Full Femoral Osteomyelitis Caused by Fusobacterium nucleatum in an Immunocompetent Adult: A Case Report.

CASE: We present a 46-year-old man who developed a full femoral osteomyelitis caused by Fusobacterium nucleatum. The subtle presentation of the infection and the late onset of appropriate antibiotic treatment caused a devastating bone quality of the full femur. CONCLUSIONS: A successful outcome was obtained with surgical debridement, antibiotics, and return to weight bearing guided by a laboratory and radiographic scale specially designed to avoid pathologic fractures toward his full functional recovery.

Quiste neuroentérico intradural: Reporte de un caso / Intradural neurenteric cysts. Case report

El quiste neuroentérico espinal es una lesión de rara presentación, sólo existen reportes de casos aislados. Representa del 0,3% al 1,3% de los tumores espinales según las distintas citas bibliográficas. Suele afectar el canal espinal, especialmente a nivel cervical bajo y torácico superior. Aproximadamente el 90% de estos quistes se localiza en el espacio intradural/ extramedular, mientras que el 10% restante se divide entre la localización intradural/intramedular o extradural. El tratamiento de los quistes neuroentéricos intraespinales es quirúrgico, mediante la resección lo más radical posible. Los resultados son favorables y las tasas de recurrencia después de la resección parcial son bajas. Nivel de Evidencia: IV

Spinal neurenteric cyst is a rare lesion, only anecdotal case reports have been published. The neurenteric cyst accounts for 0.3 to 1.3% of spinal axis tumors. It affects the inferior cervical and superior thoracic spine level. Approximately 90% of neurenteric cysts are located in the intradural/extramedullary compartment while the remaining10% are divided between an intradural/intramedullary or extradural location. Surgical intervention with radical resection is the best treatment. The outcome is favorable and the recurrence rates after partial resection are low. Level of Evidence: IV

Progressive Gorham disease of the forearm.

Gorham's-Stout disease is a rare but potentially debilitating disease consisting of massive bone osteolysis and bone resorption associated with vascular proliferation and increased osteoclastic activity. Although it can present in a wide variety of forms, it typically involves bones formed by intramembranous ossification such as the skull, pelvis, and scapula. It can occur spontaneously or after trauma. Most cases are monofocal and resolved spontaneously, although there are reports of multifocal and rapidly progressing disease. It typically presents as disuse muscle atrophy or pathologic fracture during the second through fourth decades of life, yet it has also been reported in childhood and in the elderly. The etiology of Gorham's disease remains to be fully elucidated. Gorham attributed the origin of the disease to uncontrolled proliferation of small vessels eating away bone tissue. Other authors attribute the cause of the disease to increased osteoclastic activity mediated by elevated cytokine levels and increased osteoclastic differentiation. Treatment is not established and focuses at stopping osteoclastic activity and angiogenic proliferation. Radiation therapy, chemotherapy, bone grafting, and antiresorptives medications have all been used with different degrees of success. In an effort to further characterize this elusive disease, we report on an unusual presentation of a patient with Gorham's disease of the radius spreading to the ulna and then the proximal humerus with a 13-year follow-up. To our knowledge this is the first report in the literature of a saltatory type of Gorham's disease spreading from bone to bone across a joint.

Trans-iliac removal of bullet fragments from the sacroiliac joint.

The need for removal of intra-articular bullet fragments is well documented in the literature. Arthroscopy and arthrotomy are the preferred methods to access large superficial joints; however, these methods cannot be effectively used to access the sacroiliac joint. Its relationship to vital soft tissues and its convoluted joint anatomy make it almost impossible to explore even under open methods. We propose a new percutaneous technique for the removal of intra-articular bullet fragments from the sacroiliac joint. Our method meets two important goals: 1) percutaneous minimally invasive approach to the joint, and 2) removal of the bullet fragments while avoiding the potential morbidity of an open procedure.

An in vivo rabbit model for cartilage trauma: a preliminary study of the influence of impact stress magnitude on chondrocyte death and matrix damage.

OBJECTIVE: This study was designed to evaluate the postimpact response of the articular cartilage in the rabbit knee after a single traumatic episode. DESIGN: A novel servo-controlled Rabbit Impact Test System (RITS) was developed to apply a well-defined trauma to the femoral condyle in the rabbit knee. The RITS was first used in an in vitro study to determine an appropriate stress to cause cartilage damage without bone fracture. Viable rabbit knees (n = 18) were impacted with stresses of 15 to 50 MPa at a stress rate of 420 MPa/s, the latter corresponding to joint impact rates commonly seen in sports injuries and vehicular accidents. Based on the in vitro study, we performed an in vivo study by impacting the knees of rabbits (n = 9) with a 35 MPa peak stress at a stress rate of 420 MPa/s. The articular cartilage in these knees was analyzed at 0 and 3 weeks after impaction. SETTING: Center for Laboratory Animal Services, Hospital for Special Surgery. SUBJECTS: A total of 27 New Zealand White rabbits were used in this study. INTERVENTION: A rabbit's knee was rigidly immobilized in the adjustable frame of the RITS. A small incision on the knee exposed the lateral condyle and the impactor was positioned perpendicular to the surface of the condyle. The lateral femoral condyle of the left knee was impacted, whereas the right knee was sham operated and used as a control. MAIN OUTCOME MEASUREMENTS: Visual matrix damage, cell viability, and microscopic matrix damage was assessed. RESULTS: In the in vitro study, matrix damage was observed at stress magnitudes > or =30 MPa. However, cell death was initiated at approximately 20 MPa at the articular surface and increased in depth with increasing stress magnitude (2.8 +/- 2% thickness/MPa,). In the in vivo study, visible surface damage was observed immediately after impaction but not at 3 weeks after impaction. At 3 weeks, the articular cartilage showed significant arthritic changes (matrix damage, chondrocyte death, and proteoglycan loss) typical of late-stage osteoarthritis. CONCLUSIONS: Our novel impact test system was able to accurately apply a quantifiable stress magnitude at a constant stress rate to rabbit femoral condyles in the in vitro and in vivo settings. At the time of impaction, the extent of cell death depended with the intensity of trauma (stress magnitude) in which complete cell death was observed in the impacted site at >40 MPa. Under in vivo conditions, the test system was able to consistently produce superficial matrix damage and cell death at 35 MPa stress magnitude at the time of impaction. This resulted in cartilage "arthritic" changes by 3 weeks postinjury.

Anatomic location of the peroneal nerve at the level of the proximal aspect of the tibia: Gerdy's safe zone.

BACKGROUND: Injury to the peroneal nerve is one of the most serious complications in orthopaedic surgery. Because percutaneous procedures at the level of the proximal aspect of the tibia are becoming increasingly popular, it is critical to have a thorough knowledge of the trajectory of the peroneal nerve and its main branches at the level of the proximal aspect of the tibia. This anatomic study was conducted in an attempt to (1) define the anatomy of the common peroneal nerve and its branches in a three-dimensional fashion and (2) identify an anatomic landmark on the surface to help define a safe area that is void of the main nerve and its branches. METHODS: Thirty-one adult unembalmed cadaveric legs were dissected. The peroneal nerve was identified at the level of the posterior aspect of the lateral femoral condyle and was dissected distally to the level of its intramuscular branches. The relationship between the peroneal nerve and Gerdy's tubercle was explored, and the distances from the nerve and its branches to the tubercle were measured and recorded in millimeters. The average distances and standard deviations from Gerdy's tubercle to the neural structures were calculated. RESULTS: The course of the common peroneal nerve trunk and its anterior recurrent branch defined an arc with a circumference having an average radius of 45 mm. This circumferential trajectory was seen to be centered at the most prominent aspect of Gerdy's tubercle. CONCLUSIONS AND CLINICAL RELEVANCE: The path of the common peroneal nerve and its proximal branch were notable in two regards: their circular nature and their consistent relationship to the most prominent aspect of Gerdy's tubercle. With Gerdy's tubercle used as a landmark, the trajectory of the peroneal nerve can be easily defined at the level of the proximal aspect of the tibia and marked prior to the placement of devices and instrumentation, thereby avoiding damage to the peroneal nerve and its branches.

Subtrochanteric fracture after cannulated screw fixation of femoral neck fractures: a report of four cases.

Subtrochanteric fractures after screw or pin fixation of femoral neck fractures are a recognized complication. No literature is available on this complication after fixation using the recently popularized cannulated screws. We present our experience in treating four of these complications. The common denominator for all four patients seemed to be an entry point in the lateral cortex below the level of the most inferior edge of the lesser trochanter.

Bilateral Monteggia fractures.

The current concepts of anatomic and stable fixation followed by early mobilization in Monteggia fractures have clearly resulted in improvements in treatment and outcome. Bilateral Monteggia fractures are unusual and to the best of our knowledge have not been the subject of any reports in the literature. In this case report, we describe the operative technique for treating bilateral Monteggia fractures and the common pitfalls associated with this treatment. Despite the surgical and rehabilitative challenges posed by our patient's case, excellent results were obtained for both elbows.

Expression and activation of the BMP-signaling components in human fracture nonunions.

BACKGROUND: The potential use of bone morphogenetic proteins (BMPs) to promote bone-healing is of great interest to orthopaedic surgeons. Although the complex mechanism leading from the local presence of BMP (whether endogenous or exogenous) to bone formation is increasingly understood, limited information is available as to whether endogenous BMPs, their receptors, or other molecules involved in their signal transduction, such as Smad1, are present or disappear during the development of fracture nonunions. The purpose of the present study was to determine, by immunohistochemical analysis, whether BMPs, BMP receptors, or Smad1 disappear from tissues during the development of a fracture nonunion. METHODS: Twenty-one patients (average age, sixty-one years; range, thirty to eighty-five years) with a delayed union (four patients) or a nonunion (seventeen patients) were included. The average duration of the delayed union or nonunion was twenty-two months (range, 3.5 to 120 months). With use of immunohistochemical analysis, we studied the localization of BMP-2, BMP-4, and BMP-7 and their receptors BMPR-IA, BMPR-IB, and BMPR-II as well as pSmad1. With use of a pSmad1 antibody, we also studied whether the BMP receptors that were expressed were activated. RESULTS: The immunohistochemical localization of all seven BMP-signaling components was demonstrated in seventeen (81%) of the twenty-one patients. The remaining four patients lacked one or more of the components. Areas of newly formed bone had the highest percentage of positively staining cells, with the staining generally decreasing in areas remote from bone formation. However, even in areas of dense fibrous tissue and in specimens that lacked newly formed bone, immunostaining was still present. The staining patterns showed co-localization of the BMP-2, BMP-4, and BMP-7 proteins with the BMP receptors. The presence of pSmad1 signified the activated state of the BMP receptors, which implies that the BMP signal is transduced inside the cell.

Open reduction and internal fixation of humeral nonunions : a biomechanical and clinical study.

BACKGROUND: Several studies have compared different methods for fixation of the midpart of the humeral shaft, but there are only scattered data regarding which type of plate construct provides the best fixation for humeral nonunion. The objectives of this study were (1) to obtain objective data on the performance of four different plate constructs used for fixation of humeral nonunion, and (2) to report our clinical experience with plate fixation of thirty-seven nonunions of the midpart of the humeral shaft. METHODS: In the first part of the study, four plate constructs were compared in a Sawbones model. The groups consisted of (1) a posterior limited-contact dynamic compression plate alone; (2) a posterior limited-contact dynamic compression plate and an interfragmentary screw; (3) a posterior limited-contact dynamic compression plate, a lateral 3.5-mm reconstruction plate, and an interfragmentary screw; and (4) a posterior limited-contact dynamic compression plate and a lateral 3.5-mm reconstruction plate. Tests were performed with use of an MTS Bionix machine in anterior-posterior four-point bending, medial-lateral four-point bending, and external rotation torque. In the second part of the study, the charts of thirty-seven consecutive patients in whom a nonunion of the midpart of the humeral shaft had been treated with plate fixation were reviewed retrospectively. The average age of the patients was forty-eight years (range, thirteen to seventy-eight years). Nineteen patients were treated with a single posterior plate, and eighteen were treated with a two-plate construct with the plates parallel and lying at 90 degrees to each other. All of the nonunions were treated with bone-grafting, and an interfragmentary screw was used in thirty-six of the thirty-seven patients. Radiographs and the clinical status were evaluated at an average of thirteen months postoperatively. RESULTS: The biomechanical testing showed that the two-plate constructs were significantly stiffer than the single-plate constructs in all test modes (p < 0.05). In the clinical part of the study, thirty-four (92%) of the nonunions healed without complications at an average of 4.8 months. Two nonunions treated with the two-plate construct and one treated with one plate failed to heal. CONCLUSIONS: No significant difference in the healing rate was found between the two clinical groups (p = 0.4, beta = 0.9), and the overall healing rate was 92%. However, a two-plate construct with the plates at right angles is mechanically stiffer than a single-plate construct, which might be helpful if rigid stabilization of the humerus at the midshaft level is needed.

MRI assessment of the posterior acetabular wall fracture in traumatic dislocation of the hip in children.

Traumatic hip dislocations associated with posterior wall fractures of the acetabulum in the pediatric population are in general a consequence of high-energy trauma. After expeditious reduction, instability mandates for further diagnosis and intervention. Plain radiographs or computerized tomography (CT) scans can misjudge the involvement of the posterior wall of the acetabulum due to the partially calcified nature of the pediatric bone. We present two cases of pediatric traumatic hip dislocation associated with posterior wall fractures of the acetabulum. In both cases, obvious postreduction instability was noted without conclusive findings of etiology on plain X-rays or CT scans. Magnetic resonance imaging (MRI) disclosed an extensive posterior wall traumatic involvement in both cases and helped to decide in favor of open reduction of the hip and internal fixation of the posterior wall fragment.

Fracturas de la pelvis: su importancia y planificación terapéutica / Pelvis fractures: its importance and therapeutic planning

Durante muchos años y hasta la década del 80, las lesiones inestables del anillo pelviano se trataban de manera conservadora. La tasa de mortalidad en relación a estas lesiones se acercaba al 20 por ciento y las secuelas ortopédicas en los casos que sobrevivían a la lesión eran múltiples. Con el avance en los conocimientos anatómicos, biomecánicos y fisiopatológicos se revirtió esta tendencia. Actualmente su diagnóstico forma parte de la evaluación de todo paciente politraumatizado con el objeto de brindarle tratamiento quirúrgico precoz y así disminuir la tasa de mortalidad y las secuelas ortopédicas y devolver al paciente a una vida lo más digna posible. La disrupción del anillo pelviano provoca que el retroperitoneo deje de ser una cavidad virtual para convertirse en real y almacenar hasta 2 volemias en su interior provocando una inestabilidad hemodinámica que puede ser mortal. La intervención del traumatólogo es la de estabilizar la pelvis para contribuir, mediante el cierre del retroperitoneo, a la detención del sangrado. El adecuado conocimiento de la biomecánica pelviana permite orientar la planificación terapéutica hacia la meta de recomponer la anatomía para una función plena. Presentamos el análisis del tratamiento de 84 pacientes portadores de lesiones inestables del anillo pelviano con una edad promedio de 36 años, tratados entre 1991 y 1999, con un tiempo de seguimiento promedio de 46 meses. Para la evaluación de las lesiones se utilizaron la radiología convencional, la tomografía computada y la valoración dinámica de la estabilidad pelviana. La clasificación de Young y Burgess permite estadificar las fracturas e identificar lesiones asociadas a cada mecanismo de acción aportando no sólo al diagnóstico sino también a la programación terapéutica. Se distinguen los mecanismos de acción de compresión lateral, compresión anteroposterior, y cizallamiento vertical. Un cuarto mecanismo es la combinación de dos de los anteriores. Se utilizaron las técnicas de fijación externa, y fijación interna según el tipo de lesión. La tasa de complicaciones locales se mantuvo de acuerdo a los publicado en la literatura internacional especializada. La tasa de mortalidad de la serie fue del 4.7 por ciento. La totalidad de las lesiones cicatrizaron...(TRUNCADO)

Fracturas de la pelvis: su importancia y planificación terapéutica / Pelvis fractures: its importance and therapeutic planning

Durante muchos años y hasta la década del 80, las lesiones inestables del anillo pelviano se trataban de manera conservadora. La tasa de mortalidad en relación a estas lesiones se acercaba al 20 por ciento y las secuelas ortopédicas en los casos que sobrevivían a la lesión eran múltiples. Con el avance en los conocimientos anatómicos, biomecánicos y fisiopatológicos se revirtió esta tendencia. Actualmente su diagnóstico forma parte de la evaluación de todo paciente politraumatizado con el objeto de brindarle tratamiento quirúrgico precoz y así disminuir la tasa de mortalidad y las secuelas ortopédicas y devolver al paciente a una vida lo más digna posible. La disrupción del anillo pelviano provoca que el retroperitoneo deje de ser una cavidad virtual para convertirse en real y almacenar hasta 2 volemias en su interior provocando una inestabilidad hemodinámica que puede ser mortal. La intervención del traumatólogo es la de estabilizar la pelvis para contribuir, mediante el cierre del retroperitoneo, a la detención del sangrado. El adecuado conocimiento de la biomecánica pelviana permite orientar la planificación terapéutica hacia la meta de recomponer la anatomía para una función plena. Presentamos el análisis del tratamiento de 84 pacientes portadores de lesiones inestables del anillo pelviano con una edad promedio de 36 años, tratados entre 1991 y 1999, con un tiempo de seguimiento promedio de 46 meses. Para la evaluación de las lesiones se utilizaron la radiología convencional, la tomografía computada y la valoración dinámica de la estabilidad pelviana. La clasificación de Young y Burgess permite estadificar las fracturas e identificar lesiones asociadas a cada mecanismo de acción aportando no sólo al diagnóstico sino también a la programación terapéutica. Se distinguen los mecanismos de acción de compresión lateral, compresión anteroposterior, y cizallamiento vertical. Un cuarto mecanismo es la combinación de dos de los anteriores. Se utilizaron las técnicas de fijación externa, y fijación interna según el tipo de lesión. La tasa de complicaciones locales se mantuvo de acuerdo a los publicado en la literatura internacional especializada. La tasa de mortalidad de la serie fue del 4.7 por ciento. La totalidad de las lesiones cicatrizaron...(TRUNCADO)(AU)

Pseudoartrosis diafisaria del fémur: tratamiento con enclavado endomedular previo fresado / Diaphysial pseudoarthrosis of the femur: treatment of endomedular nailing previous milling

Se efectúan consideraciones acerca del enclavado intramedular como método de tratamiento de las fracturas de los huesos largos y la evolución de algunos conceptos relacionados con este procedimiento a partir de las ideas revolucionarias expuestas por Gherard Küntscher en la década del cuarenta. En aquella época una de las lesiones traumáticas más difíciles de tratar eran las fracturas de la diáfisis del fémur, debido a las importantes secuelas que dejaban, siendo una de ellas la no consolidación o pseudoartrosis. Este trabajo se basa en la experiencia recogida durante 27 años en el tratamiento de las pseudoartrosis diafisarias del fémur mediante el procedimiento de enclavado intramedular previo fresado. En dicho lapso se trataron 81 pacientes portadores de pseudoartrosis femorales, de las cuales 65 se encontraban en zona netamente diafisaria; 11 en zona subtrocantérica y 5 en zona diafisometafisaria distal. En todas se efectuó enclavado intramedular, previo fresado del canal y siempre que las circunstancias lo permitieron, se realizó a cielo cerrado. En 74 pacientes (91,4 por ciento, la pseudoartrosis consolidó en un promedio de 10 meses. En los 7 restantes (8,5 por ciento) hubo que repetir el procedimiento, retirar el clavo, volver a fresar el canal y colocar un clavo 2 o 3 mm mayor en diámetro... (TRUNCADO)

Pseudoartrosis diafisaria del fémur: tratamiento con enclavado endomedular previo fresado / Diaphysial pseudoarthrosis of the femur: treatment of endomedular nailing previous milling

Se efectúan consideraciones acerca del enclavado intramedular como método de tratamiento de las fracturas de los huesos largos y la evolución de algunos conceptos relacionados con este procedimiento a partir de las ideas revolucionarias expuestas por Gherard Küntscher en la década del cuarenta. En aquella época una de las lesiones traumáticas más difíciles de tratar eran las fracturas de la diáfisis del fémur, debido a las importantes secuelas que dejaban, siendo una de ellas la no consolidación o pseudoartrosis. Este trabajo se basa en la experiencia recogida durante 27 años en el tratamiento de las pseudoartrosis diafisarias del fémur mediante el procedimiento de enclavado intramedular previo fresado. En dicho lapso se trataron 81 pacientes portadores de pseudoartrosis femorales, de las cuales 65 se encontraban en zona netamente diafisaria; 11 en zona subtrocantérica y 5 en zona diafisometafisaria distal. En todas se efectuó enclavado intramedular, previo fresado del canal y siempre que las circunstancias lo permitieron, se realizó a cielo cerrado. En 74 pacientes (91,4 por ciento, la pseudoartrosis consolidó en un promedio de 10 meses. En los 7 restantes (8,5 por ciento) hubo que repetir el procedimiento, retirar el clavo, volver a fresar el canal y colocar un clavo 2 o 3 mm mayor en diámetro... (TRUNCADO)(AU)

Sección bilateral espontánea del tendón cuadricipital: comunicación de un caso y revisión bibliográfica

La sección bilateral espontánea del tendón del cuadriceps es una patología de rara incidencia. Se asociaa procesos traumáticos, degenerativos o metabólicos,pudiendo ser también de origen inespecífico. La clínica puede corroborarse mediante imágenes por resonancia magnética para una mayor precisión diagnóstica. La discontinuidad del aparato extensor debe restaurarse en forma quirúrgica. La rehabilitación muscular es un requisito indispensable para lograr un buen resultado. Se describe el caso de un paciente con ruptura bilateral espontánea del tendón cuadricipital, el diagnóstico, la reconstrucción quirúrgica y la rehabilitación muscular

Sección bilateral espontánea del tendón cuadricipital: comunicación de un caso y revisión bibliográfica

La sección bilateral espontánea del tendón del cuadriceps es una patología de rara incidencia. Se asociaa procesos traumáticos, degenerativos o metabólicos,pudiendo ser también de origen inespecífico. La clínica puede corroborarse mediante imágenes por resonancia magnética para una mayor precisión diagnóstica. La discontinuidad del aparato extensor debe restaurarse en forma quirúrgica. La rehabilitación muscular es un requisito indispensable para lograr un buen resultado. Se describe el caso de un paciente con ruptura bilateral espontánea del tendón cuadricipital, el diagnóstico, la reconstrucción quirúrgica y la rehabilitación muscular