A novel technique for managing symptomatic spinal cysts using epiduroscopic neural laser decompression: technical note and preliminary results.

BACKGROUND: Benign spinal cysts are relatively common, but can cause significant pain. However, consensus regarding the best method for treating these cysts has not been established. We aimed to examine the usefulness of epiduroscopic neural laser decompression (ENLD), a novel percutaneous treatment, for treating lumbo-sacral cysts. METHODS: Ten patients (6 men, 4 women; mean age 45.5 years) with benign lumbo-sacral cysts underwent ENLD. The lumbo-sacral cysts were caused by multiple pathophysiologies and displayed different characteristics. Cysts were evaluated using a recorded epiduroscopic procedure video, magnetic resonance imaging (MRI), and electronic medical records. In all patients, MRI identified cysts with well-defined margins that were compressing the nerves in the lumbo-sacral region and were associated with the pain symptoms of the patients. Retrospectively, we reviewed a series of consecutive patients who underwent surgery (two with discal cysts, four with facet cysts, and four with Tarlov cysts). Low back/leg pain was evaluated using a 1-10 visual analog scale. Functional improvement was evaluated using Oswestry Disability Index scores. Outcomes were evaluated pre- and post-operatively and 1 year post-surgery. RESULTS: Patients were examined between May 2016 and August 2017. Average pain scores improved from 4.7 pre-surgery to 1.8 post-surgery (low back; p < .001) and from 5.8 pre-surgery to 1.6 post-surgery (leg; p < .001). Disability scores decreased from 27.2% pre-surgery to 14.6% post-surgery. CONCLUSION: Currently, no standard treatment strategy for symptomatic spinal cysts exists. These results show that ENLD using a Holmium: YAG laser can be useful in treating symptomatic benign spinal cysts. TRIAL REGISTRATION: Not applicable as this is a retrospective chart review.

Delayed femoral fracture through a tracker pin site after navigated total knee arthroplasty.

Femoral shaft fractures through a tracker pin site after computer navigated total knee arthroplasty are being increasingly reported. All previously reported fractures have occurred within 3 months of surgery, and thus, any patient with an unexpected thigh pain during the early postoperative period should be carefully monitored for a potential fracture and receive appropriate follow-up care. However, unlike these fractures, we encountered a navigation pin-associated delayed femoral shaft fracture during the late postoperative period (at 12 months postoperatively), which we believe, might be associated with transcortical drilling marks.

Arthroscopic repair of the posterior horn of the medial meniscus with opening wedge high tibial osteotomy: surgical technique.

Simultaneous repair of a radial tear at the tibial attachment site of the posterior horn of the medial meniscus under special circumstances requiring tibial valgus osteotomy is technically difficult. First, most patients who need an osteotomy have a narrowed medial tibiofemoral joint space. In such a situation, the pull-out suture technique is more difficult to perform than in a normal joint space. Second, pulling out suture strands that penetrate the posterior horn of the medial meniscus to the anterior tibial cortex increases the risk of transection during osteotomy. We performed a meniscus repair combined with an opening wedge tibial valgus osteotomy without complications and present our technique as a new method for use in selective cases necessitating both meniscus repair of a complete radial tear and opening wedge tibial osteotomy.

A modified keyhole technique for minimizing size mismatches during a smaller than optimal lateral meniscal allograft transplantation: surgical technique.

Despite careful preoperative and intraoperative sizing of lateral menisci in recipient knees, size mismatches between allografts and recipient menisci are often encountered. To minimize size mismatches during the transplantation of smaller than expected lateral meniscal allografts, we devised a modified keyhole technique by dividing the central bone bridge into 2 bony fragments. The fragments are attached to the anterior and posterior horns. In the event of mismatch, the anterior bony fragment is moved anteriorly in the keyhole tunnel. Although the technique of meniscal transplantation is technically demanding, the central bone bridge can be divided without difficulty. The described technique is considered a useful alternative method during lateral meniscal transplantation.

Arthrodesis of the knee using computer navigation in failed total knee arthroplasty.

Arthrodesis is used most commonly as a salvage procedure for failed total knee arthroplasty (TKA). For successful arthrodesis, a stable fusion technique and acceptable limb mechanical alignment are needed. Although the use of TKA intramedullary alignment rods may be helpful in terms of achieving an acceptable limb mechanical axis, fat embolism and intramedullary dissemination of an infection or reactivation of latent infection may occur in failed TKA cases with an active infection or a past history of infections. In this situation, computer-assisted surgery allows precise cuts to be made in the frontal and sagittal planes without breaching medullary cavities. Navigated femoral and tibial bone resections were performed perpendicular to the coronal mechanical axis. Also, femoral resection was conducted at 0 degrees of flexion to the sagittal axis, and the tibial resection at 7 degrees of flexion to the sagittal axis. The arthrodesis was held in proper axial and rotational alignment. First, the tibia was placed against the femur, ensuring good bony apposition mediolaterally and anteroposteriorly. Second, the rotational alignment was also rechecked based on the information obtained from the navigation system, suggesting that the mechanical axis will be neutral if the rotational alignment is correct because the tibial slope was increased posteriorly. Knee arthrodesis was completed using the Ilizarov method. Postoperative radiographs revealed satisfactory alignment. We believe that computer navigation could be an alternative surgical option for arthrodesis for failed TKA secondary to intra-articular infection and could be used for failed TKA with extra-articular deformity.

ACL injury while jumping rope in a patient with an unintended increase in the tibial slope after an opening wedge high tibial osteotomy.

High tibial osteotomy (HTO) is an accepted surgical technique for the treatment of medial compartmental arthrosis of the knee in younger patients. Compared to total knee arthroplasty, HTO may be a good choice in patients who wish to continue with heavy labor and/or impact sports. Based on the rehabilitation protocol after HTO, impact sports, such as running, jumping rope, and full sports activities, are generally permitted 6 months postoperatively. Jumping rope is an excellent form of aerobic exercise, and when done properly, jumping rope can lead to a dramatic improvement in rehabilitation and full sports activities. However, an adequate evaluation should be performed prior to initiating impact sports. We present the case of a ruptured anterior cruciate ligament that occurred in a patient with an unintended increase in the tibial slope after an opening wedge HTO who was jumping rope.

Lateral meniscus and lateral femoral condyle cartilage injury by retained cement after medial unicondylar knee arthroplasty.

The authors experienced an unusual case of a patient with a complex tear of the lateral meniscus and adjacent lateral femoral condyle cartilage injury in the contralateral compartment by retained cement, possibly located at the posteromedial side of the medial tibial component after unicondylar knee arthroplasty. Arthroscopic partial meniscectomy and cartilage microfracture were successfully performed. Two small cement fragments were removed from the posterolateral compartment. A sharp pain in the lateral side disappeared postoperatively and posterior knee pain was much reduced.

'Fine-tuned' correction of tibial slope with a temporary external fixator in opening wedge high-tibial osteotomy.

The authors describe a surgical procedure to 'fine-tune' the tibial slope during high-tibial osteotomy. Fifteen consecutive patients were treated for medial compartment osteoarthritis of the knee using a temporary unilateral external fixator and accompanying internal fixator composed of two plates (with different sized space). All 15 patients were evaluated by measuring femoro-tibial angles (FTAs) in the frontal plane, and using the proximal tibial anatomical axis (PTAA) and the posterior tibial cortex (PTC) methods to assess tibial slope in the sagittal plane. FTA, PTAA, and PTC angles were measured using: (1) radiographs taken before surgery, (2) fluoroscopic images taken after inserting the first plate during surgery, (3) fluoroscopic images taken after tibial slope restoration using an external fixator system during surgery, and finally using, (4) radiographs taken after surgery. In all patients, preoperative PTAA and PTC angles increased significantly after inserting the first plate posteromedially at osteotomy site. After tibial slope had been accurately restored using the external fixator system, PTAA and PTC angles decreased to the preoperative tibial slope level without changing femorotibial angles in the coronal plane. The authors were able to acquire a consistent and reproducible natural tibial slope using tibial slope "fine tuning" using an external fixator and a stable internal fixator.

Arthroscopic double bundle ACL reconstruction using a bone patellar tendon bone-gracilis tendon composite autograft: a technical note.

The authors devised an alternative arthroscopic double bundle ACL reconstruction technique using a bone patellar tendon bone (BPTB)-gracilis tendon composite autograft. One tibial and two femoral tunnels were used to reconstruct two bundles of anterior cruciate ligaments (ACL) [an anteromedial bundle (AM) and a post-erolateral bundle (PL)]. BTBB was fixed in the tunnels produced on the isometric points of the tibia and femur using the conventional technique. The gracilis tendon was then fixed in a PL tunnel produced using the outside-in technique. The authors consider that the devised technique based on a combination of autogenous bone patellar bone graft and gracilis tendon, can minimize tunnel widening post-operatively, allow easier revision should the reconstructed ACL fail, and also provides an alternative means of restoring rotation stability.

Treatment of persistent extraarticular infection using a temporary cement spacer on the tibia after ACL reconstruction.

Postoperative infection after anterior cruciate ligament (ACL) reconstruction is an uncommon but serious complication. Although several treatments for intraarticular infection have been reported, no report has been recorded on the treatment of persistent extraarticular infections. The authors experienced reconstructed graft removal due to a refractory extraarticular infection on tibia. Early ACL reimplantation was performed using a temporary cement spacer containing antibiotics and a irradiated bone patellar tendon bone allograft.

Trochlear deformity occurring after distal humeral fractures: magnetic resonance imaging and its natural progression.

Eighteen children (mean age 50.7 months) with trochlear deformities occurring after and related to distal humeral fractures (12 Salter-Harris type 2, 5 supracondylar, 1 Salter-Harris type 4) were evaluated with serial radiographs. The carrying angle and range of motion were measured throughout the follow-up period (up to 13 years after trauma) after definitive treatment. Bony defects on the medial (17 patients) and central (1 patient) regions of the trochlea were observed at a mean of 3.4 months after the trauma. They also persisted up to 4 to 7 years (latest follow-up in an intermediate follow-up group) and eventually reossified by skeletal maturity (in a long-term follow-up group). Magnetic resonance imaging was performed on eight patients after a mean of 1.9 years from injury. Low signal intensity on T2 indicative of cartilage necrosis and an intact articular surface were found. Cubitus varus deformity, which developed in almost all patients, was observed to be nonprogressive after 3 to 4 years but persisted until maturity. Limitation of motion and late neuropathy were not seen.