Successful Conservative Management of a Patient With Symptomatic Cervical Perineural Cysts: A Case Report.

Perineural cysts, also known as Tarlov cysts, are rare benign cerebrospinal fluid-filled cysts usually located at the junction of the posterior nerve root and the dorsal root ganglion and are usually asymptomatic. They are most commonly found in the sacral region and are uncommon in the cervical spine. Despite their rarity, symptomatic cases may present with neurological symptoms due to the compression of adjacent neurological structures. Symptomatic cervical perineural cysts are extremely rare, and there is limited consensus on management strategies. We present the case of a 56-year-old woman who presented with a four-week history of radicular symptoms involving the right C7 and C8 nerve roots, including neck and arm pain, paresthesias, and mild triceps weakness. Magnetic resonance imaging revealed two perineural cysts at the C6-C7 and C7-T1 levels. A conservative approach was chosen with a 14-day course of oral corticosteroids, use of a soft collar, and activity restrictions. Following this conservative treatment, a significant reduction in symptoms and complete neurological recovery were achieved. This case highlights the efficacy of conservative approaches in selected cases of mildly symptomatic cervical perineural cysts and contributes to a better understanding of management strategies for this condition.

S1 Radiculopathy Initially Presenting With Sole Knee Flexion Weakness: A Case Report.

Lumbar disc herniation can lead to low back pain and/or sciatica, as well as manifest with neurological symptoms in specific dermatomal/myotomal patterns due to nerve root irritation. S1 radiculopathy is the result of L5-S1 disc herniation and is usually presented with foot plantar flexion/eversion weakness and hypoesthesia in the lateral aspect of the foot. We present a case of S1 radiculopathy that initially presented with hamstring weakness and posterior knee pain as the only manifestations, leading to a delay in the initial diagnosis and treatment. To the best of our knowledge, no previous studies have reported this atypical presentation that resulted from S1 radiculopathy. This case report is of great clinical value, as it will help diagnosticians broaden the diagnostic range in patients with similar symptomatology and avoid diagnostical pitfalls.

Interventions used to mitigate muscle fatty degeneration following the repair of massive rotator cuff tears. A systematic review of animal studies.

BACKGROUND: Muscle fatty degeneration following rotator cuff tears has been unequivocally associated with poorer functional outcomes and increased risk for retear following rotator cuff repair. Promising results have emerged from animal studies, with the implementation of various interventions for biologic inhibition of this fatty muscle degeneration. The lack of high quality randomized human evidence on this topic, increases the impact of pooled results from animal literature. The aim of the present study was to systematically review the available published literature for animal studies evaluating the ability of several interventions used to mitigate muscle fatty degeneration following the repair of massive rotator cuff tears. PATIENTS AND METHODS: A comprehensive search was conducted on Pubmed, Scopus and Google Scholar, covering the period from conception until 16th April 2022. Datasets were stratified based on the type of intervention performed. SYRCLE risk of bias instrument was implemented for quality assessment of the included studies. RESULTS: Rotator cuff repair augmentation with Adipose derived stem cells (ADSC's), Mesenchymal stem cells (MSC's) and Nandrolone was effective against fatty infiltration, but less effective against muscle atrophy. More beneficial effect was shown by the utilization of Beige adipose tissue - Fibroadipogenic progenitors (BAT-FAP) stimulation, using either Amibregon or BAT-FAPs transplantation. Both provided good results in mitigating muscle atrophy, fatty infiltration and fibrosis. DISCUSSION: ADSC's, MSC's, Nandrolone and BAT-FAP stimulation may have a role in mitigating muscle fatty degeneration following rotator cuff tears. Large scale human studies are required to further elucidate their role in the clinical setting. LEVEL OF EVIDENCE: V; systematic review of pre-clinical studies.

Molecular sequencing technologies in the diagnosis and management of prosthetic joint infections.

INTRODUCTION: Prosthetic joint infections (PJIs) can be challenging to eradicate and have high morbidity and mortality. Current microbiology culture methods can be associated with a high false-negative rate of up to 50%. Early and accurate diagnosis is crucial for effective treatment, and negative results have been linked to a greater rate of reoperation. AREAS COVERED: There has been increasing investigation of the use of next-generation sequencing (NGS) technology such as metagenomic shotgun sequencing to help identify causative organisms and decrease the uncertainty around culture-negative infections. The clinical importance of the organisms detected and their management, however, requires further study. The polymerase chain reaction (PCR) has shown promise, but in recent years multiple studies have reported similar or lower sensitivity for bacteria detection in PJIs when compared to traditional culture. Furthermore, issues such as high cost and complexity of sample preparation and data analysis are to be addressed before it can move further toward routine clinical practice. EXPERT OPINION: Metagenomic NGS has shown results that inspire cautious optimism - both in culture-positive and culture-negative cases of joint infection. Refinement of technique could revolutionize the way PJIs are diagnosed, managed, and drastically improve outcomes from this currently devastating complication.

Anterior femoral notching ≥ 3 mm is associated with increased risk for supracondylar periprosthetic femoral fracture after total knee arthroplasty: a systematic review and meta-analysis.

PURPOSE: Anterior femoral notching (AFN) may be associated with a higher risk for supracondylar periprosthetic fracture (sPPF) after total knee arthroplasty (TKA), although studies have yielded inconclusive results. We aimed to systematically investigate and meta-analyze the best available evidence regarding the association between AFN and the risk of sPPF after TKA. METHODS: A comprehensive search of PubMed, Scopus, Mendeley, Google Scholar and Cochrane databases was performed, from conception to February 29, 2020. Data were expressed as odds ratio (OR) with 95% confidence intervals (CI). I2-index was employed for heterogeneity. Newcastle-Ottawa scale was implemented for quality assessment of the included studies. RESULTS: Nine studies fulfilled the eligibility criteria, including a total of 3264 patients subjected to TKA. Among them, there were 150 patients who sustained a sPPF. Overall, patients exposed to AFN (AFN group) demonstrated an increased risk for sPPF compared to those not exposed (control group) (OR 3.91, 95% CI 1.22-12.58, p = 0.02; I2 68.52%). Subgroup analysis based on AFN depth with a cut-off value of 3 mm further clarified this association. Patients with AFN ≥ 3mm were at higher risk for sPPF compared to patients with AFN < 3 mm and control group (OR 4.85, 95% CI 2.08-11.33, p = 0.00; I2 0.0%). On the contrary, fracture risk was not significant for patients with AFN < 3 mm compared to the control group (OR 5.0, 95% CI 0.44-56.82, p = 0.19; I2 42.99%). CONCLUSION: Patients, exposed to AFN ≥ 3 mm in depth, are at higher risk for sustaining a sPPF.

Quadratus Femoris Partial Tear Secondary to Occult Ischiofemoral Impingement.

Introduction: Hip pain in children and adolescents may become a diagnostic challenge. A wide range of causes must be considered in the deferential diagnosis. Ischiofemoral impingement (IFI) is a pathological condition defined by hip pain associated with narrowing of the ischiofemoral (IF) space. We report the case of an adolescent patient with non-traumatic quadratus femoris (QF) tear secondary to an occult IFI syndrome. To the best of our knowledge, this is the first such case reported in the literature. Case Report: A 15-year-old girl reported persisting hip pain for a month following increased physical activity. The symptoms had started a couple of days following a weekend of increased activity due to her participating in a dancing contest. Physical examination and imaging studies (standard anterior pelvis radiograph and MRI-scan) failed to reveal any pathology apart from an area of diffused edema in the IF space. Standard hematology and biochemistry laboratory tests were all within normal range. Conservative treatment for 6 months with rest and modification of physical activities failed. A new MRI scan showed partial edema resolution and marked reduction in the IF and QF spaces (12 mm and 8 mm, respectively), thus suggesting IFI, which, in turn, led to a partial rupture of the QF. The patient underwent a local infiltration of the QF with betamethasone sodium phosphate and betamethasone acetate (6+6 mg/2 ml) under CT guidance, which led to the complete resolution of all her symptoms. She remains symptoms free for 24 months. Conclusion: IFI is a rather uncommon condition in the developing skeleton. As in adults, in adolescents as well, MRI is the study of choice in cases of IFI, since it shows QF pathology and allows measurement of the IF and QF spaces, assisting physicians in establishing the right diagnosis. However, the coexistence of a QF hematoma and/or edema, may temper with the initial MRI measurements and render the diagnosis of the primary condition rather difficult. Conservative treatment (with local infiltration of the QF) was proven to be successful in the hereby described case.

Critical shoulder angle is intrinsically associated with the development of degenerative shoulder diseases: A systematic review.

Aim of this study was to investigate the potential influence of Critical Shoulder Angle (CSA) as a predisposing factor for the development of degenerative full-thickness rotator cuff tears (DRCT) or primary glenohumeral osteoarthritis (PGOA). A systematic review of the Pubmed, Scopus, Mendeley, ScienceDirect and the Cochrane Central Register of Controlled Trials online databases was performed for literature regarding CSA and its association with DRCT and PGOA. In order to evaluate solely the relationship between CSA as a predisposing factor for the development of the aforementioned degenerative shoulder diseases (DSDs), we precluded any study in which traumatic cases were not clearly excluded. Our search strategy identified 289 studies in total, nine of which were eligible for inclusion based on our pre-established criteria. Quality assessment contacted using the Newcastle Ottawa Scale for case-control studies. There were a total of 998 patients with DRCT and 285 patients with PGOA. The control groups consisted of a total of 538 patients. The mean CSA ranged from 33.9° to 41.01° for the DRCT group, from 27.3° to 29.8° for the PGOA group and from 30.2° to 37.28° for the control group. All studies reported statistically significant differences between the DRCT and PGOA groups and the respective control groups. Our study results showed that there is moderate evidence in the literature supporting an intrinsic role of CSA in the development of DSDs. Level of evidence: IV. Systematic review of diagnostic studies, Level II-IV.

Acute Complete Foot Drop Caused by Intraneural Ganglion Cyst without a Prior Traumatic Event.

Intraneural ganglion cysts are benign soft-tissue masses located in the epineurium of peripheral nerves. They originate from nearby joint connections via articular branches. Traumatic events seem to play a role in their pathogenesis as well. Clinical manifestations include pain over the area of the cyst, palpable tender mass, hypoesthesia, and muscle weakness depending on the affected nerve. Our case highlights an uncommon clinical manifestation of this entity with acute foot drop, as the primary symptom, without any previous traumatic event, enriching by this way the current diagnostic thinking process of clinical physicians. We report a case of a 42-year-old military officer who presented to our emergency department with acute foot drop that appeared during a march. Initially, the common peroneal palsy was misdiagnosed as L5-S1 disc herniation, but investigation with lumbar MRI scan led to rejection of our primary diagnosis. After performing EMG of the lower extremity and knee MRI, an intraneural ganglion cyst of the common peroneal nerve was diagnosed. Patient was treated with surgical decompression of the cyst, followed by ligation and complete resection of the articular branch, as well as disarticulation of the superior tibiofibular joint. At a twelve-month follow-up, the patient showed significant functional recovery. This is, to the best of our knowledge, the first case of intraneural ganglion cyst manifested with an acute complete foot drop without a clear prior traumatic event. We underline the need for a high index of suspicion when dealing with cases of acute peroneal palsy without any accompanying symptoms.