Lateral ankle ligament reconstruction using the anterior half of the peroneus longus tendon.

PURPOSE: The purpose of this study was to assess the results of a novel surgical technique for the treatment of chronic lateral ankle instability with attenuated or deficient ligamentous tissue that the modified Broström procedure could not be performed. A lateral ankle ligament reconstruction using the anterior half of the peroneus longus tendon has been performed. METHODS: Thirty-four consecutive patients treated with lateral ankle ligament reconstruction using anterior half of the peroneus longus tendon were enrolled. Median age at surgery was 24 years (range 19-46 years). The clinical and radiologic outcomes were evaluated preoperatively and at a median of 21 months (range 12-51 months) follow-up. RESULTS: The Karlsson-Peterson ankle score significantly improved from 58.2 ± 10.9 points preoperatively to 83.9 ± 7.0 points at the last follow-up. Mechanical stability was achieved. The mean talar tilt angle significantly improved from 15.7° ± 3.5° preoperatively to 4.6° ± 1.7° at the last follow-up, and the mean anterior talar translation significantly improved from 7.3 ± 2.6 mm preoperatively to 4.1 ± 1.7 mm at the last follow-up. Fifteen patients (52%) were very satisfied with the results, nine patients (31%) were satisfied, four patients (14%) were fair, and one patient (3%) was dissatisfied with the results. CONCLUSIONS: Lateral ankle ligament reconstruction using the anterior half of the peroneus longus tendon can be a surgical option for chronic lateral ankle instability with attenuated or deficient ligaments. LEVEL OF EVIDENCE: Case-series, Level IV.

Local application of low-dose Depo-Medrol is effective in reducing immediate postoperative back pain.

This prospective, randomised case-control study was made to determine effectiveness of low-dose Depo-Medrol applied to the affected nerve root after discectomy. Fifty seven patients with L4-5 or L5-S1 single level disc herniation with unilateral leg pain were selected for the study and were divided in two groups. Twenty eight patients were in the control group and 29 in the steroid group. Discectomy was done after flavotomy in all patients. In the steroid group low-dose 40 mg Depo-Medrol soaked Gelfoam was applied over the affected nerve root after discectomy while in the control group neither saline nor plain Gelfoam was applied to affected root. Postoperatively, patients were asked to evaluate backache using VAS which was compared statistically using the unpaired t test. Statistical difference was significant (p < 0.0001) regarding postoperative VAS during the first month and then it became insignificant. Results show that local application of low-dose Depo-Medrol is helpful in reducing immediate postoperative backache after discectomy, but it is not effective in the long-term.

Torsional malalignment, how much significant in the trochanteric fractures?

OBJECTIVES: The rotational alignment is definitely important in the long bones such as tibias and femurs. We also predict the importance of rotational alignment in the trochanteric fractures. So we measured torsional malalignment in trochanteric fracture and anlaysed their risk factors and their clinical significance. METHODS: A total of 109 inpatients who had undergone internal fixation following trochanteric fracture and a postoperative pelvic CT scan between 2008 and 2013, with at least one year follow-up, were selected. Factors that affect torsional malalignment, such as age, gender, fracture stability, injured area, operative time, time of surgery after admission, and ASA status, were investigated. Factors that affect the patients' clinical results in malrotation, including ambulation time after surgery, postoperative complication rates, pain assessment of VAS one year postoperatively and Koval score, were also investigated. RESULTS: Of the 109 subjects, torsional malalignment was observed in 28 (25.7%) subjects with a mean torsional malalignment angle of 20.7° (range: -31.2° to 27.1°). Torsional malalignment risk factors were fracture stability (p=0.021) and operative time (p=0.043). In terms of the time to ambulation after surgery, the postoperative complication rates, and the VAS and Koval scores at one year postoperatively, no statistically significant difference was observed between the torsional malalignment patients and the non-deformity patients. CONCLUSIONS: In this study, 25.7% of the patients who had undergone internal fixation following trochanteric fracture experienced torsional malalignment. Major factors of the torsional malalignment were an unstable fracture and the consequent delay in the operative time. But the torsional malalignment was deemed to have no effect on clinical results.

Solitary epidural lipoma with ipsilateral facet arthritis causing lumbar radiculopathy.

A 55-year-old obese man (body mass index, 31.6 kg/m(2)) presented radiating pain and motor weakness in the left leg. Magnetic resonance imaging showed an epidural mass posterior to the L5 vertebral body, which was isosignal to subcutaneous fat and it asymmetrically compressed the left side of the cauda equina and the exiting left L5 nerve root on the axial T1 weighted images. Severe arthritis of the left facet joint and edema of the bone marrow regarding the left pedicle were also found. As far as we know, there have been no reports concerning a solitary epidural lipoma combined with ipsilateral facet arthorsis causing lumbar radiculopathy. Solitary epidural lipoma with ipsilateral facet arthritis causing lumbar radiculopathy was removed after the failure of conservative treatment. After decompression, the neurologic deficit was relieved. At a 2 year follow-up, motor weakness had completely recovered and the patient was satisfied with the result. We recommend that a solitary epidural lipoma causing neurologic deficit should be excised at the time of diagnosis.

Use of Huckstep nail in the periimplant femoral shaft fracture.

87-year-old female underwent open reduction of distal femoral fracture and internal fixation with locking compression plate and bone graft. She was operated for ipsilateral proximal femoral fractures and stabilized by intramedullary interlocked nail 5 years ago. She developed stress fracture proximal to locked plate. We inserted Huckstep nail after removal of the previous operated proximal femoral nail without removing the remaining plate and screws. At 15 month followup the fractures have united. The Huckstep nail has multiple holes available for screw fixation at any level in such difficult situations.

The impact of fentanyl matrix on pain and function in spinal disorder-related chronic pain: an open label trial in Korea.

STUDY DESIGN: This is a multicenter, open-label prospective, non interventional study. PURPOSE: We wanted to evaluate the impact of fentanyl matrix on the pain and function of patients with spinal disorder-related chronic, non-malignant pain. OVERVIEW OF LITERATURE: Patients with severe non-malignant chronic low back pain may require opioid analgesics for effective pain management. METHODS: A total of 1,576 patients with severe pain (numeric rating scale = 7) were evaluated for their pain intensity at the initial visit and at weeks 4 and 8 (Visits 1, 2, and 3, respectively). Disturbances in sleep, daily living and social activities, the Oswestry Disability Index (ODI), the researchers' and patients' global assessment and the patients' treatment preference were also assessed. RESULTS: The pain intensity score significantly decreased from 8.1 at Visit 1 to 5.4 and 4.4 at Visits 2 and 3, respectively. Sleep disturbance also significantly decreased and the extent of disturbance of daily and social activities was also significantly improved. The ODI significantly decreased from 61.9% to 45.8% and 38.2% at Visits 1, 2, and 3, respectively. Adverse events were reported by 197 (12.5%) patients and severe adverse events were reported by 12 (0.76%) patients. Overall, 76.3% of the patients and 78.4% of the investigators rated the test drug as effective. CONCLUSIONS: The fentanyl matrix is believed to be effective for the treatment of pain, sleep disturbance and the impact upon daily and social activities, yet physicians should pay attention to the risks of abuse and the adverse events.

Actin and ERK1/2-CEBPß signaling mediates phagocytosis-induced innate immune response of osteoprogenitor cells.

Wear particles at the host bone-implant interface are a major challenge for successful bone implant arthoplasties. Current understanding of aseptic loosening consists of macrophage-mediated inflammatory responses and increasing osteoclastogenesis, which lead to an imbalance between bone formation and resorption. Despite its significant role in bone regeneration and implant osteointegration, the osteoprogenitor response to wear particles has been examined recent years. More specifically, the intracellular mechanism of osteoprogenitor mediated inflammation has not been fully elucidated. In this study, we examined the role of osteoprogenitors and the cellular mechanism by which metal wear particles elicit an inflammatory cascade. Through both in vivo and in vitro experiments, we have demonstrated that osteoprogenitor cells are capable of initiating inflammatory responses by phagocytosing wear particles, which lead to subsequent accumulation of macrophages and osteoclastogenesis, and the ERK_CEBP/ß intracellular signaling is a key inflammatory pathway that links phagocytosis of wear particles to inflammatory gene expression in osteoprogenitors. AZD6244 treatment, a potent inhibitor of the ERK pathway, attenuated particle mediated inflammatory osteolysis both in vivo and in vitro. This study advances our understanding of the mechanisms of osteoprogenitor-mediated inflammation, and provides further evidence that the ERK_CEBP/ß pathway may be a suitable therapeutic target in the treatment of inflammatory osteolysis.

Arthroscopic treatment of septic arthritis of acromioclavicular joint.

Septic arthritis requires an early diagnosis and proper treatment to prevent the destruction of articular cartilage and joint contracture. This paper presents a rare case of septic arthritis of the acromioclavicular joint that was treated with arthroscopic debridement and resection of the distal clavicle.

Stress fracture of bilateral posterior facet after insertion of interspinous implant.

STUDY DESIGN: A case report of stress fracture of bilateral lumbar posterior facet after implantation of interspinous process device is reported and the literature reviewed. OBJECTIVE.: To report the rare case of stress fracture of bilateral lumbar posterior facet after implantation of interspinous process device. SUMMARY OF BACKGROUND DATA: A 64-year-old woman presented with severe back pain and radiating pain in both legs. In her history, she had undergone implantation of L4-L5 interspinous process device (Coflex, Paradigm Spine, Wurmlingen, Germany) for her neurogenic claudication at 6 years ago. Magnetic resonance image demonstrated signal change suggesting bilateral L4 inferior process. To the best of the authors' knowledge, there has been no report stress fracture of posterior facet after implantation of interspinous process device. METHODS: This study reviewed the patient's medical record, her imaging studies, and related literatures. RESULTS: In the reported case, stress fracture of bilateral posterior facet was documented with MRI and confirmed with surgical treatment for the surgical treatment of spinal stenosis. The involved facet joint was at the site affected by previously implanted interspinous process device. CONCLUSION: Posterior facet fracture can occur as a complication of interspinous process device.

Bilateral traumatic anterior dislocation of the hip with an unstable lumbar burst fracture.

Traumatic anterior dislocation of the hip is rare. Bilateral traumatic anterior dislocation is an even rarer injury; indeed, only 5 cases have been reported in the English literature. We describe a case of a bilateral traumatic anterior dislocation of the hip and a concomitant unstable lumbar burst fracture following a mechanism of injury distinctly different from other reports.

Two levels above and one level below pedicle screw fixation for the treatment of unstable thoracolumbar fracture with partial or intact neurology.

BACKGROUND: Treatment of unstable thoracolumbar fractures is controversial regarding short or long segment pedicle screw fixation. Although long level fixation is better, it can decrease one motion segment distally, thus increasing load to lower discs. METHODS: We retrospectively analyzed 31 unstable thoracolumbar fractures with partial or intact neurology. All patients were operated with posterior approach using pedicle screws fixed two levels above and one level below the fracture vertebra. No laminectomy, discectomy or decompression procedure was done. Posterior fusion was achieved in all. Post operative and at final follow-up radiological evaluation was done by measuring the correction and maintenance of kyphotic angle at thoracolumbar junction. Complications were also reported including implant failure. RESULTS: Average follow-up was 34 months. All patients had full recovery at final follow-up. Average kyphosis was improved from 26.7 degrees to 4.1 degrees postoperatively and to 6.3 degrees at final follow-up. And mean pain scale was improved from 7.5 to 3.9 postoperatively and to 1.6 at final follow-up, All patients resumed their activity within six months. Only 4 (12%) complications were noted including only one hardware failure. CONCLUSION: Two levels above and one level below pedicle screw fixation in unstable thoracolumbar burst fracture is useful to prevent progressive kyphosis and preserves one motion segment distally.

F-18 FDG PET-positive fibrous dysplasia in a patient with intestinal non-Hodgkin's lymphoma.

Fibrous dysplasia (FD) is a common benign bone disorder of an unclear etiology. It is known that FD can appear without an increased FDG uptake on F-18 fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT). However, there are also several reports that FD showed increased FDG uptake and this mimicked malignant bone involvement on FDG-PET. Herein we describe a case of biopsy-proven FDG-PET positive FD in a patient with intestinal non-Hodgkin's lymphoma (NHL). A 45-year-old woman was diagnosed with intestinal NHL, which was removed by right hemicolectomy. After the operation, the FDG-PET/CT scan showed hypermetabolic activity in the right transverse process of the T10 vertebra. The patient then received a total of 6 cycles of R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone) chemotherapy every 3 weeks. After completion of the planned chemotherapy, the 2(nd) FDG-PET/CT showed increased FDG uptake (SUVmax=6.0 g/mL) of the previous bone lesion. The MR images revealed a T1-hypointense lesion with sharp borders in the same region, and this showed homogenous contrast enhancement on the fat-suppressed T1-weighted images. After the radiologic studies were carefully reviewed, the bone lesion was assumed to be benign such as FD. We performed bone biopsy and the histological examination confirmed the diagnosis of FD. In conclusion, bone lesions with FDG uptake need to be carefully interpreted when evaluating patients with known malignancy.

Ideal entry point for the thoracic pedicle screw during the free hand technique.

We have attempted to determine the spatial orientation of the base of the superior articular process in relation to the centre of the pedicle and then measure the transverse and sagittal screw angles using this ideal pedicle screw entry point - the base of the superior articular process at the junction of the lateral one-third and medial two-thirds. The proposed advantages of this technique are the easily identifiable entry point, the well-defined transverse and sagittal screw angles and a very low incidence of medial and inferior pedicle violation.

Comparative study of balloon kyphoplasty with unilateral versus bilateral approach in osteoporotic vertebral compression fractures.

This study analyses the radiological and clinical results according to the two techniques of unilateral and bilateral balloon kyphoplasty in osteoporotic vertebral compression fractures. Fifty-two patients with osteoporotic vertebral compression fractures occurring at the thoracolumbar junction were enrolled in this study. All patients were classified into two groups; group I was treated with a unilateral approach and group II with a bilateral approach. The Cobb angle was measured each time to evaluate the kyphotic angle during the pre- and post-operative periods and at last follow-up, and a 10-point visual analog scale for pain was recorded at the same time. We found that the bilateral approach had a greater advantage in the reduction of kyphosis and the loss of reduction was less than the unilateral approach for the treatment of osteoporotic vertebral compression fractures.

Facet joint violation during pedicle screw insertion: a cadaveric study of the adult lumbosacral spine comparing the two pedicle screw insertion techniques.

This article analyses the incidence of facet joint violation by pedicle screws inserted via the two most commonly used techniques, intersection and mammillary. Pedicle screws were inserted on each side of fresh-frozen human cadevaric specimen lumbosacral spines using the two techniques. All facet joints which were violated were found to be on the right side, where the mamillary process technique was employed. The incidence of facet joint violation was higher in the mammillary technique, which was statistically significant. The intersection technique appears to be safer than the mamillary with respect to violation of the adjacent superior facet joint.