Association between MRI findings and clinical outcomes in a period of 5 years after lumbar spine microdiscectomy.

BACKGROUND: To evaluate the associations between magnetic resonance imaging (MRI) findings and pain, disability and quality of life before surgery and up to 5 years after lumbar microdiscectomy. MATERIALS AND METHODS: Sixty-one patients who underwent one-level lumbar microdiscectomy by the same surgeon participated in this analytic, observational, prospective study. Lumbar spine MRI was performed preoperatively and 5 years postoperatively. Pain, disability and quality of life were measured with VAS, ODI, Roland Morris and SF-36 pre- and up to 5 years postoperatively. Subsequently associations between radiological findings and clinical outcomes were recorded. RESULTS: Before surgery patients with disc extrusion or sequestration, with increased thecal sac compression (d > 2/3), with Modic changes (MC) 2 and 3 on the operated level and Pfirrmann grades IV and V on the operated and both adjacent discs presented the worst preoperative clinical outcomes. MC preoperatively were not related with postoperative results, in contrast with the type of disc herniation and thecal sac compression. Preoperative Pfirrmann grade IV and V on the operated and both adjacent discs and postoperative MC 2 and 3 on the operated level were related to poor clinical outcomes 36-60 months post-discectomy. CONCLUSIONS: Extrusion or sequestration of the operated disc, increased compression of thecal sac, MC 2 and 3 on the operated level and Pfirrmann grades IV and V on the operated and adjacent discs were associated with the worst clinical outcomes. Nerve root impingement, facet joint arthritis, perineural fibrosis and disc granulation tissue had no effect on clinical scores.

Postoperative MRI findings 5 years after lumbar microdiscectomy.

BACKGROUND: Lumbar microdiscectomy is a common procedure with satisfactory results; however, postoperative events like progressive adjacent level degeneration and perineural fibrosis can contribute to long-term pain. The purpose of the study was to evaluate MRI changes 5 years after lumbar microdiscectomy and assess their association with clinical parameters. MATERIALS AND METHODS: A prospective study enrolling 61 patients who underwent microdiscectomy. Changes between preoperative and postoperative MRI findings were recorded, and these findings were tested for associations with demographic, clinical and perioperative parameters. The measured imaging parameters were degeneration of the operated and adjacent discs and endplates, morphology of the disc herniation, facet joints arthritis and the presence of postoperative perineural fibrosis. RESULTS: Statistically significant differences were found between preoperative and postoperative morphology of the operated disc, facet joints arthritis and degeneration of the operated and caudal adjacent disc. There were no differences between preoperative and postoperative disc degeneration of the superior adjacent disc and in degeneration of the operated and adjacent endplates. Postoperatively perineural fibrosis was common; however, thecal sac compression and nerve root impingement were reduced. Age at the time of surgery was the only parameter associated with postoperative changes. CONCLUSION: Five years after microdiscectomy, several postoperative MRI changes including operated disc's morphology, facet joints arthritis and degeneration of the operated and caudal adjacent disc were shown. Taking into consideration that participants were on average middle-aged, these changes could be attributed not only to the impact of the surgery but also to the natural history of lumbar spine degeneration.

Clinical outcomes after lumbar spine microdiscectomy: a 5-year follow-up prospective study in 100 patients.

BACKGROUND: To evaluate the effect of lumbar microdiscectomy (LM) in pain, disability and quality of life in a 5-year period and to identify potential demographic and clinical risk factors. METHODS: One hundred patients who underwent LM by the same surgeon participated in this prospective study. Clinical assessment was made with validated questionnaires preoperatively and up to 5 years postoperatively. Subsequently, associations between clinical outcomes and demographic data were recorded. RESULTS: In every assessment questionnaire, there was a significant improvement in the first postoperative month, which lasted up to 1 year post-discectomy. After that, improvement was statistically significant (p < 0.05) but without clinical importance. Women reported more pain preoperatively and 1 month after surgery. Urban residents also presented more pain preoperatively. Older patients had more pain, disability and worse quality of life 1-5 years postoperatively. Similarly, patients with lower education presented the worst scores in every questionnaire at the same time. Smokers reported less pain 1.5-4 postoperative years. Higher alcohol consumption and obesity were associated with lower levels of preoperative pain. However, obese patients had worse SF-36 and ODI scores after the 6th postoperative month. Patients with heavy jobs presented the worst preoperative ODI scores. CONCLUSION: Significant clinical improvement was recorded from the first postoperative month to the first postoperative year; stabilization was noticed later on. Feminine gender, urban residency, older age, low level of education, obesity and heavy physical occupation were negative prognostic factors. Oddly smoking and alcohol were correlated with less pain.

Long Term Outcomes of Total Hip Arthroplasty With Custom Made Femoral Implants in Patients With Congenital Disease of Hip.

We evaluated the outcomes of total hip arthroplasty in 67 patients (86 hips) with congenital hip disease and excessive abnormal anatomy of the proximal femur with the use of custom-made femoral stems. The design of the stem was based on CT data following the principles of CAD-CAE-CAM technique. No serious complications attributed to the femoral stem were seen. Within a median follow-up of 127.5 months the 10-year survival of any of the components was 95.4% and respective value when aseptic loosening of the stem was considered was 98.1%. Patients with high dislocations had a 10-fold risk for loosening compared to those with low dislocations. No other parameter was associated with outcomes. The clinical and radiological evaluation was in consistency with the above outcomes.

Flow cytometry as a diagnostic tool for identifying total hip arthroplasty loosening and differentiating between septic and aseptic cases.

PURPOSE: Implant loosening represents one of the major factors of total hip arthroplasty (THA) failure. The purpose of this study was to identify specific markers indicative of septic and aseptic loosening in patients that underwent THA. METHODS: Flow cytometry was performed in blood samples of 20 patients with loosening (10 septic/10 aseptic). Additional ten healthy individuals served as a control group. The expression of surface receptors and cytoplasmic molecules in patients that underwent THA was quantified. CD62L, CD18, CD11a, CD11b and CD11c expressions were evaluated and correlated with the presence of loosening. Also, a comparison between septic and aseptic THA loosening characteristics was performed. RESULTS: The mean fluorescence intensity (MFI) for CD18 was significantly decreased on all leukocytes subsets in both septic and aseptic loosening compared to control group (p < 0.005 in all occasions). Patients with aseptic loosening showed increased MFI for CD11b in granulocytes and for CD11c in monocytes and granulocytes compared to the control and aseptic group (p = 0.02 and p = 0.005, respectively). In patients with septic loosening, an increase in MFI for CD11c was observed in monocytes only compared to control group (p = 0.03). The comparison between aseptic and septic loosening showed significantly lower CD18 MFI value in granulocytes for aseptic loosening (p = 0.008). CONCLUSIONS: CD11 and CD18 MFI values appear to be indicative of loosening in THAs. Flow cytometry markers can be used to identify THA loosening, as well as to differentiate between septic and aseptic cases.

Accuracy of pedicle screw placement: a systematic review of prospective in vivo studies comparing free hand, fluoroscopy guidance and navigation techniques.

INTRODUCTION: With the advances and improvement of computer-assisted surgery devices, computer-guided pedicle screws insertion has been applied to the lumbar, thoracic and cervical spine. The purpose of the present study was to perform a systematic review of all available prospective evidence regarding pedicle screw insertion techniques in the thoracic and lumbar human spine. MATERIALS AND METHODS: We considered all prospective in vivo clinical studies in the English literature that assessed the results of different pedicle screw placement techniques (free-hand technique, fluoroscopy guided, computed tomography (CT)-based navigation, fluoro-based navigation). MEDLINE, OVID, and Springer databases were used for the literature search covering the period from January 1950 until May 2010. RESULTS: 26 prospective clinical studies were eventually included in the analysis. These studies included in total 1,105 patients in which 6,617 screws were inserted. In the studies using free-hand technique, the percentage of the screws fully contained in the pedicle ranged from 69 to 94%, with the aid of fluoroscopy from 28 to 85%, using CT navigation from 89 to 100% and using fluoroscopy-based navigation from 81 to 92%. The screws positioned with free-hand technique tended to perforate the cortex medially, whereas the screws placed with CT navigation guidance seemed to perforate more often laterally. CONCLUSIONS: In conclusion, navigation does indeed exhibit higher accuracy and increased safety in pedicle screw placement than free-hand technique and use of fluoroscopy.

Intramuscular hemangioma of the foot: A case report and review of the literature.

Intramuscular hemangiomas (IHs) are rare benign neoplasms usually seen in children, adolescents and young adults. Although lower extremities are the commonest localization, the localization at the foot is extremely rare since only a few cases have been reported. We report a case of mixed type IH of the flexor digitorum brevis muscle in a 12-year-old boy who was treated with surgical excision, with wide surgical margins.

Is TKA with computer-assisted navigation associated with less blood loss? A comparative study between computer-navigated and conventional method.

The aim of this study is to evaluate whether computer-assisted navigated TKA reduces perioperative blood loss. Patients were randomly divided into 2 groups and underwent either a conventional TKA (n = 40) or a TKA with computer-assisted navigation (n = 40). Perioperative blood loss was evaluated by laboratory parameters, postoperative drain output and number of required transfusions. Change in hemoglobin concentration and in hematocrit levels was similar. Also, there was no statistically significant difference in drain output and in the number of transfused units. The results of this study showed that TKA with computer-assisted navigation is similar to the conventional TKA regarding perioperative hemorrhage.

Is prophylaxis for heterotopic ossification with radiation therapy after THR associated with early loosening or carcinogenesis?

INTRODUCTION: Heterotopic ossification may develop after major hip surgeries, thus preventive strategies including radiation therapy and non steroid anti-inflammatory drugs are commonly employed. There are certain concerns regarding the effects of radiation therapy on implant loosening and carcinogenesis. Our study aims to evaluate whether radiation therapy results in implant loosening or radiation-induced tumours in the long term. PATIENTS AND METHODS: This was a prospective study including 97 high-risk patients for heterotopic ossification who underwent total hip arthroplasty. Patients were divided into 2 groups and received either a combination of radiation therapy and indomethacin (Group A), or indomethacin alone (Group B). Evaluated outcomes included implant loosening or development of radiation-induced tumours during the follow-up period. RESULTS: The follow-up period of the study was 10 years. Group A consisted of 50 patients, while Group B consisted of 47 patients. 3 patients died during the follow-up. There were 2 cases of implant loosening, 1 from each of the 2 groups at 9 and 10 years after surgery respectively; thus, no statistically significant difference regarding implant loosening was found (p < 0.05). During the follow-up period no cases of radiation-induced tumours were identified. CONCLUSION: Our results are consistent with those of other studies supporting the safety of radiation therapy as a preventive strategy for heterotopic ossification following major surgeries in high risk patients. Further studies with even longer follow-up may be required to definitely exclude the possibility of adverse outcomes linked with radiation therapy.

Combined radiotherapy and indomethacin for the prevention of heterotopic ossification after total hip arthroplasty.

BACKGROUND AND PURPOSE: :Heterotopic ossification (HO) is a frequent complication following total hip arthroplasty. The aim of this study was to evaluate the efficacy of combined radiotherapy and indomethacin as compared to indomethacin alone for the prevention of HO after hip arthroplasty. PATIENTS AND METHODS: 96 patients were prospectively enrolled to receive either a single dose of postoperative radiotherapy of 7.0 Gy and indomethacin for the first 15 postoperative days or indomethacin alone for the same period. A historical group of 50 patients that received indomethacin alone served as control. Primary endpoint was the radiographic evidence of HO at 6 months. Secondary endpoints were the evaluation of factors related to HO development, side effects from each treatment, and group differences in the clinical assessment with the Merle d'Aubigné Score. RESULTS: Four patients in the combined-therapy group developed HO compared to 13 patients in the indomethacin group (p < 0.05) and 13 patients in the historical group (p < 0.05). One patient each in the combined group and the historical group developed Brooker III HO (nonsignificant difference). Duration of surgery and congenital hip disease were associated with HO development in the indomethacin groups, while age and congenital hip disease showed such an association in the combined-therapy group. The side effects and mean Merle d'Aubigné Score did not differ significantly between the three groups. CONCLUSION: Combined radiotherapy and indomethacin was more efficacious in preventing HO after total hip arthroplasty compared to indomethacin alone and should be considered for future investigation.

Three-dimensional analysis of cervical spine motion: reliability of a computer assisted magnetic tracking device compared to inclinometer.

We aimed to investigate the reliability and reproducibility of a magnetic tracking technique for the assessment of overall cervical spine motion (principal and coupled movements). Ten asymptomatic male volunteers with a mean age of 29.3 years (range 20-37 years) were included in the study. Flexion, extension, left and right lateral bending and left and right axial rotation were measured using a magnetic tracking device (MTD) mounted onto a custom head-piece. For rotational movements in the frontal and sagittal planes the results were compared with the measurements of two standard inclinometers. Intra-observer, inter-observer and intra-instrument reliability was assessed with the intraclass correlation coefficient method. There were no significant differences for all motion measurements between the MTD and the inclinometer. High inter-observer reliability was found in flexion, extension, axial rotation and lateral bending indicating that the testing routine is applicable for different examiners. The intra-observer variability was high in flexion and extension, whereas in lateral bending the reliability coefficients were lower and displayed a fair to good reliability for most of the measurements with the MTD. The results of the MTD were found to be highly comparable with the inclinometer results with an inter-instrument correlation coefficient ranging from 0.88 to 0.99. The MTD is a reliable, reproducible method for three-dimensional motion analysis of the cervical spine and therefore a valuable method both for the clinical assessment of various degenerative and traumatic disorders and as a supplement of different therapeutic procedures and rehabilitation.

Intra-operative hamstring tendon graft contamination in anterior cruciate ligament reconstruction.

We aimed to evaluate the possibility of hamstring tendon contamination, the correlation with clinical infection and its association with C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) values in 89 anterior cruciate ligament reconstructions. Two tissue samples were obtained for culture from each graft: immediately after harvesting the graft and before implantation. The ESR and the CRP were evaluated preoperatively and on the 4th and 20th postoperative days. Nine patients (10%) had positive cultures but no patient had signs of postoperative infection. All patients had ESR and CRP values elevated at the 4th postoperative day. ESR and CRP values returned to normal levels at the 20th postoperative day. Higher mean values of CRP levels at the 4th day were observed in patients with contaminated grafts compared to those with uncontaminated. Both values reached normal levels at the 20th postoperative day.

Normative data on hand grip strength in a Greek adult population.

The objectives of this study were to establish data concerning normal hand grip strength (GS) and to explore possible associations with anthropometric parameters. GS was measured in 232 individuals in a standard arm position using the Jamar dynamometer. We examined differences between right/left and dominant/nondominant hands. Possible correlations of GS with anthropometric values were evaluated. Right hand and dominant hand GS were found to be higher and statistically significant compared to left hand and nondominant hand GS, respectively. Men had higher values of GS compared to women. A negative association was observed between age and dominant hand GS. A positive association was documented between height and dominant hand GS, while the respective comparison for weight and dominant hand GS documented a statistically significant positive association only in the male group. A positive association between BMI and dominant hand GS was seen in female individuals. Additional factors associated with GS should be the goal of future investigations.

Numerical evaluation of the mechanical environment of a fractured long bone for osteoporotic and non-osteoporotic subjects.

Competent fracture healing monitoring requires an extensive knowledge of the evolution of the mechanical environment of the healing bone during daily-life activities such as walking. Fractures are caused due to a traumatic incidence, while low trauma or fragility fractures can also occur due to osteoporosis. It is expected that the mechanical behavior of healing bones differs among osteoporotic and non-osteoporotic subjects. This work presents finite element simulations of gait analysis considering a fractured long bone at the hematoma stage. The aim is to investigate the evolution of the mechanical environment of the femur for an osteoporotic and a non-osteoporotic subject. This is the first computational study providing quantitative information for the impact of osteoporosis on the mechanical environment of the femur. It was shown, that higher deformation and equivalent stress values are calculated for osteoporotic bones during a gait cycle, while the highest values were observed in the femoral head.

A biomechanical study of the effect of weight loading conditions on the mechanical environment of the hip joint endoprosthesis.

BACKGROUND: Total hip arthroplasty is one of the most successful orthopedic surgical procedures aiming to eliminate pain related to several types of hip arthritis and restore mobility. Obesity has been associated with an increased risk of complications after a total hip arthroplasty such as poor wound healing, periprosthetic joint infection, instability, and aseptic loosening. METHODS: This paper presents an in-vitro study on composite femoral models to investigate the impact of different weight loading conditions on the mechanical environment of the hip joint endoprosthesis considering normal-weight and overweight individuals from 70 to 110 kg. The micro strains on the femur during single-leg stance of gait were measured on critical stress points based on the Gruen femoral zones. FINDINGS: The micro strains increase as the weight increases implying that the displacement in the hip joint endoprosthesis is higher for overweight subjects enhancing the risk of failure. The highest increase was measured in Gruen zone 1 by 5.60% indicating that the great trochanter is subjected to higher stress shielding with increasing the weight. Also, the statistically significant increase of the micro strain values with increasing the weight in Gruen Zones 3 (2.91%), 5 (1.56%), and 11 (1.75%) may enhance the risk for a periprosthetic fracture at the lower region of the prosthesis. INTERPRETATION: This is the first biomechanical study which quantifies the effect of increasing weight loading conditions on the mechanical environment of the hip joint endoprosthesis considering different positions of evaluation.

The Efficacy of Vascularized Bone Grafts in the Treatment of Scaphoid Nonunions and Kienbock Disease: A Systematic Review in 917 Patients.

Background Vascularized bone grafts have become one of the first treatment options for scaphoid nonunions and Kienböck's disease. The aim of this study is to review the current body of the literature regarding the use of four vascularized bone grafts (1,2 ICSRA [1,2 intercompartmental supraretinacular artery] graft, 4+5 ECA [4+5 extracompartmental artery] graft, volar radial graft, and free medial femoral condyle graft) in these pathologies. Patients and Methods A search on MEDLINE and Google Scholar was performed. Exclusion criteria included language other than English, studies with no full text available, case reports, letters, editorials, and review articles. The primary outcomes included consolidation rate of the grafts and time to union regarding scaphoid nonunion, as well as the clinical outcomes (pain, grip strength, range of motion), revascularization of the lunate, and progression of the disease regarding Kienböck's disease. Results A total of 37 articles were included in the study enrolling 917 patients. Regarding scaphoid nonunion, the consolidation rate was 86.3% for the 1,2 ICSRA graft, 93.9% for the volar radial bone graft, and 88.8% for the free medial femoral condyle graft. In patients with Kienböck's disease, progression of the disease was observed in 13% of patients, and grip strength and pain were substantially improved whereas range of motion did not demonstrate statistically significant improvement ( p < 0.05). Conclusion Vascularized bone grafts yield successful outcomes in patients with scaphoid nonunions demonstrating a high union rate. In patients with Kienböck's disease, vascularized grafts lead to revascularization of the lunate in most of the cases with concomitant improvement of the clinical parameters.

Transtibial versus anteromedial portal of the femoral tunnel in ACL reconstruction: a cadaveric study.

The aim of this cadaveric study was to compare the transtibial versus the anteromedial portal with respect to the anatomic femoral positioning of the ACL attachment. Ten fresh frozen cadaveric knees were included in our study. A standard arthroscopy was performed and the normal ACL was partially cut through with arthroscopic scissors leaving a small footprint of 2 mm at the anatomical insertion area on the lateral femoral condyle. The femoral tunnel was drilled through the tibial tunnel and subsequently through the anteromedial portal. Using a probe with standard magnification, we measured the distances of the two femoral tunnels from the margin of ACL footprint arthroscopically. The femurs were then dissected and we measured the distances of the two tunnels from the posterior part of the lateral femoral condyle. The median arthroscopically measured distance of the centers of transtibial femoral tunnel and of the femoral tunnel through the anteromedial portal from the margin of the femoral ACL footprint were 6.20 mm and 2.80 mm respectively. The difference was statistically significant. After femoral dissection the median distance of the centers of the transtibial femoral tunnel and the femoral tunnel performed through the anteromedial portal from the border of the articular surface at the lateral femoral condyle was 6.10 mm and 5.25 mm respectively (p<0.001). Both measurements showed that ACL reconstruction technique through the anteromedial portal is more accurate compared to the transtibial technique.

Osteomyelitis: antigranulocyte scintigraphy with 99mTC radiolabeled monoclonal antibodies for diagnosis-- meta-analysis.

PURPOSE: To perform a meta-analysis of the sensitivity and specificity of antigranulocyte scintigraphy with monoclonal antibodies (MoAbs) in the diagnosis of osteomyelitis across different patient groups and clinical settings. MATERIALS AND METHODS: MEDLINE and EMBASE searches were conducted. Data on the diagnostic performance of antigranulocyte scintigraphy with MoAbs were combined. Weighted sensitivities and specificities were estimated by using a random-effects model that incorporated between-study heterogeneity and by constructing summary receiver operating characteristic (ROC) curves. The weighted positive and negative likelihood ratios (LRs) across studies were estimated. Data syntheses were performed for all patients and for various subgroups. The reference standard used in each individual study was accepted. RESULTS: Nineteen nonoverlapping studies with a total of 714 examinations and reference standards of cell culture, histologic examination, clinical follow-up, and radiologic examination were eligible. The independent random-effects summary estimates of sensitivity and specificity were 81% (95% confidence interval [CI]: 70%, 88%) and 77% (95% CI: 66%, 86%), respectively, with statistically significant between-study heterogeneity (exact P < .001 for both metrics). In the summary ROC curve, a sensitivity of 81% corresponded to a specificity of 86%, and a specificity of 77% corresponded to a sensitivity of 87%. The weighted positive LR was 3.02 (95% CI: 2.07, 4.42), and the weighted negative LR was 0.26 (95% CI: 0.17, 0.39), with statistically significant between-study heterogeneity (exact P < .001 for both metrics). Sensitivity was better for peripheral than for axial skeleton lesions (87% vs 53%). CONCLUSION: Antigranulocyte scintigraphy with MoAbs has a sensitivity of 81% and a specificity of 77% in the diagnosis of osteomyelitis.

Cutaneous melanoma with tonsillar metastasis.

Metastases to the tonsillar fossa due to hematogenous dissemination is an extremely rare phenomenon associated with advanced-stage disease and poor prognosis. In the present report we describe a case of cutaneous melanoma with a metastasis to the tonsil approximately 4 years after the initial diagnosis of the primary disease treated with palliative radiation therapy.

Intramuscular Lipoma of the Thenar: A Rare Case.

Lipomas are the most common benign mesenchymal tumors. They are located either subcutaneously or under the investing fascia in intramuscular or intermuscular regions. The reported frequency of intramuscular lipomas among all benign adipocytic tumors is 1.0%-5.0% and for intermuscular lipomas is 0.3%-1.9%. The frequency of these lesions is the same in all age groups, but in adults deep seated-lipomas are most commonly discovered between the ages of 30 and 60. The most common sites of involvement of intramuscular lipomas are the large muscles of the extremities, especially those of the thigh, shoulder, and upper arm. Intramuscular lipomas of the hand are extremely rare and only few cases have been reported in the literature. In cases with hand location, they may present with functional deficit or neurovascular compromise due to the effect of the mass. We report an unusual case of a large intramuscular lipoma of the thenar that was treated with surgical excision due to the impairment of hand function.