Minimally invasive treatment for idiopathic chondrolysis of the hip: analysis of forty-one cases.

PURPOSE: Idiopathic chondrolysis of the hip is characterized by the loss of the articular cartilage of the hip joint with spectrum ranging from full recovery to fibrous ankylosis. Study assessed outcomes following intra-articular steroid injections, joint manipulation and traction immobilization. METHODS: Retrospective (2012-2021) review of 41 cases treated for idiopathic chondrolysis of hip, assessed pre-operatively and post-operatively (minimum 2-year follow-up) using Children's Hospital Oakland Hip Evaluation Score (CHOHES), visual analogue scale (VAS) and range of motion measurements. RESULTS: Twenty-five patients (62%) achieved painless mobility, 6 (14%) had hip stiffness without pain and 10 (24%) had painful and stiff hips at final follow-up. They had a mean age of 12.49 ± 2.4 years and a mean follow-up duration of 33.15 ± 13.1 months. Range of motion improved significantly (p < 0.05). VAS improved to 3.93 ± 1.3 from 7.8 ± 0.7. CHOHES improved from 29.12 ± 9.9 to 56.37 ± 17.6. CONCLUSION: Intra-articular steroid injection, manipulation and traction immobilization may effectively treat idiopathic chondrolysis of the hip by enhancing patient function and reducing the need for further surgical intervention.

"Critical pedicle wall" breaches analysis in complex spinal deformity using O-arm navigation.

Background: Free-hand and fluoroscopic-guided pedicle screw placement has been associated with higher rates of pedicle breaches (frequency range 15-40% especially in deformed pedicles). Neurological complications are more "critical" (i.e., frequent and significant) with medial and inferior pedicle-wall breaches due to the proximity of the neural elements. Here, we analyzed the effectiveness of O-arm navigation in minimizing "critical" pedicle wall breaches and their complications in 21 complex spinal deformity cases. Methods: Twenty-one complex spinal deformity cases were prospectively managed with O-arm-navigated posterior-instrumented fusions. Preoperative assessment included; evaluation of the type of scoliosis, the magnitude of the deformity, and the anatomy of the pedicles - (i.e., classified using Watanabe et al.). The O-arm was used to confirm and grade both the intraoperative and postoperative location of screws. Other variables analyzed included; duration of surgery, estimated blood loss, complications, and radiation exposure. Results: In 21 patients, 259 (63.45%) of 384 pedicles were instrumented; we observed 22 of 259 pedicle screw breaches. Significant (>2 mm) breaches were observed in two medial and one inferior wall cases that required revision; the overall biomechanically significant screw breach rate was (3/259) 1.2% with an accuracy rate of 98.8%. Pedicle screw placement resulted in another 14 nonsignificant (<2 mm) breaches; ten were medial and four involved the inferior wall. As anterior, lateral, and "in-out-in" trajectory pedicle screws beaches were nonsignificant, they were not included in our analysis. Conclusion: O-arm navigation decreased the incidence of medial and inferior (i.e., >2 mm "critical") pedicle screw breaches applied in 21 patients with deformed pedicles due to scoliosis. Further, the O-arm minimized the operating time, decreased the estimated blood loss, and reduced the incidence of complications.

Efficacy and Safety of Stempeucel in Osteoarthritis of the Knee: A Phase 3 Randomized, Double-Blind, Multicenter, Placebo-Controlled Study.

BACKGROUND: Osteoarthritis is a chronic, progressive, and degenerative condition with limited therapy options. Recently, biologic therapies have been an evolving option for the management of osteoarthritis. PURPOSE: To assess whether allogenic mesenchymal stromal cells (MSCs) have the potential to improve functional parameters and induce cartilage regeneration in patients with osteoarthritis. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A total of 146 patients with grade 2 and 3 osteoarthritis were randomized to either an MSC group or placebo group with a ratio of 1:1. There were 73 patients per group who received either a single intra-articular injection of bone marrow-derived MSCs (BMMSCs; 25 million cells) or placebo, followed by 20 mg per 2 mL of hyaluronic acid under ultrasound guidance. The primary endpoint was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score. The secondary endpoints were WOMAC subscores for pain, stiffness, and physical function; the visual analog scale score for pain; and magnetic resonance imaging findings using T2 mapping and cartilage volume. RESULTS: Overall, 65 patients from the BMMSC group and 68 patients from the placebo group completed 12-month follow-up. The BMMSC group showed significant improvements in the WOMAC total score compared with the placebo group at 6 and 12 months (percentage change: -23.64% [95% CI, -32.88 to -14.40] at 6 months and -45.60% [95% CI, -55.97 to -35.23] at 12 months P < .001; percentage change, -44.3%). BMMSCs significantly improved WOMAC pain, stiffness, and physical function subscores as well as visual analog scale scores at 6 and 12 months (P < .001). T2 mapping showed that there was no worsening of deep cartilage in the medial femorotibial compartment of the knee in the BMMSC group at 12-month follow-up, whereas in the placebo group, there was significant and gradual worsening of cartilage (P < .001). Cartilage volume did not change significantly in the BMMSC group. There were 5 adverse events that were possibly/probably related to the study drug and consisted of injection-site swelling and pain, which improved within a few days. CONCLUSION: In this small randomized trial, BMMSCs proved to be safe and effective for the treatment of grade 2 and 3 osteoarthritis. The intervention was simple and easy to administer, provided sustained relief of pain and stiffness, improved physical function, and prevented worsening of cartilage quality for ≥12 months. REGISTRATION: CTRI/2018/09/015785 (National Institutes of Health and Clinical Trials Registry-India).

Chronic Intramedullary Spinal Cord Abscess Mimicking Intramedullary Spinal Cord Tumor-"Phantom Tumor": A Case Report.

CASE: A 33-year-old woman with back pain and radiculopathy had presented with bilateral ankle weakness. MRI showed an intramedullary conus lesion suggestive of neoplasm, but posterior midline durotomy revealed only pus. Pus samples showed Staphylococcus aureus, which was treated with 6 weeks of antibiotics. Two-year follow-up showed complete neurological recovery with no clinicoradiological signs of recurrence. CONCLUSION: Usually, intramedullary spinal cord abscess (ISCA) has an acute presentation and warrants an emergent line of treatment with a risk of mortality. Very rarely chronic ISCA can mimic intramedullary spinal cord tumor. It is the first case reported in the literature of chronic ISCA mimicking conus IMST.

Efficacy of less Invasive modified O-arm navigated delta fixation in osteoporotic high-grade spondylolisthesis: "a LIMO delta technique".

PURPOSE: In 1994, the technique of transdiscal screws fixation in spondylolisthesis was introduced but did not gained popularity as it failed to address problems with spinal sagittal imbalance, retroverted pelvis, pseudoarthrosis, implant failure and neural injury. Majority of problems were due to lack of clear indications; hence, in this study, with modification of traditional technique and use of O-arm navigation for selected group of patients, we have addressed the above problems and given good to excellent functional outcomes. METHODS: We did prospective study on 15 patients with osteoporotic high-grade spondylolisthesis Meyerding grade 3 & 4 admitted in period 2020-2021. Intraoperative assessment was done in form of blood loss, incision length, operative time and complications. The preoperative & postoperative assessment was done in the form of clinical and radiological parameters. RESULTS: The average follow-up was of 21.2 months (18-24 months). There was no significant difference between pre- & postoperative spinopelvic parameters. Intraoperative average blood loss was 100 ml (90-120 ml) with mean surgical time of 138 min (120-150 min). Incision length was about 5-6-cms-posterior midline with two paraspinal 1-cm incisions for transdiscal screws. Patients were mobilized on postoperative day-2. There was statistically significant improvement in mean ODI, COMI and VAS for LBP and radicular pain with no intra- or postoperative complication observed till latest follow-up with all patients showing solid monoblock fusion on 1-year follow-up CT scan. CONCLUSIONS: LIMO delta technique is a newly modified version of conventional transdiscal screw technique. Minimal incision, decreased blood loss & operative time with in situ 3-column rigid fixation and solid fusion minimizing risk of complications makes this novel technique safer, simpler & effective in osteoporotic HGS.

Less invasive O-arm navigation-guided excision of thoracic extraosseous intraforaminal osteoblastoma: A case report.

Background: Gross-total excision of spinal osteoblastomas remains challenging as they are typically found in close proximity to major neural and/or vascular structures. Here, we found that O-arm navigation allowed for safe/effective excision of a spinal osteoblastoma in a 29-year-old male. Case Description: A 29-year-old male presented neurologically intact with mid back pain of 8 months' duration and 2 months of the left-sided chest wall discomfort. X-rays showed a sclerotic left D12 pedicle, while the MRI revealed an extradural lesion in extending into the left D11-12 neural foramen (i.e., hypointense on both T1- and T2-weighted images). The CT scan suggested a "floating" foraminal radiolucent lesion with surrounding vertebral body/posterior elements sclerosis and dense peripheral rim enhancement. These findings were diagnostic for an osteoblastoma. Utilizing O-arm navigation, the nidus and full extent of the lesion were excised (i.e., utilizing intralesional curettage). Two year's postoperatively, there was no MR evidence of tumor recurrence. Conclusion: O-arm navigation provided accurate intraoperative localization to safely and fully excise a left D11- D12 spinal osteoblastoma.

Correlation between Preoperative Magnetic Resonance Imaging Signal Intensity Changes and Clinical Outcomes in Patients Surgically Treated for Cervical Myeloradiculopathy.

STUDY DESIGN: This was a single surgeon, single center-based retrospective study with prospective data collection. PURPOSE: To assess the correlation between T2-weighted magnetic resonance imaging (MRI) signal intensity (SI) changes and factors such as age, duration of symptoms, baseline modified Japanese Orthopedic Association (mJOA) score and to determine its prognostic value in predicting recovery after surgery. OVERVIEW OF LITERATURE: Whether intramedullary cord T2-weighted MRI SI changes can predict operative outcomes of cervical myeloradiculopathy remains debatable, with only a few prospective studies analyzing the same. METHODS: Forty-six consecutive patients who underwent cervical myeloradiculopathy were included and were followed up for an average of 1 year. Preoperative T2-weighted MRI SI grading was performed for all patients. The correlation between MRI SI changes and age, duration of symptoms, preoperative mJOA score, and mJOA score at 1-year follow-up were analyzed. RESULTS: Fifteen patients had single-level (21.73%) or double-level (10.86%) prolapsed discs; 54.34% had degenerative cervical spondylosis with canal stenosis or multilevel disc prolapse and 13.07% had ossified posterior longitudinal ligaments. The mean age was 56.17±9.53 years (range, 35-81 years). The mean baseline mJOA score was 10.83±2.58 (range, 6-16), which postoperatively improved to 13.59±2.28 (range, 8-17; p<0.001). There was a statistically significant correlation between mJOA score at 1 year and MRI T2 SI grading (p=0.017). CONCLUSIONS: Patients with longer symptom durations had high grades of intramedullary cord T2-weighted MRI SI changes. Age and preoperative neurological status were not significantly correlated with the existence of intramedullary cord SI changes. However, patients without or with mild and diffuse intramedullary cord T2-weighted MRI SI changes had better postoperative neurological recovery than those with sharp and focal SI changes.

Extraosseous thoracic foraminal osteoblastoma: diagnostic dilemma and management with 3 year follow-up.

Osteoblastomas are bone forming lesions arising mainly from posterior elements of the vertebra. They are commonly encountered in the cervical and lumbar regions. We present a case of a thoracic osteoblastoma which is extra osseous and is not communicating with any part of the vertebra present intraforaminally. This is a rare presentation of an osteoblastoma. Imaging studies do not accurately diagnose the osteiod lesion. The size of the lesion and cortical erosion seen on the computed tomography scan help in differentiating the osteoid osteoma and osteoblastoma, but they are less sensitive and specific. Thus a histopathology is the investigation of choice to diagnose the osteoblastoma. Early and adequate removal of mass prevents malignant transformation, metastasis, and recurrence. In our case we excised the pars interarticularis unilaterally, removed the osteoid mass intact, and performed unilateral instrumented fusion. There was no recurrence and solid fusion was seen at 3 years follow up.