Endoscopic decompression of severe post-tuberculosis kyphosis related ossification of the ligamentum flavum: case report and literature review.

PURPOSE: Spinal tuberculosis, if not promptly treated, can lead to kyphotic deformity, causing persistent neurological abnormalities and discomfort. Spinal cord compression can occur due to ossification of the ligamentum flavum (OLF) at the apex of kyphosis. Traditional surgical interventions, including osteotomy and fixation, pose challenges and risks. We present a case of thoracic myelopathy in a patient with post-tuberculosis kyphosis, successfully treated with biportal endoscopic spinal surgery (BESS). METHOD: A 73-year-old female with a history of untreated kyphosis presented with walking difficulties and lower limb pain. Imaging revealed a kyphotic deformity of 120° and OLF-induced cord compression at T8-9. UBE was performed under spinal anesthesia. Using the BESS technique, OLF was successfully removed with minimal damage to the stabilizing structures. RESULTS: The patient exhibited neurological improvement after surgery, walking on the first day without gait instability. Follow-up at 1 year showed no kyphosis progression or recurrence of symptoms. BESS successfully resolved the cord compression lesion with minimal blood loss and damage. CONCLUSION: In spinal tuberculosis-related OLF, conventional open surgery poses challenges. BESS emerges as an excellent alternative, providing effective decompression with reduced instrumentation needs, minimal blood loss, and preservation of surrounding structures. Careful patient selection and surgical planning are crucial for optimal outcomes in endoscopic procedures.

The Effects of Longer Use of Teriparatide on Clinical and Radiographic Outcomes after Spinal Fusion in Geriatric Patients.

Background: Teriparatide is an anabolic agent for osteoporosis and is believed to improve the bone healing process. Previous studies showed that teriparatide could enhance not only fracture healing but also spine fusion. It has been reported that use of teriparatide could promote the spine fusion process and decrease mechanical complications. However, there was no consensus regarding optimal treatment duration. The purpose of this study was to compare surgical outcomes between short-duration and long-duration teriparatide treatment after lumbar fusion surgery in elderly patients. Materials and Methods: All consecutive patients older than 60 years who underwent 1-level lumbar fusion surgery for degenerative diseases between January 2015 and December 2019 were retrospectively reviewed. Based on the duration of teriparatide treatment (daily subcutaneous injection of 20 µg teriparatide), patients were subdivided into two groups: a short-duration (SD) group (<6 months) and a long-duration (LD) group (≥6 months). Mechanical complications, such as screw loosening, cage subsidence, and adjacent vertebral fractures, were investigated. Postoperative 1-year union rate was also evaluated on computed tomography. Clinical outcomes were recorded using visual analog scale (VAS) and Oswestry Disability Index (ODI). Between-group differences for these radiographic and clinical outcomes were analyzed. Results: Ninety-one patients were reviewed in this study, including sixty patients in the SD group and thirty-one patients in the LD group. Their mean age was 72.3 ± 6.2 years, and 79 patients were female. Mean T-score was -3.3 ± 0.8. Cage subsidence (6.7% vs. 3.2%), screw loosening (28.3% vs. 35.5%), and adjacent vertebral fracture (6.7% vs. 9.7%) were not significantly different between the SD and LD groups. Union rate at 1-year postoperative was 65.0% in the SD group and 87.1% in the LD group (p = 0.028). Both groups showed improvement in VAS and ODI after surgery. However, the differences of VAS from preoperative to 6 months and 1 year postoperative were significantly higher in the LD group. Conclusions: Longer teriparatide treatment after lumbar fusion surgery resulted in a higher union rate at 1-year postoperative than the shorter treatment. Also, it could be more beneficial for clinical outcomes.

Junctional Failures at Both Ends After Long Fusion Arthrodesis Stopping at L5: Incidences and Risk Factors.

OBJECTIVE: Junctional failures after long fusion stopping at L5 can present at both proximal and distal ends. The purpose of this study was to investigate incidences and risk factors of proximal junctional failure (PJF) and distal junctional failure (DJF) after long lumbar instrumented fusion stopping at L5 for adult spinal deformity. METHODS: Sixty-three patients who underwent long fusion surgery stopping at L5 with a minimum follow-up of 3 years were reviewed retrospectively. PJF and DJF were defined as newly developed back pain and/or radiculopathy with corresponding radiographic failures. The incidence and risk factors of each junctional failure were analyzed using a log-rank test and Cox proportional hazards model. RESULTS: Twelve men and 51 women were included in our study. Their mean age was 68.5 ± 7.0 years and the mean follow-up period was 84.5 ± 45.3 months. PJF and DJF occurred in 17 (27%) and 16 patients (25.4%), respectively. PJF and DJF developed at median durations of 32.1 months and 13.3 months, respectively, showing no significant difference between the two. Three patients presented with both PJF and DJF. Risk factors for PJF included lower body mass index, higher preoperative lumbar lordosis, and higher postoperative sagittal vertical axis (SVA) (hazard ratio, 0.570, 1.055, and 1.040, respectively). For DJF, higher preoperative SVA was an independent risk factor (hazard ratio, 1.010). CONCLUSIONS: After long fusion surgery stopping at L5, PJF and DJF occurred at similar rates. Lower body mass index, higher preoperative lumbar lordosis, and higher postoperative SVA were risk factors for PJF. Higher preoperative SVA was an independent risk factor for DJF.

Comparison of Clinical Outcomes after Total Knee Arthroplasty with and without Patellar Resurfacing in the Same Patients.

Background: Patellar resurfacing is performed in total knee arthroplasty (TKA) to improve pain in the anterior compartment of the knee joint and to restore proper coordination and movement of the patellofemoral joint. The purpose of this study was to analyze differences in clinical outcomes according to patellar resurfacing in patients who underwent bilateral TKA. Methods: Forty-three patients who underwent bilateral primary TKA with patellar resurfacing on one side only were included. Patellar resurfacing was performed selectively according to the status of the patella cartilage surface. Knee Society score (knee and function), Feller score, Kujala score, and Samsung Medical Center (SMC) score (pain and function) were evaluated. Results: There were no significant differences in Knee Society pain and function scores, Feller score, Kujala score, and SMC pain and function scores according to patellar resurfacing. On the comparison of SMC scores, there was no difference except for two questions. Conclusions: It is advisable not to perform resurfacing on normal patellae. However, in order to apply this result to damaged patellae, comparative studies between resurfaced patellae and damaged patellae are needed.

The Impact of Epinephrine in the Periarticular Injection Cocktail using Ropivacaine for Total Knee Arthroplasty: A Prospective, Randomized, Double-Blind Comparison Study.

BACKGROUND: Epinephrine is used in periarticular injection using ropivacaine to produce a synergistic effect when used with local anesthetic agents but the effect has not been proven yet. The purpose of this study is to evaluate how effective epinephrine is on postoperative clinical outcomes in primary total knee arthroplasty (TKA). METHODS: One hundred sixteen cases (89 patients) who underwent primary TKA were randomized into 2 groups depending on whether epinephrine was mixed. Immediately after the operation, patient-controlled analgesia using fentanyl was initiated. The Numerical Rating Scale, the cumulative dose of fentanyl, active range of motion of the knee joint, and wound complications were evaluated postoperatively. RESULTS: There were no significant differences in mean postoperative Numerical Rating Scale, cumulative dose of fentanyl, and active range of motion between the 2 groups. Neither skin necrosis nor wound dehiscence requiring operative management for skin care was required in either group. CONCLUSION: The use of epinephrine in periarticular injection using ropivacaine after TKA did not have any effect on postoperative acute pain control and opioid usage. THE LEVEL OF EVIDENCE: Therapeutic level I.

Outcomes of Balloon Kyphoplasty for the Treatment of Osteoporotic Vertebral Compression Fracture in Rheumatoid Arthritis: A Case-control Study.

BACKGROUND: Patients with rheumatoid arthritis (RA) have higher rate of osteoporosis and vertebral fracture than individuals without RA. This study aimed to compare the outcomes of balloon kyphoplasty (KP) performed to treat osteoporotic vertebral compression fracture (OVCF) in RA patients with the outcomes in non-RA patients. MATERIALS AND METHODS: The patients who received KP for OVCF and could be followed up at least 1 year were included in the study. These patients were divided into RA group and non-RA group. For clinical outcomes, the visual analog scale for back pain (VAS-BP) and Korean version of the Oswestry Disability Index (K-ODI) were assessed before and after the procedure and at the 1-year followup. For radiological outcomes, the anterior vertebral height and change in local kyphotic angle were measured. Complications were also examined. RESULTS: Twenty three RA patients (31 vertebral bodies) and 107 non-RA patients (124 vertebral bodies) were analyzed. In two groups, postoperative VAS-BP and K-ODI decreased significantly to similar extents. There was a similar recovery of vertebral height and kyphotic angle in two groups. However, in terms of complications, adjacent segment fracture and recollapse were more frequent in the RA group than in the non-RA group. CONCLUSIONS: The use of KP to treat OVCF in RA group exhibited similar outcomes to non-RA group in terms of pain reduction, vertebral height restoration, and kyphosis correction. However, RA group had significantly higher rate of complications involving adjacent segment fracture and recollapse. Therefore, careful followup after KP in patients with RA is required to monitor for high complication rate.

Psychological Changes and Employment Outcomes After Kyphosis Correction in Patients With Ankylosing Spondylitis.

STUDY DESIGN: A retrospective study. OBJECTIVE: To evaluate the psychological changes and employment outcomes following corrective osteotomy in patients with ankylosing spondylitis (AS). SUMMARY OF BACKGROUND DATA: To date, no study has investigated the changes in psychological status and subsequent improvement in employment outcome after correction of kyphotic deformities in patients with AS. METHODS: This study included 48 patients with AS who underwent corrective osteotomy for severe kyphotic deformity. Sagittal alignment was assessed radiographically. Clinical status was evaluated using the Short Form-36 Health Survey, psychological status was evaluated using the Hospital Anxiety and Depression Scale (HADS), and employment outcomes were assessed using the Lam Employment Absence and Productivity Scale (LEAPS). The degree of postoperative sagittal alignment correction was measured, and changes in clinical and employment outcomes and psychological status were evaluated. The relationship between the degree of sagittal alignment correction and each evaluation item was analyzed. RESULTS: Following postoperative sagittal alignment correction, all patients could stand erect and look straight. Significant improvements were observed in the clinical and employment outcomes, as well as in patients' psychological status. The degree of sagittal vertical axis correction was significantly correlated with the HADS depression and the LEAPS total scores. The degree of correction of the chin-brow vertical angle was significantly correlated with the Short Form-36 mental health score, the HADS depression and anxiety scores, and the LEAPS total and productivity subscores. Notably, the improvement in the HADS depression score was significantly correlated with the LEAPS total score. CONCLUSION: This study demonstrated the psychological changes and subsequent improvement in employment outcomes after corrective osteotomy in patients with AS. The degree of sagittal alignment correction was correlated with improvements in psychological status and employment outcomes. LEVEL OF EVIDENCE: 4.

Evaluation of the Acromioclavicular Joint Morphology for Minimizing Subacromial Erosion after Surgical Fixation of the Joint Using a Clavicular Hook Plate.

BACKGROUND: Subacromial erosion remains a major concern after surgical fixation of acromioclavicular (AC) joint using a clavicular hook plate. To minimize postoperative subacromial erosion, we investigated the structural relationship between distal clavicle and acromion around the AC joint by considering the surgical fixation of the joint using the hook plate technique. METHODS: Computed tomography scans of 101 AC joints without any inherent pathology were analyzed. The angle between the distal clavicle and acromion around the AC joint (AC angle), depth of the acromion, differences in height between distal clavicle and acromion (AC height difference), and thickness of distal clavicle and acromion at the AC joint were measured. Descriptive statistics were calculated for each anatomical parameter, and all results were compared between gender groups. RESULTS: The mean AC angle was 17.1°(range, -8.0° to 39.0°), and the mean AC height difference was 3.5 mm (range, -0.7 to 8.7 mm). Both factors showed very high variability (coefficients of variation=62.6% and 46.6%, respectively). The mean AC angle was significantly higher in the female gender than in the male gender (19.8° vs. 13.8°, p=0.048). The mean acromion thickness and distal clavicular thickness were both significantly thinner in the female group than in the male group (p<0.001). CONCLUSIONS: Taken together, we believe our results might be helpful in minimizing postoperative subacromial erosion when performing surgical fixation of the AC joint using the hook plate, and be valuable in improving future design of the hook plate.

Percutaneous balloon kyphoplasty for the treatment of very severe osteoporotic vertebral compression fractures: a case-control study.

BACKGROUND CONTEXT: Controversy exists regarding percutaneous balloon kyphoplasty (PBK) in patients with a very severe osteoporotic vertebral compression fracture (vsOVCF). PURPOSE: The study was conducted to investigate the clinical and radiological outcomes of PBK for the treatment of vsOVCF compared with those of non-vsOVCF. STUDY DESIGN/SETTING: This is a retrospective, case-control study. PATIENT SAMPLE: A total of 167 consecutive patients (210 vertebral bodies) who underwent PBK for OVCF between March 2010 and January 2015 were assessed. OUTCOME MEASURES: Visual analog scale (VAS) scores for back pain, Korean Oswestry disability index (K-ODI) scores, vertebral body height variations, and kyphotic angles were evaluated preoperatively, postoperatively, and 1 year after treatment. MATERIALS AND METHODS: Patients in the non-vsOVCF group (anterior vertebral compression of more than two-thirds on plain radiograph) who had undergone PBK where compared with those in the non-vsOVCF group (compression between 30% and two-thirds). Clinical and radiological outcomes were compared. In addition, complications were evaluated. RESULTS: In total, 31 patients (33 vertebrae) in the vsOVCF group and 136 patients (177 vertebrae) in the non-vsOVCF group were treated with PBK. Both groups had significant postoperative improvements in the clinical and radiological outcomes (VAS score, K-ODI score, vertebral body height variation, and kyphotic angle). There was no difference regarding the VAS score and the K-ODI score between the two groups at the final follow-up (p>.05). The cement leakage occurred frequently in the vsOVCF group (26 vertebrae, 78.8%) than in the non-vsOVCF group (92 vertebrae, 52.0%), the difference was statistically significant (p<.05). But there was no case that showed neurologic complication or pulmonary embolism caused by cement leakage. The incidence of recollapse was significantly higher in the vsOVCF group (five vertebrae, 15.2%) than in the non-vsOVCF group (seven vertebrae, 4.0%) (p<.05). The incidence of an adjacent segment fracture (vsOVCF group, 6 vertebrae, 18.2%; non-vsOVCF group, 21 vertebrae, 11.9%) was not significantly different (p=.320). CONCLUSIONS: Percutaneous balloon kyphoplasty is a safe and effective procedure for the treatment of vsOVCF.

Aneurysmal bone cyst of the zygomatic bone.

Aneurysmal bone cyst is a rare, non-neoplastic lesion that mostly involves the long bone and the spine, and is characterized by its expansile, vascular, and multi-cystic features. Reports of facial bone lesions are rare, and when it occurs, is usually located in the mandible. Herein, this report is aimed to describe a very rare case of an aneurysmal bone cyst in the zygoma with a brief review of the literature.

Leiomyosarcoma of the Face.

Leiomyosarcoma is a rare form of soft tissue neoplasm, with only 1% to 5% occurring in the head and neck region. Current recommended treatment suggests surgical excision with a wide lateral margin, but no definite guidelines regarding excisional margin have been established yet. Recently, complete excision with a narrow surgical margin has been recommended, and the authors present a case of cutaneous leiomyosarcoma on the face that was successfully managed by complete removal with a narrow excisional margin. A 74-year-old woman presented with a 3 cm sized, rapidly growing cutaneous mass on her right preauricular area. Preoperative biopsy of the skin lesion suggested a cutaneous leiomyosarcoma. The authors performed complete surgical excision with a 1 cm lateral margin, and the resulting skin defect was repaired with bilateral V-Y advancement local flaps. Histopathology and immunohistochemistry evaluation confirmed a moderately differentiated cutaneous leiomyosarcoma, with negative margin involvement. The patient refused of any additional treatment, but showed no locoregional recurrence during the 1.5 years of postoperative follow-up period. With a regular postoperative follow-up, cutaneous leiomyosarcomas may be successfully treated with a narrow surgical margin.

A simple and reproducible surgical technique for the management of preauricular sinuses.

Preauricular sinus is a relatively common congenital anomaly that mainly exists on the anterior aspect of the anterior limb of the ascending helix. Although many surgical techniques have been developed, extirpation of the sinus is not easy because of the ramifications of the sinus, remnants of the sinus wall, and infection with or without formation of abscesses, which can all lead to disease recurrence. In our institution, we have surgically treated a total of 141 cases of congenital preauricular sinuses. Instead of using the conventional lacrimal probe and methylene blue method, we used a gentian violet-soaked Cottonoid, which has antibacterial effects against the main pathogen responsible for causing infection of the preauricular sinus. Results have been very favorable, with a zero recurrence rate. We present here a simple and reproducible surgical technique using a gentian violet-soaked Cottonoid that even beginning surgeons can easily follow.

Relationships of pulse waveform parameters to mood states and chronic fatigue.

PURPOSE: The present study examined if pulse waveform parameters (PWPs) are indicative of mood state and chronic fatigue associated with pathologic patterns in East Asian medicine and if cardiovascular autonomic function is associated with relationships among PWPs, mood, and fatigue. METHODS: A total of 43 healthy college students (men:women=31:12), ages 19-24, were enrolled in the study. Each subject completed the standard Profile of Mood States and the revised Chalder Fatigue Questionnaire. The current authors developed a MATLAB-based software program to calculate time- and amplitude-related photoplethysmography (PTG) and the parameters of the first and second derivatives of PTG (FDPTG and SDPTG, respectively). Based on peak-to-peak intervals detected using PTG, we also calculated pulse rate variability parameters, such as low frequency (LF), high frequency (HF), total power (TP), and the ratio of low frequency to high frequency power (LF/HF). RESULTS: In men and women, time-related dicrotic parameters of the FDPTG and SDPTG were indicative of depression and anger related to Liver Qi Stagnancy and Phlegm patterns. In men, time-related dicrotic wave parameters were indicative of mental fatigue associated with the Heart Deficiency pattern, whereas vascular augmentation-related parameters were indicative of physical fatigue associated with the Spleen Deficiency pattern in women. In women, sympathovagal balance-related LF/HF was associated with relationships among vascular augmentation-related parameters, fatigue mood, and chronic fatigue. CONCLUSIONS: These results suggest that PWPs are indicative of mood state and chronic fatigue associated with pathologic patterns in East Asian medicine. The results also showed significant gender differences.

En-masse retraction dependent on a temporary skeletal anchorage device without posterior bonding or banding in an adult with severe bidentoalveolar protrusion: seven years posttreatment.

This report describes a novel concept of en-masse retraction with temporary skeletal anchorage devices in place of posterior bonding or banding. The patient was a Korean woman, aged 24 years 4 months, with a Class II Division 1 malocclusion with severe mandibular anterior crowding. Both molars showed decalcification of the cervical areas. Partial osseointegration-based C-implants and C-tube plates were placed bilaterally between the maxillary second premolars and the first molars and in the posterior mandible. These temporary skeletal anchorage devices were used as independent appliances for full retraction of the maxillary and mandibular anterior teeth 3-dimensionally without the assistance of posterior bonded appliances. The posterior occlusion was not changed during treatment, and Class I occlusal relationships with optimal overjet and overbite were achieved. The 7-year posttreatment records showed a stable result.

Determinants of successful chincup therapy in skeletal class III malocclusion.

The purpose of this study was to investigate skeletal characteristics that determine successful chincup therapy in patients with skeletal Class III malocclusions by using longitudinal follow-up data of 40 patients (18 male, 22 female). Lateral cephalometric radiographs were taken before chincup therapy (T0), after chincup therapy (T1), and after fixed orthodontic treatment and retention (T2). From the measurements at T2, the patients were classified into group 1, showing good retention results (n = 21; 9 male, 12 female), or group 2, showing poor results (n = 19; 9 male, 10 female). The differences at each stage and during T0 to T1 and T1 to T2 between the 2 groups were compared by t tests. The major effect of chincup therapy was backward rotation of the mandible in both groups; however, the amount of rotation was greater in group 2. After retention, group 2 showed more forward rotation and forward growth of the mandible than group 1. Cephalometric measurements that showed significant differences in skeletal and dental morphology between the 2 groups at T0 were L1 to occlusal plane (P <.001), upper gonial angle, AB to occlusal plane angle, AB to mandibular plane angle, ANB, anteroposterior dysplasia indicator, Wits appraisal (P <.01), articular angle, gonial angle, facial convexity angle, AB to facial plane angle, and L1 to A-Pog (P <.05). These factors apparently contributed to the difference of long-term results in the 2 groups. It is necessary to evaluate these items in the diagnosis and treatment planning of skeletal Class III malocclusion in growing patients when chincup therapy is being considered.