Dorsal nail plate versus percutaneous k-wire fixation in the treatment of displaced distal radius fractures.

Distal radius fractures are the most common fractures in the elderly, yet the treatment is controversial and still debated in the literature. Twenty four patients aged older than sixty with distal radial fractures were treated by dorsal nail plate. We compared them with twenty four similar matched patients treated by percutaneous Kirschner wiring surgical method. The patients were operated on by a surgeon experienced in carrying out hand surgery. The purpose of this retrospective review was to compare the clinical and radiological outcomes in elderly patients with displaced distal radial fractures who were treated with either the dorsal nail plate or percutaneous Kirschner wiring surgical procedures. Both groups had high union rates and low complication rates for the treatment of displaced distal radius fractures in elderly patients. However, better functional results can be expected in dorsal nail plate.

Computed tomography-guided bupivacaine and corticosteroid injection for the treatment of symptomatic calcification in the great toe tendon.

BACKGROUND: Calcification in the great toe tendon is a rare disorder that is characterized by the deposition of calcium on degenerative collagen fibrils. CASE PRESENTATIONS: IN THIS REPORT, WE PRESENT TWO CASES OF CALCIFIC TENDONITIS: one in the adductor hallucis and the other in the flexor hallucis longus tendon. We preferred computed tomography-guided steroid injection in our cases because of pain unresponsive to conservative treatment. Patients were free of symptoms at the follow-up visit, 4 weeks after injection. CONCLUSION: Calcification of the hallux tendons is a rare disorder. Treatment of tendonitis consists of nonsteroidal anti-inflammatory drugs. Local anesthetic and steroid injection may be considered in cases unresponsive to conservative treatment. Because of the anatomic location of tendons, injection could be difficult. Computed tomography guidance may improve the success rate of injections.

Giant sacral schwannoma: a case report and review of the literature.

Intraspinal schwannomas localized in the sacrum are relatively infrequent, accounting for 1-5% of all spinal axis schwannomas. They frequently grow to considerable size before detection; hence, the term giant sacral schwannoma. Sacral schwannomas arise from the sacral nerve roots. The diagnosis of schwannomas in the spinal canal is difficult because of their slow growth, often resulting in extensive bony destruction. This case report documents the management of a 48-year-old male with a giant sacral schwannoma. We performed a two-stage surgery with intralesional tumour resection. The patient is now free of any complaint, complications and there is no recurrence two years after resection of the schwannoma. Intralesional excision of a sacral schwannoma is a less invasive procedure than total or partial sacrectomy. Using a combined anterior and posterior approach, satisfactory tumour excision and stabilization can be achieved, while avoiding the high morbidity related with total sacrectomy.

The pedicle screw fixation with vertebroplasty augmentation in the surgical treatment of the severe osteoporotic spines.

STUDY DESIGN: Retrospective clinical study. OBJECTIVE: To present the early clinical results of pedicle screw fixation augmented by vertebroplasty using polymethylmethacrylate in severely osteoporotic patients requiring spine surgery due to the neurologic deficit. SUMMARY OF BACKGROUND DATA: It is postulated that combining a formal vertebroplasty-that is, maximum filling of the trabecular space with polymethylmethacrylate-with pedicle screw placement in osteoporotic vertebrae could result in resistance to pullout forces significantly. METHODS: Between the years 2003 and 2006, pedicle screw placement with vertebroplasty augmentation was performed in 49 patients who had severe osteoporosis and who required spine surgery due to neurologic deficit. Eleven patients with less than 2 years of follow-up and 2 patients who died from unrelated illness were excluded from the study. Thirty-six of 49 patients having minimum 2 years of follow-up were included. Cement augmentation was also performed in segments proximal and distal to instrumentation to prevent junctional segment fractures. Early and late postoperative complications were recorded during follow-up. RESULTS: The mean postoperative follow-up was 37 (24 to 48) months. The average age of the patients was 66 (59 to 78) years. The instrumentation was performed meanly at 5 segments and vertebroplasty was performed averagely at 7 segments. All patients had the T-score value of less than -2.5 from the anteroposterior and lateral lumbar spine and hip views, so regarded as severe osteoporosis. In our study group, there were no extravasation and subsequent thermal neural injury. Four superficial wound infections have been observed and they responded well to local debridement and antibiotics. There were no proximal and distal junctional segment fractures during the follow-up course. Postoperatively, all patients with neurologic symptoms had complete relief of their nerve compression symptoms. CONCLUSIONS: In patients requiring spine surgery due to neurologic deficit and having no sufficient time for the medical treatment of severe osteoporosis, pedicle screw fixation with vertebroplasty augmentation and vertebroplasty in segments proximal and distal to the instrumented segments can be good alternative methods to provide well fixation and fusion while preventing proximal and distal junctional fractures. One should be careful about pulmonary cement embolism after such kind of procedures.

A rare cause of neuromuscular scoliosis: Alexander disease.

Alexander disease belongs to a group of progressive neurological disorders in which the destruction of white matter in the brain is accompanied by the formation of fibrous, eosinophilic deposits known as Rosenthal fibers. Spinal deformity rarely accompanies this disease. The aim of this report is to present a patient with juvenile-onset Alexander disease, who also had progressive neuromuscular type scoliosis requiring surgical stabilization. A 13-year-old male presented with bilateral weakness in both lower extremities and scoliosis. Results of an examination of the spine showed a left thoracic scoliosis with prominent left paraspinous prominence and elevation of the ipsilateral shoulder. Spinal fusion with rigid internal stabilizing instrumentation was selected for surgical treatment of the scoliosis. The fusion area was to be from T2 to L4. He was instrumented with pedicle screw fixation system, and he underwent fusion with an allogenous bone graft. Satisfactory correction of the sagittal and coronal plane deformity was achieved, reducing the scoliosis to 14 degrees . At the 5-year follow-up, results of a clinical examination showed a marked improvement in truncal balance and walking ability. The patient had a rapidly progressive scoliosis and severe decompensation requiring surgical stabilization. The scoliosis behaved in a manner similar to that of neuromuscular scoliosis. Therefore, more aggressive treatment was warranted to prevent decompensation. For that reason, posterior long segment (T2-L4) pedicle screw instrumentation and fusion was performed for surgical treatment.

Multiple-level cement vertebroplasty in patients with vertebral commpression fractures from osteodystrophy in chronic liver disease.

Multiple compression fractures of osteoporotic vertebrae are common in patients with a liver transplant or with chronic liver disease. The authors describe two such patients, treated with percutaneous cement vertebroplasty at 12 levels, respectively in 4 and in 2 sessions. No complications were seen after follow-up periods of 12 and 8 months respectively. However, this is not a grant for the future, and further followup is necessary. Multiple-level cement vertebroplasty should not be generalized before further experience is gained. Moreover, medical treatment continues to play an important role.

[Early results of autologous mononuclear bone marrow cell implantation in nontraumatic avascular necrosis of the femoral head]. / Travmaya bagli olmayan femur basi osteonekrozunda otolog konsantre mononükleer kemik iligi hücre naklinin erken dönem sonuçlari.

OBJECTIVES: We evaluated early clinical and radiologic results of core decompression combined with autologous mononuclear bone marrow cell implantation for early stage nontraumatic avascular necrosis of the femoral head. METHODS: The study included nine patients (1 female, 8 males, mean age 46.5 years; range 33 to 59 years) with stage I-II nontraumatic avascular necrosis of the femoral head, according to the Steinberg classification. Bone marrow-derived CD34 cells were injected through a core decompression channel into the femoral head. Clinical assessment included a visual analog scale (VAS), Harris hip score, and the WOMAC Osteoarthritis Index. Radiologically, femoral head collapse, narrowing of the coxofemoral joint space, and the size of the osteonecrotic area were assessed. The mean follow-up was 27.2 months (range 24 to 38 months). RESULTS: Pre- and postoperative (24th month) evaluations showed that the mean VAS score and the WOMAC Osteoarthritis Index decreased from 3.4+/-0.4 to 1.2+/-0.6, and from 33+/-3 to 11+/-6, respectively, with an increase in the Harris hip score (from 54 to 92). Preoperatively, two patients were Steinberg I-B, four were I-C, and three were II-A. Finally, all the patients were stage 0 except for one patient who regressed to I-A. None of the patients exhibited femoral head collapse or narrowing of the coxofemoral joint space. CONCLUSION: Autologous mononuclear bone marrow cell implantation relieves articular pain, prevents the progression of osteonecrosis, and hence subchondral fractures. Therefore, it may be treatment of choice particularly in stage I-II avascular necrosis of the femoral head.

Double-segment total vertebrectomy for the surgical treatment of congenital kyphoscoliosis: a case report.

BACKGROUND CONTEXT: Congenital kyphosis or kyphoscoliosis is an uncommon deformity that usually is progressive without surgical intervention. In the lately diagnosed or neglected cases of congenital kyphoscoliosis, the patients may come with shoulder-trunk imbalance anomalies, severe deformity in coronal and sagittal plane, rib cage deformities, pelvic tilt, presence of intramedullary anomalies, neurological deficit, and difficulty in walking and cardiopulmonary problems. PURPOSE: To present a technical note related with double-segment total vertebrectomy for the surgical treatment of a patient who had neglected congenital kyphoscoliosis in lumbar spine. STUDY DESIGN: Case report. METHODS: A 19-year-old girl had submitted to our center with complaints of deformity and pain in her back. Her physical examination revealed scoliosis and gibbosity in lumbar region. Her neurological examination was normal. In the radiological examination, X-ray films showed 42 degrees lumbar scoliosis in frontal plane and 35 degrees kyphotic curvature in the sagittal plane. RESULTS: Three-staged (posterior-anterior-posterior) surgery in the same session (same anesthesia) was performed. CONCLUSION: Total or partial vertebrectomy on the apex of the deformity and the adjacent vertebral bodies along with anterior stabilization by means of a cylindrical cage combined in one operative procedure preceded by temporary posterior instrumentation and followed by posterior instrumentation and fusion may be preferred for the treatment of congenital kyphoscoliosis in neglected cases to provide spinal cord decompression.

A clay-shoveler's fracture with renal transplantation and osteoporosis: a case report.

INTRODUCTION: Clay-shoveler's fracture is a rare cervicodorsal spinous process fracture and there is little information regarding the prognosis of patients with this condition in conjunction with osteoporosis and corticosteroid use. CASE PRESENTATION: A 39-year-old man was admitted to our institution with a 6-month history of cervicodorsal pain prior to admission. The patient had previously undergone renal transplantation and was on corticosteroids, and had developed osteoporosis. We treated him with a cervical collar, non-steroidal anti-inflammatory agents and alendronate. The patient was advised against performing weight-bearing activities for 6 months. CONCLUSION: Clay-shoveler's fracture with osteoporosis and corticosteroid use presented by fracture of the cervicodorsal aspect of the spinous processes may be successfully treated with a collar, alendronate and long-term rest.

Patients with isolated musculoskeletal trauma have lower mental status scores.

UNLABELLED: The subjective concerns and needs of patients who have experienced trauma are important to recovery. However, the mental status of patients with isolated musculoskeletal trauma is not known. Is the mental status of such patients different and does the severity, site, and type of trauma affect this difference? We evaluated the mental status of 195 patients hospitalized for isolated musculoskeletal trauma and determined the characteristics of the factors that affect mental status; 197 patients hospitalized for elective surgery and not exposed to acute trauma constituted the control group. We administered the Mini-Mental State Examination to study and control groups within the first 24 hours of hospitalization. Age, gender, and educational status in the study and control groups were recorded. In addition, the severity, site, and type of trauma in the study group were recorded. Mini-Mental State Examination scores of the trauma group were lower than those of the control group. Mini-Mental State Examination scores decreased with increasing trauma severity. The mental status of the patients sustaining isolated musculoskeletal trauma was affected by the severity, site, and type of trauma. LEVEL OF EVIDENCE: Level I, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Severe erosion of lumbar vertebral body because of a chronic ruptured abdominal aortic aneurysm.

BACKGROUND CONTEXT: Erosion of vertebral bodies because of abdominal aortic aneurysm is an extremely rare condition. This vertebral destruction is usually seen after aortic graft surgery; nevertheless, it is not expected in primary aortic aneurysms. PURPOSE: The purpose of this article was to present a patient who suffers from back and hip pain because of a chronic ruptured primary aortic aneurysm. STUDY DESIGN: Case report. METHOD: A 51-year-old patient had complaints of back pain. Physical examination revealed a pulsatile mass in the periumblical region. By using conventional radiographies, vertebral erosion was detected at the anterior part of L3-L4-L5 vertebrae. A chronic ruptured thrombosed aortic aneurysm was identified by magnetic resonance imaging. RESULTS: After resection of the aneurysm, it was possible that the lack of anterior column support could result in future instability. Therefore, an L4-L5 anterior partial corpectomy and reconstruction of the anterior defect with titanium mesh cage with posterior instrumentation and fusion were performed. CONCLUSION: It was concluded that back pain caused by chronic aortic aneurysms is a rare condition and may be one of the possible etiologies in differential diagnosis of low back pain and/or sciatica in some patients.

Posterior vertebrectomy in kyphosis, scoliosis and kyphoscoliosis due to hemivertebra.

Vertebrectomy and instrumentation only via the posterior approach has been increasingly used in sagittal, frontal plane and combined deformities. The aim of this retrospective study is to evaluate the clinical and radiological results of hemivertebrectomy and instrumentation only via the posterior approach in congenital spinal deformities. Between 1998 and 2003, we performed hemivertebrectomy and interbody fusion using posterior instrumentation with titanium mesh cage via the posterior approach in 19 patients (three scoliosis, five kyphosis and 11 kyphoscoliosis). The age of the patients ranged from 2 to 22 years and they all underwent hemivertebrectomy (at thoracic level in six patients, at thoracolumbar level in eight patients and at lumbar level in five patients). A titanium mesh cage was used for anterior column support and interbody fusion in patients who had residual anterior gap preventing bone-to-bone contact. Correction and stabilization were achieved by posterior polyaxial pedicle screws. Follow-up was an average of 4.6 years (range: 2-7 years). We did not confront any loss of correction, pseudoarthrosis, and titanium mesh cage collapse or implant failure. Hemivertebrectomy and instrumentation via the posterior approach is a good one-stage surgical treatment option that can be used to avoid the surgical trauma and morbidity related to anterior surgery. It is a technically demanding surgical procedure, however, requiring extreme care and experience in spine surgery.

Comparative analysis of pedicle screw versus hybrid instrumentation in adolescent idiopathic scoliosis surgery.

The expectations of both the patient and surgeon have been greatly revised in the last 10 years with the introduction of pedicle screws (PS) in spinal surgery. In this study, we have retrospectively evaluated and compared the results of PS instrumentation and the Hybrid System (HS), the latter consists of pedicle screws, sublaminar wire and hooks. The mean follow-up period was 60.1 months (range: 49-94 months) for the patients of the HS group and 29.3 months (range: 24-35 months) for those of the PS group. In the HS group, pedicle screws were used at the thoracolumbar junction and lumbar vertebra, the bilateral pediculotransverse claw hook configuration was used at the cranial end of the instrumentation, sublaminar wire was used on the concave side of the apical region and the compressive hook was used on the convex side. In the PS group, PS were used on the concave sides at all levels and on the convex side of the cranial and caudal end of instrumentation, in the transition zone and at the apex. The two groups were comparable for variables such as mean age, preoperative Cobb angle, thoracic kyphosis angle, lordosis angle, coronal balance, flexibility of the curve, apical vertebra rotation (AVR), apical vertebra rotation (AVT) and the number of vertebrae included in the fusion (p>0.05). The parameters of values of correction, ratio of correction loss, AV derotation, AVT correction ratio, amount of blood loss, operation time, postoperative global coronal and sagittal balance, thoracic kyphosis angle and lumbar lordosis angle were measured at the last follow-up and used for comparing the HS and PS groups. There was no statistically significant difference between the groups for correction ratio, postoperative coronal balance, postoperative thoracic kyphosis and lumbar lordosis angle, operation time, amount of blood loss and number of fixation points (p>0.05) The difference for the ratio of correction loss, AV derotation angle and the AVT correction ratio at the last follow-up visit and for the total follow-up period between the groups was found to be statistically significant (p<0.05). Although it is possible to obtain a similar amount of correction by either instrumentation system, the loss of correction seems to be lower with the more rigid PS construction. The PS system also has a stronger effect on vertebral bodies, thereby providing better AV de-rotation. There was no significant difference (p>0.05) between the groups in terms of correction rate, postoperative coronal and sagittal balance, operation time, blood loss and number of fixation points. This may indicate that anchor points are more important than the use--or not--of screws. Correction durability and AV de-rotation was better with PS instrumentation, while AVT was better corrected by HS instrumentation (p<0.05). We propose that the reason for the better correction of AVT with HS instrumentation is the forceful translation offered by the sublaminar wire at the apical region, while the reason for the better correction durability of the PS instrumentation may be due to the fact that multiple pedicle screws which afford three-column control are better at maintaining the correction and preventing late deterioration.

Treatment approach in tandem (concurrent) cervical and lumbar spinal stenosis.

Spondylotic degeneration can manifest as tandem (concurrent) cervical and lumbar spinal stenosis. The primary manifestations include neurogenic claudication, gait disturbance and a mixture of findings of myelopathy and polyradiculopathy in both the upper and lower extremities. The purpose of this retrospective study was to report the existence and management of tandem (concurrent) cervical and lumbar spinal stenosis. Between 1998 and 2004, 8 patients (6 women and 2 men) were diagnosed with tandem spinal stenosis in a series of 230 patients who underwent surgery for spinal stenosis (3.4%). Three patients received cervical surgery first and 5 patients lumbar surgery first. The Japanese Orthopaedic Association Score of all patients improved from an average of 8.1 preoperatively to an average of 11.8 points at discharge and maintained an average of 12.7 points at final follow-up. Oswestry Disability Score improved from mean 58.1 to 29 at discharge and 19.3 at latest follow-up. All the patients had excellent or good results and none deteriorated neurologically. Although tandem spinal stenosis occurred relatively infrequently, we concluded that its possible presence should not be overlooked. The treatment plan must be designed according to the chief complaints and symptoms of the patient.

[Total disc prosthesis for painful degenerative lumbar disc disease]. / Lomber dejeneratif disk hastaligii total disk protezi ile tedavisi.

OBJECTIVES: We evaluated clinical and radiographic results of patients treated by the ProDisc II total disc prosthesis (TDP) for painful degenerative lumbar disc disease. METHODS: The study included 34 patients (25 females, 9 males; mean age 44 years; range 37 to 54 years) who underwent a total of 62 lumbar TDP procedures for degenerative lumbar disc disease. Lumbar disc replacement involved one level in 12 cases, two levels in 17 cases, three levels in four cases, and four levels in one case. Clinical and radiographic assessments were made preoperatively and at 3, 6, 12, and 24 months postoperatively. Clinical evaluations were made with a visual analog scale (VAS) and the Oswestry Disability Index (ODI). Radiographic parameters included lumbar lordotic angle, the height and flexion-extension range of the affected discs. The mean follow-up period was 29.3 months (range 24 to 39 months). RESULTS: Low back pain and lower extremity pain showed near-complete improvement up to the third postoperative month. At the end of the 24th month, preoperative ODI and VAS scores of 59.6 and 7.8 decreased to 19.8 and 1.0, respectively. Preoperative and postoperative lumbar lordotic angles were 52.6 degrees and 57.1 degrees , respectively. The mean disc height of implanted discs increased from 4.6 mm to 12.1 mm postoperatively. The mean flexion-extension angle increased from 2.8 degrees to 8.4 degrees at L5-S1, and from 2.6 degrees to 9.8 degrees at L4-5. The overall improvement in the mean flexion-extension angle was 7.2 degrees . CONCLUSION: Lumbar disc prosthesis offers significant advantages in terms of functional improvement and increased quality of life in the surgical treatment of degenerative disc disease.