A Novel Diabetic Arthritic Model in Rats Induced by Streptozotocin, High-Fat Diet, and Complete Freund's Adjuvant.

Introduction: Ankle arthrodesis is one of the treatments of choice, particularly in late-stage and unstable diabetic Charcot arthropathy. Unfortunately, poor healing capacity might play a role in the high nonunion rate (10-40%). The advancement in regenerative medicine opens a new horizon for enhancing fusion after ankle arthrodesis in patients with poor healing capacity. However, a suitable small animal model is warranted to study the effectivity of these regenerative medicine approaches. Streptozotocin (STZ)-induced diabetes models and adjuvant-induced arthritis models with complete Freund's adjuvant are two established models. However, no study has combined those two models to make a diabetic arthritic model that more closely resembles the condition in Charcot arthropathy. Methods: Twenty male Sprague-Dawley rats were assigned into five groups, consisting of one control group, and four diabetic groups which were induced by STZ injection and a high-fat diet. Among these diabetic rats, two groups received complete Freund's adjuvant (CFA) injections to the left ankle of the hind limb. The control group, one of the diabetic-only groups, and one of the arthritic-diabetic-induced groups were euthanized at 4 weeks after STZ induction, and the remainder were euthanized 6 weeks after STZ induction. Clinical, radiological, and histological examinations were then compared in all five groups. Results: Diabetic status was successfully achieved in the model, which was maintained until the completion of the study. The CFA-induced ankles were significantly larger than the contralateral ankles in all groups (p<0.05). Histopathological evaluation confirmed arthritic changes in the CFA-induced group with less variability after 4 weeks of arthritis induction. Conclusion: This rat model of arthritic diabetic mimics the progressive and chronic nature of Charcot arthropathy in humans. This model can be further use to study treatments that might enhance the fusion rate in ankle arthrodesis in healing-defective patients such as those with diabetes. Level of Clinical Evidence: 5.

Gigantic aneurysmal bone cyst of the scapula in children treated with left total scapulectomy and humeral suspension: A case report.

INTRODUCTION AND IMPORTANCE: Aneurysmal bone cyst (ABC) is a benign, rapidly growing, osteolytic and could have hemorrhagic lesion. This cyst mostly occurs in females under 20 years old and is located predominantly in the metaphysis of long bones, followed by the pelvis and spine. ABC of the scapula is a rare case, and their treatment still remains controversial. CASE PRESENTATION: A 7-year-old girl has had a growing lump on her left shoulder since two years ago. Physical examination revealed local tenderness and a firm and immobile mass, which limit shoulder motion. The radiological and histopathological results confirmed the diagnosis of ABC of the scapula. The patient underwent a left total scapulectomy and humeral suspension reconstruction and was augmented with surgical mesh. There were no signs of postoperative infection or recurrence during the 1-year follow-up. The MSTS score was 24. CLINICAL DISCUSSION: There are many options for ABC treatment. Resection of the cyst is the treatment of choice for aggressive tumors (Enneking stage 3) or lesions in less essential bones. In scapula, the ABC treatment with total scapulectomy followed by humeral suspension is an effective method to decrease complications and reduce the risk of recurrence with a good clinical outcome. CONCLUSION: ABC of the scapula is a rare case. Tumor resection for aggressive ABC should be considered to decrease the recurrence rate. Total scapulectomy with humeral suspension is an effective method for treating ABC scapula (Enneking stage 3).

Functional Outcomes of Neglected Elbow Dislocation Treated with Double Approach Surgery.

Background: Neglected elbow dislocation is common in developing countries. The chronic nature of the disease results in a level of complexity that makes treatments and outcomes contradictory. Several treatment methods have been described for neglected elbow dislocations. The goal of this study was to evaluate the results of neglected elbow dislocations treated using the double approach of reduction and K-wire fixation. Methods: This series included patients with neglected elbow dislocations who were treated with open reduction using double approaches (medial and lateral incisions) between November 2020 and March 2021. Patients were evaluated for a minimum of 6 months to ascertain functional recovery in accordance with the Mayo Elbow Performance Index (MEPI) and Disability of Arm, Shoulder, and Hand (DASH) score. Results: Nine patients with neglected elbow dislocations were included in the study, with an average delay of 3.44 months. Four patients had an excellent MEPI and five had a good score at the final follow-up, with a mean MEPI score of 86.67. The average DASH score was 36 (31-59). Five patients (55.56%) experienced no pain, but four patients (44.44%) had mild pain, with a range of pain points of 30-45. The motion arc improvement was 60°-100°, with a mean of 74.44°. Almost all of the patients (eight patients, 88.89%) had elbow stability, but one patient had ulnar nerve paresthesia postoperatively. Heterotopic ossificans was associated in 1 patient, and triceps lengthening was needed in 1 patient; both came 5 months later. Conclusion: Open reduction surgery with a double approach offers a good chance of a good result with few side effects and should be considered for all patients who have this condition.

Horner syndrome as an unusual presentation of cervical radiculomyelopathy associated with cervical disc herniation: A case report.

INTRODUCTION AND IMPORTANCE: Horner syndrome, an oculo-sympathetic pathway disorder, is a very rare manifestation of cervical spine pathologies which usually present with either axial neck pain, radiculopathy, or myelopathy symptoms (or combinations of these). It is more-likely to happen in the upper cervical level involvement. CASE PRESENTATION: A 44-year-old male presented with a complaint of right eyelid drop two months before admission. The symptom was accompanied by radicular neck pain and weakness of the right upper extremity (M4) since 1 month earlier. An MRI revealed a cervical herniated disc at the C5-6 spine level. CLINICAL DISCUSSION: The patient underwent open discectomy followed by cervical disc replacement. Symptoms were significantly improved following surgery. CONCLUSION: In the presence of cervical symptoms, a focused evaluation of Horner syndrome can be done, and symptom resolution can be expected after the appropriate treatment. Otherwise, a thorough examination must be obtained to find the pathology along the tract of the oculo-sympathetic pathway and prevent irreversible neurological disturbance.

Vertical Rectus Abdominis Myocutaneous Flap for Reconstruction of Forequarter Amputation Defect after Shoulder Soft Tissue Sarcoma Resection: Technical Consideration.

Forequarter amputations in advanced local malignancy or trauma cases often leave a large defect that is challenging to reconstruct. Options for defect closure are varied. A vertical rectus abdominis myocutaneous (VRAM) flap could be an alternative to close a significantly large defect, which is relatively easier than the more technically demanding free flap. This case presents a 64-year-old man with a soft tissue sarcoma in the left shoulder that was treated by forequarter amputation and subsequent defect closure using a VRAM flap. The VRAM flap was initially used to reconstruct the chest and abdominal walls. There have been no reported uses for the shoulder defect. The repair site defect was viable even with a less aesthetic donor site, and all of the defects were closed without any signs of infection. The VRAM flap is a good option for a large defect closure at the shoulder region, particularly after forequarter amputation.

A rare presentation of osteochondroma at the spinous process of the cervical spine: a case report.

Osteochondroma is a benign cartilaginous tumor that usually arises from the growth plate of the long bones. Its presentation in flat bones is uncommon. Spinal osteochondroma is a rare case, with only a 4% incidence compared to all spinal neoplasms. We report an unusual case of osteochondroma at the spinous process of the C4 spine of a 15-year-old patient with the chief complaint of neck discomfort on movement. The patient has previously been diagnosed and treated for multiple hereditary exostoses of other bones. The patient underwent surgery for the current lesion with complete excision to the base of the lesion. Histopathology revealed a benign osteochondroma with a thin layer of cartilaginous cap. The patient was healed uneventfully and had no recurrence of the lesion on the same site at the 1-year follow-up. Surgical resection remains the mainstay treatment of osteochondroma and has proved to the low recurrence. In the case of cervical osteochondroma, surgery is advisable, particularly in symptomatic patients, to prevent complications.

Intratendinous ganglion cyst of extensor indicis propius tendon: A case report.

INTRODUCTION AND IMPORTANCE: The intratendinous ganglion cyst is an extremely rare entity. Thus, the global incidence has not been reported yet. The literature search showed scarce case reports and none has reported its occurrence in extensor indicis propius (EIP) tendon. The benign nature and the region at the dorsal hand mimic to the more common dorsal wrist ganglion. However, the surgical treatment arises significant risk to the function and may require subsequent tendon graft or tendon transfer. CASE PRESENTATION: A 51-year-old-female presented with 4 years history of a slow-growing lump over the dorsal region of the right hand with discomfort during finger motions. The ultrasonography confirmed the diagnosis of dorsal wrist ganglion. CLINICAL DISCUSSION: Intraoperatively, unlike the common presentation which is the well encapsulated mass originating from the carpal joint, the mass was found within the EIP tendon sheath and infiltrate the tendon substance. Surgical debulking was done and left the tendon partially intact. The frayed part was trimmed to ensure a smooth gliding. On the 6 month follow up, patient was symptom-free without any recurrence. CONCLUSION: The intratendinous growth of a ganglion must be identified preoperatively for a proper management plan and inform consent. The intratendinous ganglion cysts frequently weaken the tendon. Hence, surgical excision is necessary with the preparation of secondary tendon reconstruction.

Time to surgery and myo-d expression in biceps muscle of adult brachial plexus injury: a preliminary study.

BACKGROUND: Brachial Plexus Injury (BPI) is one of the peripheral nerve injuries which causes severe functional impairment and disability. Without prompt treatment, prolonged denervation will cause severe muscle atrophy. MyoD, which is expressed by satellite cells, is one of the parameters that relate to the regeneration process in post-injury muscle and it is presumed to determine the clinical outcome following neurotization procedure. This study aims to understand the correlation between time to surgery (TTS) and MyoD expression in satellite cells in the biceps muscle of adult brachial plexus injury patients. METHODS: Analytic observational study with a cross-sectional design was conducted at Dr. Soetomo General Hospital. All patients with BPI who underwent surgery between May 2013 and December 2015 were included. Muscle biopsy was taken and stained using immunohistochemistry for MyoD expression. Pearson correlation test was used to assess the correlation between MyoD expression with TTS and with age. RESULTS: Twenty-two biceps muscle samples were examined. Most patients are males (81.8%) with an average age of 25.5 years. MyoD expression was found to be highest at TTS of 4 months and then dropped significantly (and plateau) from 9 to 36 months. MyoD expression is significantly correlated with TTS (r=-0.895; p = 0.00) but not with age (r=-0.294; p = 0.184). CONCLUSION: Our study found, from the cellular point of view, that treatment of BPI needs to be done as early as possible before the regenerative potential - as indicated by MyoD expression - declined.

A Novel Utility of Bilobed Flap for Amputation Stump Coverage.

Preparing a good amputation stump with a well-padded, stable, sensate, and painless soft tissue coverage is of utmost importance to achieve early ambulation and return the patient to the daily activity level. When the primary closure is impossible or fails to achieve a good closure, secondary closure must be considered. To date, no literature reported the use of bilobed flaps for stump defect closure. We aimed to utilize this technically easy procedure for better management of defect closure on amputated limb stumps that often cause complex clinical problems. This is a retrospective observational study in limb amputation patients with various etiologies: crush injury, chronic limb necrosis, and amniotic band syndrome. All patients had stump defect closure with bilobed flap and were observed with a minimum of 6-months follow-up to evaluate the wound healing, the use of prosthesis, and the complications. A bilobed flap was performed in 11 amputation cases as the final closure (64% trans-femoral, 18% trans-tibial, 9% trans-humeral, and 9% trans-radial). The mean follow-up time was 8.5 ± 2.21 months. Most of the patients healed uneventfully with the optimal use of prosthesis in a mean healing time of 29.64 ± 7.49 days. The bilobed flap potentially provides a good amputation stump coverage that is ideal for prosthesis fitting. This simple procedure can be done without the necessity of special microsurgery settings. Thus, when the neighboring tissue is available and mobile enough to be transposed to the stump defect, a bilobed flap can be considered.

Treatment of chronic mallet finger with swan neck deformity using a modified Spiral Oblique Retinacular Ligament (SORL) reconstruction procedure: A case series and technical note.

INTRODUCTION AND IMPORTANCE: Chronic terminal extensor tendon injury produces mallet deformity and secondary swan neck deformity. It can be found in neglect cases and in a failed cases after conservative treatment or primary surgical repair. Surgery is considered in cases with extensor lag of more than 30° and functional deficit. Reconstruction of the spiral oblique retinacular ligament (SORL) has been reported in literatures to correct swan neck deformity by a dynamic mechanical basis. CASE PRESENTATION: Three cases of chronic mallet finger associated with swan neck deformity were treated by the modified technique of SORL reconstruction. Range of motion (ROM) of distal interphalangeal (DIP) joints and proximal interphalangeal (PIP) joints were measured along with the complications. The clinical outcome was reported using the Crawford's criteria. CLINICAL DISCUSSION: All patients had an average age of 34 years (20-54). Average time to surgery was 16.67 months (2-24) and average of DIP extension lag was 66.67°. All patient gave excellent Crawford criteria at the latest follow up (average 15.3 months). The average PIP joint ROM were -1.60 (00 to -50) of extension and 1100 (1000-1200) of flexion for the PIP joint and -1.60 (00 to -50) of extension and 83.330 (800-850) of flexion for the DIP joint. CONCLUSION: We present our technique to manage chronic mallet injury which only utilized two skin incisions and one button at the distal phalanx to minimize risk of skin necrosis and patient discomfort. This procedure can be considered as one of the options for the treatment of chronic mallet finger deformity associated with swan neck deformity.

Recurrent schwannoma of digital nerve on both hands: A very rare case report.

INTRODUCTION AND IMPORTANCE: Schwannoma is the most common benign tumor of peripheral nerves and usually occurs solitary with a very low risk of recurrence. Schwannoma of the hand, particularly involving the digital nerve, is sporadic and most commonly leads to a misdiagnosis due to its rarity. Histopathology remains the gold standard diagnostic, however, with a thorough physical examination and radiologic imaging, this benign tumor can be managed well with the preservation of nerve function. CASE PRESENTATION: We reported a rare case of digital nerve schwannomas on the bilateral hands of a 52-year-old white male with one recurrent mass on the right hand despite a previously complete debulking of the mass. CLINICAL DISCUSSION: Intraoperatively, we removed lobulated whitish-yellow masses and left the nerve origin of the tumor intact (common palmar digital nerve and ulnar-side digital nerve). The histopathology supported the diagnosis of schwannoma. At the one-year follow-up, there is no recurrence and the patient remains asymptomatic. CONCLUSION: Determining differential diagnosis by both clinical and preoperative imaging is essential, especially in the case of recurrence and multiple tumorous lesions. Malignancy or malignant degeneration should still be kept in mind. Complete removal is needed to prevent recurrence followed by a long-term follow-up.

Validity and Reliability of Prognosis Brachial Plexus Injury Score for Traumatic Brachial Plexus Injury.

Background: Brachial plexus injury (BPI) is a peripheral nerve injury that results in severe functional impairment and disability. Even after prompt treatment, predicting the prognosis of BPI is not easy as it involves various factors. An objective and valid scoring system would aid clinicians in informing families and anticipating problems related to the recovery of BPI. Prognosis BPI (PRO-BPI) score, a new prognostic score to predict the outcome of traumatic BPI (TBPI), was developed in 2019 by Suroto and Rahman. This study aimed to evaluate its validity and reliability. Methods: Retrospective cohort analysis was conducted for 111 BPI patients. A serial assessment of Disabilities of the Arm, Shoulder and Hand (DASH) score and PRO-BPI score was done. Validity analysis was done by assessing Spearman correlations between PRO-BPI score and other scoring systems (DASH, Michigan hand outcomes, and 36-item short form survey score [SF-36]). Internal structure consistency using Cronbach's alpha and test-retest reliability were measured for reliability analyses. A p-value was considered significant if < 0.05. Results: A total of 96 male and 15 female patients were included in our study with a mean age of 27.9 ± 10.6 years. Most of the patients (56.75%) had a poor prognosis based on the scoring system (average, 14.38 ± 3.98). Major contributors of this low score were the persistent pain (score 1 in 57.7% patients) and initial pain scale score (score 1 in 31.5% patients). Validity test showed that 6 parameters were all valid (p < 0.01). Reliability testing was done using Cronbach's alpha and found acceptable internal consistency (α = 0.767). Test-retest reliability was high. Moderate correlations were observed between the measures. Conclusions: PRO-BPI score is a valid and reliable scoring system in predicting the prognosis of TBPI.

Morphology of Humeral Head and Glenoid in Normal Shoulder of Indonesian Population.

Purpose: Shoulder prostheses designed and used around the world may not fit an Asian shoulder. Normal shoulder morphology in Asian population had been reported, ie, Chinese, Indian, Japanese, and Thai populations, but no data from the Indonesian population. The aim of this study was to evaluate the three-dimensional (3D) morphology of the glenohumeral joint in the normal Indonesian population, identify its normal values, and compare them with those of other populations in the literature. Patients and Methods: Images for analysis were computed tomography (CT) scans of 85 normal shoulders from 71 patients who had CT scans for another diagnosis. Morphometry of the humeral head and glenoid were measured using 3D reconstruction. Gender differences and correlations between age, height, and glenohumeral morphometry were evaluated. Indonesians' glenohumeral morphometry was compared with those of other populations in the literature. Results: In the normal Indonesian population, the mean of humeral head inclination (HHI), height (HHH), diameter in sagittal plane (DS), diameter in frontal plane (DF), radius of curvature in sagittal plane (RS), and radius of curvature in frontal plane (RF) were 134.1°, 15.6mm, 39.3mm, 41.3mm, 20.4mm, and 21.4mm, respectively. The glenoid height (GH), upper width (GUW), lower width (GLW), inclination (GI), and version (GV) mean values were 34.2mm, 18.4mm, 24.5mm, 74.0mm, and 12.3mm, respectively. There was a significant difference in HHH, DS, DF, RS, RF, GH, GUW, GLW between males and females. Except for HHI and GI, glenohumeral morphometry was correlated with patient height. Age was not correlated with any glenohumeral morphometry. Conclusion: In the Indonesian population, males had a larger humeral head and glenoid than females, and the size of the humeral head and glenoid was correlated to body height. Indonesians' humeral head and glenoid sizes were smaller than those of Western populations, but close to those of other Asian populations.

The Characteristic of 374 Surgically Treated Traumatic Brachial Plexus Injury Patients at an Indonesian Orthopedic Referral Hospital: An Epidemiologic and Sociodemographic View.

Background: Traumatic brachial plexus injury (TBPI) is a severe injury in the upper extremity which can affect the quality of life. The incidence of these injuries has been increasing in recent years. The purpose of this study was to describe the characteristic of TBPI patients treated by surgery at a tertiary Orthopedic hospital in Surakarta, Indonesia. Methods: This is a descriptive retrospective study of patients diagnosed with TBPI who underwent surgery between July 2013 and December 2021. Results: This study included 374 patients with male predominance (86.10%) and an average age of 30.61 years. The most common age group was 20-29 years (45.45% of all age groups). Traffic accidents were the most common cause of this injury (91.98%), especially motorcycle accidents (94.48% of traffic accidents). The most frequent type was complete preganglionic complete injury (48.93%). Most of the patients were the result of traction injury (96.26%). The right side (58.02%) was more common. One patient (0.27%) presented with bilateral lesions. As much as 52.67% of patients presented with concomitant injuries. Fractures were the most common concomitant injuries (90.73%). Humeral shaft fractures were the most common fractures (29.10%), followed by forearm and clavicle fractures (16.10% and 21.98% respectively). A total of 19.52% of patients underwent surgery between 3 and 6 months after trauma. Nerve procedures were performed in 57.38% of all surgical procedures and the rest were secondary procedures: Tendon transfers (36.92%), arthrodesis (2.53%), and Free Functional Muscle Transfer (FFMT) 2.74%. Conclusion: The young population, especially men, were commonly subjected to this injury with motorcycle accidents as the most common cause. Early recognition and optimum treatment must be done to improve functional outcomes. Improvement of road safety and spreading the health education of TBPI are recommended to reduce the incidence of injury and improve functional outcomes.

Full Endoscopic Lumbar Stenosis Decompression: A Future Gold Standard in Managing Degenerative Lumbar Canal Stenosis.

BACKGROUND: Until recently, open decompression was considered the gold standard for the management of spinal stenosis, but the evolution of minimally invasive spine instruments has brought a new dimension to the management of spinal stenosis. Full endoscopic surgery has a lot of advantages in terms of minimal soft tissue damage, less bleeding, shorter hospital length of stay, and earlier return to work. Our aim was to evaluate the efficacy of full endoscopic lumbar decompression for degenerative lumbar canal stenosis compared with classic open decompression surgery. METHODS: This is a retrospective cohort study of degenerative lumbar spinal stenosis without instability, consisting of 132 open decompression and 163 full endoscopic decompression patients. We evaluated the clinical result of the pre- and postoperative visual analog scale (VAS) of leg pain, back pain, and Oswestry Disability Index (ODI). We observed the patients until 1 year after the operation. RESULTS: The postoperative ODI scores and VAS scores for back pain and leg pain were better than the preoperative scores. The ODI scores and VAS scores for leg pain were significantly better in both groups (P = 0.033 and 0.04, respectively). The main difference between open and full endoscopic decompression was the VAS back pain and amount of bleeding. In the full endoscopic group, the mean VAS back pain was 1.6 and the amount of bleeding was minimal. In the open decompression surgery, the mean VAS back pain was 3.5 and the amount of bleeding was around 84 mL. The length of hospital stay was shorter in the full endoscopic group, which was 1.5 days compared with 3.4 days in open decompression (P = 0.034). CONCLUSION: Full endoscopic decompression showed better early results compared with the conventional group, but a long-term study is still needed for further evaluation of the clinical results. The use of the full endoscopic technique is very promising in the management of spinal stenosis. CLINICAL RELEVANCE: This study provides a comparison of the efficacy of open decompression and full endoscopic decompression in degenerative lumbar canal stenosis.

The Unpredictable Palmaris Longus Tendon Variation in Distal Radio-Ulnar Joint Reconstruction: A Technical Consideration for Undersized Graft.

Background: Distal radioulnar joint (DRUJ) instability results from the disruption of the triangular fibrocartilaginous complex consisting of DRUJ's primary and secondary stabilizers. The gold standard of stabilization procedure remains ligament reconstruction that utilizes tendon grafts to reanimate the volar and dorsal radioulnar ligament (RUL) as the primary stabilizers of the joint. The palmaris longus (PL) tendon, the graft of choice in reconstructive surgery, is commonly used in DRUJ reconstruction. However, it can exhibit anatomic variations from agenesis to the variation in morphology, location, and attachment that is rarely encountered other than in cadaveric studies. Case Presentation: We present a case of a 14-year-old boy with ulnar-sided wrist pain and instability following an injury in a boxing match four months before admission. The clinical and radiological results suggested a DRUJ injury with extensor carpi ulnaris (ECU) tendinitis. A ligament reconstruction using the PL tendon graft was planned. Intraoperatively, the PL was found anomalous with dual distal attachments and a short graft length. Results: We performed Adams ligament reconstruction technique with some modifications to the original design. To overcome the under-sized graft, instead of passing it around the ulnar neck, we added one more bone tunnel on the ulna to enhance the construct stability by a tendon to bone healing. Conclusion: In reconstructive surgeries, surgeons should consider the other sources of grafts as graft variations exist. Otherwise, as in our case, modifications to the standard technique can be made.

The Use of 3D Polylactic Acid Scaffolds with Hydroxyapatite/Alginate Composite Injection and Mesenchymal Stem Cells as Laminoplasty Spacers in Rabbits.

Several types of laminoplasty spacer have been used to fill bone gaps and maintain a widened canal. A 3D scaffold can be used as an alternative spacer to minimize the risk observed in allografts or autografts. This study aims to evaluate the in vivo biocompatibility and tissue−scaffold integration of a polylactic acid (PLA) scaffold with the addition of alginate/hydroxyapatite (HA) and mesenchymal stem cell (MSc) injections. This is an experimental study with a pretest and post-test control group design. A total of 15 laminoplasty rabbit models were divided into five groups with variations in the autograft, PLA, HA/alginate, and MSc scaffold. In general, there were no signs of inflammation in most samples (47%), and there were no samples with areas of necrosis. There were no significant differences in the histopathological results and microstructural assessment between the five groups. This demonstrates that the synthetic scaffolds that we used had a similar tissue reaction and tissue integration profile as the autograft (p > 0.05). We recommend further translational studies in humans so that this biocompatible fabricated scaffold can be used to fill bone defects.

The Relationship Between Patient Factors and Clinical Outcomes of Free Functional Muscle Transfer in Patients with Complete Traumatic Brachial Plexus Injury.

Purpose: Traumatic brachial plexus injury (TBPI) causes severe disabilities to the patients, affecting not only upper limb function but also the psychosocial and economic aspects. Free functional muscle transfer (FFMT) is one of the reconstruction modalities for the management of TBPI. The aim of this study is to evaluate the functional outcomes and their correlation to patient factors. Patients and Methods: This is a retrospective study of 131 patients who suffered from complete TBPI (C5-T1) and were treated with the FFMT procedure to restore elbow flexion and wrist extension from 2010 to 2018 in our institution. We evaluated the active range of motion (AROM), muscle power with MRC (Medical Research Council) scale, DASH score, and complications, with a minimum of 12-month follow-up. Results: Following FFMT surgery, elbow flexion was significantly and successfully restored (MRC ≥ 3) in 75.5% of patients with an average AROM of 88.17 ± 41.29°. The wrist extension was restored in 42% of the patients with an average AROM of 20.69 ± 18.72°. There was no correlation between age, side of injury, and time to surgery with the functional outcomes. There was a weak correlation between education level, rehabilitation compliance, and elbow functional outcomes. Conclusion: FFMT is a reliable surgical option to restore elbow flexion in TBPI with a high satisfactory result. Our findings suggested that the FFMT indication is potentially expanded regardless of the patient factors.

Particular precautions and the role of intraoperative neuromonitoring in cervical cord injury in elder recreational cyclist: A case report.

INTRODUCTION AND IMPORTANCE: The trend in cycling nowadays affects all age groups. However, special precautions must be considered in the elderly group. Minor trauma to the cervical region can cause severe neurological deterioration, leading to fatality because of the pre-existing degenerative process. CASE PRESENTATION: We present a case of a 61-year-old male recreational cyclist with acute onset of tetraplegia following a minor fall. The radiological result revealed a long-standing degenerative process. Unfortunately, the patient deceased due to the sequelae of the paralysis and cardiac event despite our prompt surgical decompression and the improvement shown on intraoperative neuromonitoring. CLINICAL DISCUSSION: The degenerative process can aggravate cervical cord injury even in its mildest form of injury. In this study, immediate improvement was detected by the intraoperative neuromonitoring (IONM) - although the clinical improvement had not improved yet as the general condition is poor. CONCLUSION: The elder cycling population is increasing. Safety measures and injury avoidance are advisable along with expert consultation before the exercise. In a pre-existing degenerative condition of the cervical, a special precaution is also needed during the exercise. If the surgery has been indicated, the use of intraoperative neuromonitoring is found to be useful to guide the decompression and potentially beneficial as a predictive value for the clinal outcome.

Full Endoscopic Posterior Cervical Foraminotomy in Management of Foraminal Disc Herniation and Foraminal Stenosis.

BACKGROUND: The development of full endoscopic procedures enables surgeons to visualize the operative field very clearly. Posterior foraminotomy using endoscopy was developed as a minimally invasive procedure to reduce the complication of the anterior cervical approach and to preserve the segmental motion without decreasing the effectiveness of nerve decompression. Our aim is to evaluate the result of full endoscopic posterior cervical foraminotomy in our center. METHODS: This is a prospective single-arm study of 65 foraminal disc herniation and foraminal stenosis patients that underwent full endoscopic posterior foraminotomy procedures. All patients were routinely observed for 12-months duration to evaluate Visual Analog Score (VAS) of the neck, arm, and modified Macnab criteria. RESULTS: Arm pain VAS decreased significantly compared with the pre-operation state (p < 0.001, 0.034, 0.001 on immediate post-operative, 6-months follow-up, and 12-months follow-up, respectively) even though 6.15% of patients had hypesthesia on follow-up. There was no neck pain observed during 1 year follow-up, and modified Macnab criteria showed a good outcome following full endoscopic posterior foraminotomy. CONCLUSION: Full endoscopic posterior foraminotomy provides good nerve decompression with all the benefits of endoscopic spine procedure.