two most important variables in predicting outcomes in patients with periprosthetic infections.

Osteogenic protein-1 (bone morphogenetic protein-7) in the treatment of tibial nonunions.

BACKGROUND: The role of bone morphogenetic proteins (BMPs) in osseous repair has been demonstrated in numerous animal models. Recombinant human osteogenic protein-1 (rhOP-1 or BMP-7) has now been produced and was evaluated in a clinical trial conducted under a Food and Drug Administration approved Investigational Device Exemption to establish both the safety and efficacy of this BMP in the treatment of tibial nonunions. The study also compared the clinical and radiographic results with this osteogenic molecule and those achieved with fresh autogenous bone. MATERIALS AND METHODS: One hundred and twenty-two patients (with 124 tibial nonunions) were enrolled in a controlled, prospective, randomized, partially blinded, multi-center clinical trial between February, 1992, and August, 1996, and were followed at frequent intervals over 24 months. Each patient was treated by insertion of an intramedullary rod, accompanied by rhOP-1 in a type I collagen carrier or by fresh bone autograft. Assessment criteria included the severity of pain at the fracture site, the ability to walk with full weight-bearing, the need for surgical re-treatment of the nonunion during the course of this study, plain radiographic evaluation of healing, and physician satisfaction with the clinical course. In addition, adverse events were recorded, and sera were screened for antibodies to OP-1 and type-I collagen at each outpatient visit. RESULTS: At 9 months following the operative procedures (the primary end-point of this study), 81% of the OP-1-treated nonunions (n = 63) and 85% of those receiving autogenous bone (n = 61) were judged by clinical criteria to have been treated successfully (p = 0.524). By radiographic criteria, at this same time point, 75% of those in the OP-1-treated group and 84% of the autograft-treated patients had healed fractures (p = 0.218). These clinical results continued at similar levels of success throughout 2 years of observation, and there was no statistically significant difference in outcome between the two groups of patients at this point (p = 0.939). All patients experienced adverse events. Forty-four percent of patients in each treatment group had serious events, none of which were related to their bone grafts. More than 20% of patients treated with autografts had chronic donor site pain following the procedure. CONCLUSIONS: rhOP-1 (BMP-7), implanted with a type I collagen carrier, was a safe and effective treatment for tibial nonunions. This molecule provided clinical and radiographic results comparable with those achieved with bone autograft, without donor site morbidity.

Osteomyelitis debridement techniques.

Debridement of chronic osteomyelitis can be technically demanding and difficult. The surgical principles that govern treatment of osteomyelitis involve an atraumatic approach and complete removal of all devitalized tissue and foreign material. Despite recent advances in medical science, the quality of surgical debridement remains the most critical factor in the successful management of chronic orthopaedic infections. Important areas discussed include thorough preoperative evaluation, the surgical philosophy, soft tissue aspects, bone considerations, and dead space management.

Infected tibial nonunions (1981-1995). The evolution of change.

Between 1981 and 1995, 150 consecutive cases of middiaphyseal, infected nonunions of the tibia were treated prospectively on the author's osteomyelitis service. Thirty-nine (78%) of the 49 patients seen between 1981 and 1986 and 94 (93%) of the 101 patients seen 1986 through 1994 underwent successful salvage protocols with a minimum followup of 5 years. The difference in outcomes seen in the two groups eloquently reflects the emergence of specific pharmaceutic, technical, and biologic advances earmarking these two, distinct eras of care.

Delayed local treatment of rabbit tibial fractures with biodegradable cefazolin microspheres.

The prevention of infection is a primary objective in the treatment of open fractures. The objective of this study was to compare the efficacy of biodegradable, poly (DL-lactide-co-glycolide) cefazolin microspheres and free cefazolin powder in Staphylococcus aureus contaminated rabbit tibial fractures when treatment was delayed for 2 hours. Fractures were produced in the tibia of rabbits, inoculated with Staphylococcus aureus, and 2 hours later treated by either direct local application of cefazolin microspheres or an equivalent dose of free cefazolin powder. Control animals did not receive antibiotic therapy. The fractures then were stabilized with a bone plate, and the animals were observed for 8 weeks. Local antibiotic therapy with biodegradable cefazolin microspheres prevented the establishment of infection in all animals, and cultures of the tibiae were sterile in all cases. In contrast, clinical evidence of infection developed in 50% of the rabbits that had been treated with free cefazolin powder and 71% of the control animals. Staphylococcus aureus was recovered from the tibiae of 75% and 100% of these animals, respectively. The results of this study suggest that local antibiotic therapy with biodegradable, controlled release cefazolin microspheres may be useful for the management of open fractures in humans, even when treatment is delayed for several hours after bacterial contamination.

Segmental tibial defects. Comparing conventional and Ilizarov methodologies.

Forty-four consecutive patients with segmental debridement defects of the tibia had limb-salvage surgery. Twenty-one patients (Group I) were managed using methods as described by Ilizarov. Twenty-three patients (Group II) underwent conventional treatment with massive cancellous grafts and tissue transfers. Total wound consolidation and infection arrest took place after the first treatment in 71% of the Ilizarov wounds and 74% of the conventionally treated wounds. The major complication rates were 33% and 60% for Groups I and II respectively. The patient population at highest risk for failure was the compromised host treated conventionally (44%). The cost for retreatment and overall success rate (95%) were the same for both groups. Ilizarov reconstructions averaged nine fewer hours in the operating theater, 23 fewer days in the hospital, five fewer months' disability (17 months versus 22 months), and a savings of nearly $30,000 per application.

Invasive infection due to Apophysomyces elegans in immunocompetent hosts.

A previously well 59-year-old man developed necrotizing, invasive cellulitis and subsequent osteomyelitis at what was judged to be the site of a bite or sting. The pathogen isolated was Apophysomyces elegans. Eventually, in addition to treatment with intravenous amphotericin B, en bloc resection was required for cure. Only six previous cases of A. elegans infection have been reported in the literature. The lack of underlying disease in six of the total of seven cases contrasts with the usual findings for other zygomycoses. This article describes all seven reported cases as well as the characteristics of this unique fungal pathogen.

Evaluation of biodegradable cefazolin sodium microspheres for the prevention of infection in rabbits with experimental open tibial fractures stabilized with internal fixation.

Immediate internal fixation of severe open tibial fractures usually is contraindicated due to the high risk of infection. The objective of this study was to evaluate the efficacy of local antibiotic therapy with biodegradable poly-(DL-lactide-co-glycolide) cefazolin-loaded microspheres for the prevention of infection in experimental open fractures stabilized with internal fixation. Rabbits with experimental tibial fractures that were contaminated with Staphylococcus aureus were treated with local application of cefazolin microspheres, an equivalent local dose of free Ancef powder, or systemic Ancef therapy. The bones then were fixed with a four-hole plate, and the animals were observed for 8 weeks. Clinically, deep infection was present in 86% of control animals that received no antibiotics and in 60% of animals that received a 7 day course of systemic Ancef therapy. In contrast, no infections were noted among any of the surviving rabbits that received local therapy with either cefazolin microspheres or free Ancef powder. Significantly higher levels of serum cefazolin were measured at 1 h for animals treated with free Ancef powder (18.7 +/- 6.1 micrograms/ml) than for those treated with cefazolin microspheres (0.57 +/- 0.27 micrograms/ml). Follow-up studies are in progress to evaluate further the potential clinical benefits of local antibiotic therapy for the management of contaminated open fractures in humans.

Bony reconstruction in the lower extremity.

The reconstructions of large debridement defects of the tibia are difficult and, at times, discouraging. To maximize the potential for limb salvage, a rigorous patient selection algorithm is essential. Each therapeutic option must consider various host factors, anatomic restraints, physician skills, and institutional resources. In this article, the cost effectiveness and morbidity of two distinct methodologies are compared to bring the guidelines for patient selection to perspective.

In vitro and in vivo evaluation of antibiotic diffusion from antibiotic-impregnated polymethylmethacrylate beads.

The elution of antibiotics from antibiotic-impregnated polymethylmethacrylate (PMMA) beads was measured in mongrel dogs. The antibiotics, used in mixture with Simplex cement, included cefazolin (Ancef; 4.5 g/40 g cement powder), ciprofloxacin (Cipro; 6 g/40 g powder), clindamycin (Cleocin; 6 g/40 g powder), ticarcillin (Ticar; 12 g/40 g powder), tobramycin (Nebcin; 9.8 g/40 g powder), and vancomycin (Vancocin; 4 g/40 g powder). After a pneumatic drill was used to dredge a trough in the tibia, five beads were implanted. During the next 28 days, seroma samples and serum samples were taken for antibiotic measurements. On Day 28, the dogs were killed, beads removed, and the seroma, serum, bone, and granulation tissue sampled. The results of the study showed that clindamycin, vancomycin, and tobramycin exhibited good elution characteristics and had consistently high levels in bone and granulation tissue.

Evaluation of biodegradable ampicillin anhydrate microcapsules for local treatment of experimental staphylococcal osteomyelitis.

Successful treatment of chronic osteomyelitis requires sustained high concentrations of antibiotics locally within the infected bone. The efficacy of biodegradable (poly-DL-lactide-co-glycolide) microspheres containing 30.7% ampicillin anhydrate for the local treatment of experimental staphylococcal osteomyelitis was evaluated in rabbits. In the initial experiment, antibiotic therapy was initiated immediately following injection of Staphylococcus aureus into the proximal tibial metaphysis. A single intramedullary injection of microencapsulated ampicillin (100 mg) prevented osteomyelitis in all seven animals tested and was as effective as a two-week course of parenteral ampicillin administration. When antibiotic therapy was delayed for seven days, osteomyelitis developed in four of eight animals treated locally with microencapsulated ampicillin and in six of eight animals that received parenteral ampicillin therapy. When antibiotic therapy was delayed for seven days and was preceded by debridement, all ten animals treated locally with microencapsulated ampicillin had sterile bone cultures. In contrast, seven of ten animals treated locally with unencapsulated ampicillin powder developed osteomyelitis. Biodegradable antibiotic-loaded microspheres may be of clinical benefit for the local treatment of chronic osteomyelitis.

Ankle arthrodesis in the presence of continuous sepsis. Indications, methods, and results.

On 26 patients, 28 ankle fusions were performed and followed 2 or more years. A functional limb salvage was gained in 25 limbs (96%) with an overall arrest rate of 92%. There was one amputation (4%). The major complication rate was 38% for the series and 86% for patients with uncorrected wound-healing deficiencies (B-hosts). All of the first and second treatment failures were associated with a central column deficiency (C-).

Chronic osteomyelitis: results of treatment.

As stated previously, approximately 8% of the patients evaluated do not require curative treatment and palliative treatment with suppressive therapy may be successful (Fig 2). For the most part, these are C-hosts for whom the morbidity of treatment is greater than the morbidity of disease or exceeds the expected gain. The overall spectrum of treatment in 411 of my patients (1983-1988) is seen in Table 5. Of the 411 patients, 228 (55%) required a bone graft; of these, 42% were primary grafts. Soft-tissue reconstructions were required in 37% of the entire patient population and in 59% of the type IV lesions. The overall amputation rate was 9%. There were no statistical differences in success rates between stable and unstable lesions, nor when cases were stratified for the type or number of bacteria present. However, compromised patients had a statistically inferior prognosis compared with patients who had normal physiologic profiles (Outline 1).

Long acting somatostatin analogue in dumping syndrome.

The effect of long acting somatostatin analogue, SMS 201-995, on postprandial dumping syndrome was studied in eight patients with Billroth II gastric resection. Each patient was subjected to two oral glucose challenges with 75 g glucose. One challenge was premedicated with 50 micrograms SMS 201-995 subcutaneously 15 min before the oral intake of glucose, the other with placebo. With placebo all patients experienced the subjective symptoms of the early dumping syndrome with significant (P less than 0.001) increases (mean (s.d.)) in pulse rate (from 66 (8) to 102 (10) beats/min), in packed cell volume (from 0.36 (0.05) to 0.43 (0.1) l/l) and in the plasma levels of vasoactive intestinal polypeptide (from 3.0 (0.5) to 10.2 (1.8) pmol/l). During the somatostatin study the subjective symptoms and the changes in the various parameters were not detected. In the control study seven patients showed postprandial hypoglycemia. In these patients significant elevations (P less than 0.001) in the insulin level (from 10 (0.9) to 40 (9.1) microE/ml) and gastric inhibitory peptide (GIP) concentration (from 100 (13) to 220 (41) ng/l) were seen, compared with the initial values. During the application of SMS 201-995 hypoglycaemia did not develop and plasma insulin and GIP concentrations remained unchanged. These results indicate that the long acting somatostatin analogue alleviates the symptoms of early and late postprandial dumping syndromes.

Ankle arthrodesis in the presence of ongoing sepsis. Indications, methods, and results.

The prognosis for ankle arthrodeses performed in the presence of chronic joint sepsis is addressed. The described methods afford reliable and highly successful results, even in cases with massive hard- and soft-tissue deficits. An ankle fusion can be reliably accomplished in the presence of wound contamination, inadequate bone stock, and an ischemic soft-tissue envelope. The methods used must be tailored to the anatomic extent of disease, the physiologic condition of the host, and institutional resources.