Proximal tibia with an inserted nail can be an available donor site for harvesting cancellous bone.

INTRODUCTION: A pre-existing implant at the harvesting site might dissuade the surgeon from considering the site as available for bone harvesting. This study aimed to investigate the quantity of cancellous bone graft that can be harvested from a proximal tibia with an inserted nail and to report the clinical outcomes of this bone graft harvesting technique. HYPOTHESIS: Our hypothesis was that a certain amount of cancellous bone graft could be harvested from a proximal tibia with an inserted nail without compromising the surrounding environment and outcome of nonunion treatment. MATERIAL AND METHODS: Bone grafting from an ipsilateral proximal tibia with an inserted nail was performed in 32 patients for treating defect nonunion. The amount of harvested bone was measured using three parameters (weight, height, and volume). The effects of the proximal locking screw position on the quantity and location of bone graft harvest were analyzed. Clinical outcomes were evaluated by assessing the radiologic healing of the bone graft site and by assessing the donor site complications. RESULTS: The mean bone defect volume in the nonunion site was 31.1±18.3 (range, 10.6-87.0) cm3. The mean quantity of harvested bone from proximal tibias with an inserted nail was 21.2g, height was 3.9cm, and volume was 26.3 cm3. A positive correlation was found between the quantity of harvested bone and the level of the lateral oblique interlocking screw hole in the tibial nail. All grafted bone successfully consolidated in all cases at an average of 5.8 months postoperatively. However, joint penetration during bone harvesting occurred in one case. DISCUSSION: The bony defect, which measured about 14.3 cm3 could be filled with cancellous bone from a PT with an existing IM nail, without additional bone graft requirements. Even if an intramedullary nail exists inside the proximal tibia, harvesting cancellous bone at this site can be a viable option without serious complications. LEVEL OF EVIDENCE: IV; Retrospective descriptive study.

Bilateral giant cell tumor of tendo Achilles: A case series on reconstruction by peroneus brevis - tibialis posterior tendon.

Giant cell tumor of tendon sheath usually is localized painless solitary benign swelling, which presents as a firm nodular gradually growing mass. Giant cell tumor is infrequent in the lower limb and its incidence in the tendo Achilles is rare. It is often diagnosed and treated conservatively as tendinitis in the initial stages. The slow growth and limited functional deficit is the reason for its late presentation where excision of the mass leaves a large residual defect, for which reconstruction of the tendo Achilles has to be done by mobilizing different tendons. A case series of bilateral giant cell tumor of tendo Achilles and study the functional outcome of the reconstructed tendo Achilles using peroneus brevis - tibialis posterior tendons - are presented. The outcome of reconstruction using peroneus brevis - tibialis posterior tendon gave satisfactory outcome at the end of one year. LEVEL OF EVIDENCE: Level 4.

Does the Surgical Timing and Decompression Alone or Fusion Surgery in Lumbar Stenosis Influence Outcome in Cauda Equina Syndrome?

STUDY DESIGN: A retrospective comparative analysis of 64 patients with cauda equina syndrome (CES), who underwent either decompression alone (NF) or fusion (F) surgery. PURPOSE: We compared the outcomes and timing effects. OVERVIEW OF LITERATURE: CES can cause loss of autonomic control of vesicular function and lower limb neurological deficits. Prompt diagnosis and emergency surgery markedly improve outcome. Although decompression only is a mainstream technique, there is guarded recovery of vesicular dysfunction. Decompression ventrally in a narrow window requires manipulation of neural tissue in an already jeopardised critical canal and may accentuate irreversible damages. In F surgery, the adequate exposure leads to a lower neural manipulation. METHODS: Until January 2008, we treated CES with decompression (laminectomy and/or discectomy). However, from that month forward, all our single-level CES patients have received a fusion operation. In this study, characteristic categorical variables and outcomes were analysed. RESULTS: In a retrospective analysis of 64 patients, NF (n=37) and F (n=27) who received treatment, we found that both groups improved significantly on follow-up in all objective parameters. Although, the comparison of clinical and functional outcome data between the two groups was statistically insignificant, the average value of objective outcome such as vesicular function, low back pain (LBP), and complications was better for patients in F group compared with NF group. However, the patient satisfaction for the F group was also lower, in view of their residual symptoms and disabilities. Contrary to common perceptions, we found that the timing of surgery does not influence the recovery rate for either approach. CONCLUSIONS: Although both the techniques appear to be equally effective, the fusion approach overall showed a definite edge over non-fusion, with respect to reduced incidence of iatrogenic dural tears, LBP, and overall outcome, even despite the lower patient satisfaction.

Approaches and fixation of the posterolateral fracture fragment in tibial plateau fractures: a review with an emphasis on rim plating via modified anterolateral approach.

PURPOSE: To review available approaches and fixation methods for posterolateral fracture fragment (PLF) in tibial plateau fracture, and to propose an algorithm to treat various types of plateau fractures which all involve the PLF. METHODS: This article reviews multiple surgical approaches for PLF and suggests an algorithm for suitable approach and fixation method according to PLF with combined plateau fracture. RESULTS: The modified anterolateral approach is a suitable single approach for fractures with a PLF combined with an anterolateral plateau fracture and for isolated posterolateral fracture fragments. For a multicolumn tibia plateau fracture involving the lateral, medial and posterior columns, dual approaches (modified anterolateral and posteromedial approach) can be used to access the entire plateau area. CONCLUSIONS: When considering approaches of this complex fracture pattern, one must consider local soft tissue condition, plateau fracture morphology, associated injuries, and fixation options. After review of multiple approaches described in the literature for PLF fixation, we can suggest an algorithm for the approach and fixation to treat tibial plateau fractures with posterolateral fracture fragments.

Rim Plating of Posterolateral Fracture Fragments (PLFs) Through a Modified Anterolateral Approach in Tibial Plateau Fractures.

Posterolateral fracture fragments in tibial plateau fractures have proven to be particularly difficult to reduce and adequately repair internally through anterior or anterolateral approaches, although they are safer. Posterior and posterolateral approaches offer a direct approach for the reduction and fixation of plates, but they have several limitations. Here, we have proposed a modified anterolateral approach, which ensures a safe and effective technique for the reduction and fixation of posterolateral fracture fragments, aided by our innovative rim plate.

Bilateral discoid medial menisci: a rare phenomenon.

Discoid medial meniscus is a relatively rare pathology of the knee joint, with bilateral cases even rarer. Herein, we report the case of a 25-year-old man diagnosed with discoid medial meniscus in the right knee with a horizontal tear. Increased cupping of the medial condyle of the tibia, widening of the medial joint space and the presence of discoid meniscus in the right knee prompted investigation of the asymptomatic left knee with magnetic resonance imaging. The contralateral asymptomatic knee also showed evidence of discoid medial meniscus. The symptomatic knee was successfully treated by arthroscopic partial meniscectomy, with excellent functional outcome.