Lumbosacral arthrodesis using pedicular screws and ringed rods.

Sixty-one patients who had lumbar instability and chronic low back pain or deformity from nontraumatic lumbar pathologies were studied. In all of them a posterior lumbosacral fusion with CUN (Clinic of the University of Navarre) pedicle rod fixation was used. The mean follow-up period was 36 months (range 26-46 months). The consolidation rate was evaluated according to plain and functional radiographs, and a clinical evaluation was made using an analogue pain scale. The rate of fusion was 93.5%. Neurological complications occurred in 3.3%. The incidence of screw failure was 2.3% of all the screws. No other implant failure occurred. The patients rated their clinical results as 'excellent' in 33.8% of the cases, 'good' in 42.2%, 'fair' in 16.9% and 'poor' in 6.7%. CUN instrumentation is a versatile internal fixation system that has been shown to provide satisfactory stability. Furthermore, the clinical results are comparable to those reported in studies in which the most common hardwares were used.

Congenital absence of the pedicles and the neural arch of L2.

Congenital pedicle abnormalities are rare. Unilateral aplastic and hypoplastic lumbar pedicles have been reported, but these were usually discovered incidentally and did not need surgical treatment. We present a case of absence of both pedicles and the neural arch of L2, with associated kyphoscoliosis with neurological involvement, that needed a two-stage corrective surgery. An L1-L4 fusion was achieved with relief of the symptoms.

Nerve regeneration in different types of grafts: experimental study in rabbits.

The nerve regeneration patterns of five different types of grafts were studied in 40 rabbits. Conventional nerve autografts, vascularized nerve autografts, fresh nerve allografts, frozen nerve allografts, and muscle autografts were sutured to a 1.5 cm gap in the sciatic nerve and compared with normal nerves and nerves with a 3 cm gap. Regeneration was evaluated by means of electromyography, light and electron microscopy. Quantitative data from morphometric analysis of axonal diameter and myelination were statistically analyzed. Results 5 months after grafting showed no significant differences between the conventional and vascularized nerve autografts. There were no significant differences between frozen nerve allografts and muscle autografts. The best regeneration was achieved with autografts.

[Extra-abdominal desmoid tumors. Diagnostic-therapeutic considerations and review of the literature]. / Tumores desmoides extraabdominales. Consideraciones diagnóstico-terapéuticas y revisión de la literatura.

The authors review the literature, discuss clinical aspects and options in the management of desmoid tumors, analyze recent advances in the understanding of its biology and how they affect therapeutic choices, and outline future treatment perspectives. We conclude that although recurrence rates are high, wide excision is the best firs approach. If it is not possible, marginal surgery and radiation therapy can be performed. Radiation therapy can be also use in the attempt to control recurrent disease. Although many pharmacologic agents have been advocated there is no clear proof of their usefulness. Systemic therapy may be considered for selected patients that are not amenable to local treatment.

Lumbosacral instrumentation in patients with scoliosis in cerebral palsy.

We review our experience in surgical treatment of scoliosis in cerebral palsy (CP) patients to improve the functional status of such patients. The results with two types of instrumentation are reported. The best results with fusion to the sacrum were obtained with ringed rods with sublaminar and basispinous wiring, adding distraction and compression, and pedicular screws.

Union after multiple anterior cervical fusion. 21 cases followed for 1-6 years.

With a mean follow-up of 3 (1-6) years, we report on 21 patients who underwent multiple level cervical fusion, using autologous iliac crest grafts. Dissectomies were performed in 14 patients and corpectomies in another 7. Instrumentation was used in all patients with corpectomies and in 2 patients who underwent 2-level and 3-level dissectomies. Non-union occurred in 1 patient at 1 level. Graft displacement requiring reoperation was observed in 2 patients with massive corpectomies, in 1 of them as a consequence of trauma. In both patients complete bony fusion was obtained after reoperation and no other complications were observed. We conclude that the success rate with multiple-level fusion is comparable to that of single-level fusion when adequate fixation is achieved.

Bacterial contamination of allografts.

The risk of bacterial infection through allogenic bone transplantation is one of the major problems facing tissue banks. The purpose of this study is to report the contamination rate in 987 grafts obtained under strictly aseptic conditions, between 1989 and 1992. The grafts were stored at -80 degrees C (cortical bone and tendons) and -40 degrees C (cancellous bone). The overall contamination rate was 6.6%, with Gram-positive bacteria responsible for 80% of the positive cultures. We discuss the sources of contamination, the most frequently isolated bacteria and the steps in the donation and transplantation procedures that help to reduce the risk of contamination. We conclude that the methods of acquisition, processing and storage of tissues are effective in making sterile allografts available.

Bacterial contamination of allografts.

The risk of bacterial infection through allogeneic bone transplantation is one of the problems facing tissue banks. The purpose of this study is to report the contamination rate in 987 grafts obtained under strictly aseptic conditions, between 1989 and 1992. The grafts were stored at -80 degrees C (cortical bone and tendons) and -40 degrees C (cancellous bone). The overall contamination rate was 6.6%, with Gram-positive bacteria responsible for 80% of the positive cultures. We discuss the sources of contamination, the most frequently isolated bacteria and the steps in the donation and transplantation procedures that help to reduce the risk of contamination. We conclude that the methods of procurement, processing and storage of tissues are effective in making sterile allografts available.

Lumbosacral arthrodesis with louis technique. Review of 186 cases.

A retrospective study was carried out of 186 patients surgically treated by lumbosacral arthrodesis using Louis plates from 1981 to 1989 with an average follow-up of 7.2 years (range 3-11). The average age of the patients was 42.2 years (range 11-71). The indication for surgery was a herniated disc and segmentary instability in 29% (54 patients), spondylolysis or spondylolisthesis in 26.3% (49 patients), arthrosis in 11.3% (21 patients), instability (narrowing of the disc space and zygapophyseal hypertrophy) and stenosis in 5.9% (11 patients), tumour in 5.4% (10 patients), fractures in 0.5% (1 patient) and combinations of the above in 21.5% (40 patients who mainly had a herniated disc and associated spinal stenosis). Iliac crest autograft was used in 33 cases (17.7%), bank allograft in 5 (2.6%), and in the other 148 patients the graft was obtained from the arthrodesis bed. After follow-up we observed loosening of the screws in 20 patients and screw rupture in 10. We only documented 2 cases of pseudarthrosis using dynamic X-radiography. We conclude that the Louis plate is a simple method that leads to lumbosacral arthrodesis with a low rate of pseudoarthrosis.

Eosinophilic granuloma of the spine with and without vertebra plana: long-term follow-up of six cases.

Vertebral eosinophilic granuloma is a rare condition frequently associated with vertebra plana. In this paper we present six patients with eosinophilic granuloma of the spine; three were without vertebra plana, which represents a diagnostic problem. The mean follow-up was 9 years, (range 2 to 23) and the mean age was 10.8 years at diagnosis. All complained of pain with no neurological deficit. The lesions were located on the vertebral bodies of C4, T9, T10, L1, L2, and L5, respectively. Histologic confirmation of diagnosis was obtained in all patients, two by puncture and four by open biopsy. The patients with vertebra plana (T10, L1, and L5, respectively) were treated conservatively. Long-term follow-up demonstrated total healing of the vertebral body in two and partial rebuilding 8 years after diagnosis in one. Patients without vertebra plana (C4, T9, and L2, respectively) underwent curettage and bone grafting. In the patient with T9 location, a T8-10 anterior arthrodesis with autogenous rib graft was performed. The outcome was satisfactory in all.

[Histiocytosis X]. / Histiocitosis X.

We make a clinical and bibliographical review in diagnosis and treatment of Histiocytosis X, who includes three components: Eosinophylic granuloma, Hand-Schüller-Christian disease and Letterer-Siwe syndrome. We had 28 cases, with an average age of 11.8 years. Eighteen (64%) were males and 10 (36%) females. Seventeen were solitary lesions and 8 had multiple skeletal lesions. Three patients had generalized disease: 2 with Hand-Schüller-Christian disease and 1 with Letterer-Siwe syndrome. The femur lesion was frequently observed among the solitary lesions and the cranium involvement in the multiple skeletal lesions. The total number of lesions was 47. The treatment depended on the location, the clinical manifestations and the number of lesions. The patients with solitary lesions (17) were treated with curettage and bone grafting in 6 cases, segmental resection in 3 cases, only curettage in 3, radiotherapy in one and 4 patients didn't receive treatment. The patients with multiple lesions (8), were treated surgically (4 cases), only radiation therapy (2 patients), with surgery and radiotherapy (1) and one patient had no treatment. The generalized disease was treated with surgery of the main lesion depending in the clinical manifestations and chemotherapy and radiotherapy. The prognosis was good in almost all the patients and we observed regression of the disease even without specific treatment. The case of acute generalized disease died due to systemic complications.

Arthrodiastasis for stiff hips in young patients.

Joint distraction (arthrodiastasis) with a unilateral fixator was used to treat 9 patients with stiffness of the hip which had followed Perthes' disease (3), epiphysiolysis (2), congenital dysplasia (2), tuberculosis (1) and idiopathic chondrolysis (1). Their average age was 14 years, and they all had pain, limp and shortening of the leg. Distraction of 0.5 to 1 cm was maintained for an average of 94 days. The average range of movement subsequently was 65 degrees compared with 20 degrees before. The articular space was widened by an average of 2.8 mm, and only 3 patients had pain on follow up.

Surgical treatment of the radial nerve lesions associated with fractures of the humerus.

Twelve patients who were surgically treated for radical nerve injuries associated with fractures of the humerus are reviewed. The average follow-up was 6 years (range 1-10). The mean time to full recovery was 19 months (range 12-40). Three fractures were open, and nine were closed. Seven of the fractures were located in the distal third of the humerus; two were in the middle third; two were segmental, involving both the middle and the distal thirds of the shaft; and one was supracondylar. All patients received initial treatment of the fracture in other medical units. The mean interval between the lesion and surgical treatment of the nerve injury was 6 months (range 25 days to 15 months). Perineural fibrosis at the lesion site was observed in four patients. Three nerves were found entrapped in the callus. In two cases the nerve was found to be partially divided, and in three cases a total section was observed. The techniques employed were microsurgical reconstruction with interfascicular grafting using sural nerve in six patients, neurolysis in five cases, and tendon transfers in one case. Excellent and good results were obtained in 91% of cases. In the case with a poor result, tendon transfers were made, with an acceptable functional result.

Radial shortening for the treatment of Kienböck's disease.

Twelve patients with Kienböck's disease were treated by radial shortening. Eight patients were in stage II and four in stage III. After an average of 5 years, relief of pain was satisfactory in 10 patients; 8 were in stage II before operation and 2 in stage III. Two patients were dissatisfied because they had persistent pain; both were in stage III before surgery. The range of motion improved moderately. Nonunion at the site of radial osteotomy did not occur. Radiographs at follow up showed consolidation and healing of the lunate in 2 patients, nonprogression of the disease in 9 and increase of the carpal collapse in 1. The procedure helps to prevent further collapse of the lunate especially in stage II and in some patients in stage III.