A retrospective cohort study of autogenous iliac strut bone grafting in large bone defects of the lower extremity.

Autogenous iliac bone graft (AIBG) is the treatment of choice for managing bone defects, and favorable results have been reported for bone defects < 5 cm in length. In large bone defects ≥ 5 cm, it is difficult to obtain good results with simple bone grafting, and other management options have drawbacks, such as long immobilization periods and high complication rates. We hypothesized that AIBG in the strut form might show favorable results in large bone defects with minimal complications. This study aimed to investigate the outcomes of strut-type AIBG and evaluate its effectiveness compared to cancellous AIBG. This retrospective study included 50 patients who underwent AIBG for bone defects at a single institution between March 2011 and April 2020. We performed corticocancellous AIBG in a strut form to manage bone defects ≥ 5 cm in the lower extremities. The strut bone was harvested along the iliac crest and grafted slightly longer than the bone defect to apply a sufficient compressive force. Demographic information and radiographic and clinical results of patients who underwent strut AIBG (Group S) were analyzed. The outcomes of union, time to union, complications, and reoperation were compared with those of patients who underwent cancellous AIBG (Group C). The study population comprised 37 men (74%) and 13 women (26%), with a mean age of 50.0 (range: 19-78). The average follow-up period was 25.6 months (12-104 months). Group S included 16 patients with a mean bone defect length of 6.8 ± 1.2 cm. In Group S, union was achieved in all patients, with an average time to union of 6.7 months. Complications occurred in four cases, all related to wound problems. Group C comprised d 34 patients with a mean defect length of 2.8 ± 1.1 cm. Complications occurred in five patients in Group C, including four soft tissue problems and one implant failure. When comparing the outcomes of Groups S and C, no significant differences were observed. AIBG is an effective and safe technique for managing bone defects. Strut AIBG can be used effectively for bone defects ≥ 5 cm in the lower extremities.

Acute compartment syndrome after restarting warfarin therapy following polyethylene exchange in unicompartmental knee arthroplasty: case report.

Background: Acute compartment syndrome (ACS) is one of the true emergencies in orthopedics and traumatology. It can lead to permanent damage to skeletal muscles and neurovascular structures if not promptly treated. Although ACS usually occur after major trauma or invasive surgery, it can develop without trauma or after minimally invasive operation in anticoagulated patients. Case report: A 76-year-old woman underwent a polyethylene exchange in unicompartmental knee arthroplasty (UKA). She had had undergone mitral valve replacement and tricuspid valve annuloplasty, and a pacemaker insertion. She was on warfarin therapy at a dose of 3.5 mg daily. For surgical preparation, she discontinued warfarin for 7 days prior to the surgery, and administered enoxaparin sodium at a dose of 120 mg/day. Warfarin was re-administered at a dose of 3.5 mg/day on POD #7, and no postoperative complications were observed until the sutures were removed on POD #14. However, ACS, caused by arterial branch bleeding, occurred on POD #16, 10 days after restarting warfarin therapy. Emergency fasciotomy was performed to decompress the anterior and posterior compartments of left thigh. Finally, she had minimal neurologic deficits, with a left knee ROM of 0°-100° after 6 months. Conclusion: Presented case showed that arterial branch bleeding of the surgical site could occur more than 1 week after restarting warfarin therapy, which in turn may leaded to fatal complications such as ACS. Moreover, in anticoagulated patients, postoperative arterial branch bleeding and compartment syndrome can occur following considerably less invasive surgical procedures, such as polyethylene exchange in UKA. Therefore, surgeons should be aware of the possibility of surgical site bleeding and compartment syndrome for more than a week in patients who restarted warfarin therapy postoperatively, regardless of the invasiveness of surgical procedure.

Comparison between normal and reverse orientation of graft in functional and histomorphological outcomes after autologous nerve grafting: An experimental study in the mouse model.

BACKGROUND: Autologous nerve grafting has been considered the gold standard for the treatment of irreparable nerve gaps. However, the choice of effective proximodistal orientation of autografts (normal or reversed) is controversial. Therefore, we compared functional and histological outcomes between normal and reversed orientations of autografts in a mouse sciatic nerve model. MATERIALS AND METHODS: Thirty C57BL/6J mice weighing 20-25 g were assigned to the donor, normally oriented autograft, and reverse-oriented autograft groups (n = 10 per group). A 10-mm section of the sciatic nerve was harvested from a donor mouse. Half the harvested nerve was grafted onto an irreparable gap in a recipient mouse using either a normal or reversed orientation. The sciatic functional index (SFI) was measured biweekly for up to 12 weeks postoperatively. Morphological analysis was performed using immunofluorescence staining for neurofilament (NF) and myelin protein zero (P0) in cross-sectional and whole-mount nerve preparations in 12 weeks postoperatively. Additionally, morphological analysis of the tibialis anterior muscle was performed using hematoxylin and eosin staining. NF or P0-expressing axons were counted and cross-sectional area (CSA) and minimum Feret's diameter of myofibers were measured. RESULTS: The SFI recovered gradually up to 12 weeks after autografting, but there were no significant differences in the SFI between the normal and reversed orientations. The number of NF-expressing axons in center of graft was significantly higher in the normal orientation than in the reversed orientation (P < .05). However, there were no significant differences in the number and mean intensity of P0-expressing axons between the orientations. The CSA of myofibers was significantly larger in the normal orientation than in the reversed orientation (P < .05). CONCLUSIONS: Normally oriented autografts promote axonal regrowth and prevent neurogenic muscular atrophy compared with reverse-oriented autografts. However, despite these positive histomorphometric effects, the proximodistal orientation of the autograft does not affect functional outcomes.

Outcomes of lumbar spinal fusion in super-elderly patients aged 80 years and over: Comparison with patients aged 65 years and over, and under 80 years.

ABSTRACT: Despite the increasing prevalence of spinal surgery in super-elderly (SE) patients, the outcomes and complication rates have not been fully elucidated. The purpose of this study was to compare the outcomes and complications of lumbar spinal fusion for degenerative lumbar spinal stenosis (DLSS) in SE patients aged 80 years and over with those in patients aged 65 years and over, and under 80 years.This study analyzed 160 patients who underwent spinal fusion for DLSS between January 2011 and November 2019. Thirty patients in the SE group (group SE, ≥80 years) and 130 patients in the elderly group (group E, ≥65 years and <80 years) were enrolled. The performance status was evaluated by preoperative American society of anesthesiologists (ASA) score. Visual analog scales for back pain (VAS-BP) and leg pain (VAS-LP), and Korean Oswestry disability index (K-ODI) were used to assess clinical outcomes preoperatively and 1 year postoperatively. Percent changes of VAS-BP, VAS-LP and K-ODI were also analyzed. Fusion rates were evaluated by computed tomography 6 months and 1 year postoperatively. Furthermore, bone mineral density, operative time, estimated blood loss, blood transfusion, hospital days, hospitalization in intensive care unit and postoperative complications were compared.The average age of group SE was 82.0 years and that of group E was 71.6 years. There were no differences in preoperative ASA score, preoperative or postoperative VAS BP and VAS-LP, bone mineral density, operative time, estimated blood loss, blood transfusion, hospital days, hospitalization in intensive care unit and fusion rates between the groups. Preoperative and postoperative K-ODI were higher in group SE than group E (all P < .05). However, percent changes of VAS-BP, VAS-LP and K-ODI showed no significant differences. Overall early and late complications were not significantly different between the groups; however postoperative delirium was more common in group SE than group E (P = .027). SE status was the only risk factor for postoperative delirium with odds ratio of 3.4 (P = .018).Spinal fusion surgery is considerable treatment to improve the quality of life of SE patients with DLSS, however careful perioperative management is needed to prevent postoperative delirium.

Functional recovery with histomorphometric analysis of nerves and muscles after combination treatment with erythropoietin and dexamethasone in acute peripheral nerve injury.

INTRODUCTION: Peripheral nerve injury (PNI) often leads to significant functional loss in patients and poses a challenge to physicians since treatment options for improving functional outcomes are limited. Recent studies suggest that erythropoietin and glucocoticoids have beneficial effects as mediators of neuro-regenerative processes. We hypothesized that combination treatment with erythropoietin and glucocoticoids would have a synergistic effect on functional outcome after PNI. MATERIALS AND METHODS: Sciatic nerve crush injury was simulated in ten-week-old male C57BL/6 mice. The mice were divided into four groups according to the type of drugs administered (control, erythropoietin, dexamethasone, and erythropoietin with dexamethasone). Motor functional recovery was monitored by walking track analysis at serial time points up to 28 days after injury. Morphological analysis of the nerve was performed by immunofluorescent staining for neurofilament (NF) heavy chain and myelin protein zero (P0) in cross-sectional and whole-mount nerve preparations. Additionally, morphological analysis of the muscle was performed by Hematoxylin and eosin staining. RESULTS: Combination treatment with erythropoietin and dexamethasone significantly improved the sciatic functional index at 3, 7, 14, and 28 days after injury. Fluorescence microscopy of cross sectional nerve revealed that the combination treatment increased the ratio of P0/NF-expressing axons. Furthermore, confocal microscopy of the whole-mount nerve revealed that the combination treatment increased the fluorescence intensity of P0 expression. The cross-sectional area and minimum Feret's diameter of the muscle fibers were significantly larger in the mice which received combination treatment than those in the controls. CONCLUSION: Our results demonstrated that combination treatment with erythropoietin and dexamethasone accelerates functional recovery and reduces neurogenic muscle atrophy caused by PNI in mice, which may be attributed to the preservation of myelin and Schwann cell re-myelination. These findings may provide practical therapeutic options for patients with acute PNI.