Does ultrasound-guided popliteal-sciatic nerve block have superior pain control in pediatric foot and ankle surgery? A randomized control trial.

BACKGROUND: Tendon surgery in the pediatric foot and ankle could cause severe postoperative pain, which may lead to psychologic distress and chronic pain. This study was aimed to compare the efficacy of a peripheral nerve block (PNB) and local surgical site infiltration (LSI) in pediatric foot and ankle tendon surgery. METHODS: Forty pediatric patients, who underwent foot and ankle tendon surgery were enrolled. Patients age 1-6 years old were allocated to group 1 and 7-15 years old were group 2. The popliteal-sciatic nerve block with 0.5% Bupivacaine (0.25 ml/kg) for group 1A and 2A. Group 1B and 2B received 0.5% Bupivacaine (0.25 ml/kg) local injection before wound closure. Pain score was recorded using CHEOPS in 1-6 years (Group1A, 1B), NRS in age 7-15 years (Group 2A, 2B). The post-operative morphine consumption and complications were recorded. RESULTS: For 7-15 years, pain score in group 2B was more than group 2A at postoperative 2 and 6 h [Mean difference (95% CI); -3.4 (-6.4 to -0.3), and -2 (-4.4 to 0.5), respectively], and reached MCID of 2. The number of morphine consumption was significantly higher in group 2 B at 0-6 and 6-12 h post-operatively [Mean difference (95% CI); -0.8 (-1.4 to -0.2), and -0.6 (-1.1 to -0.1), respectively, with p-value < 0.05]. For 1-6 years, there was no significant difference in pain score and number of postoperative morphine consumption. CONCLUSIONS: PNB and LSI provided effective pain management in patients aged 1-6 years old with no statistically significant difference. PNB showed significant superior pain control in patients aged 7-15 years old.

Nonfusion Muscle-Sparing Technique to Treat Long-Segment Thoracolumbar Extradural Arachnoid Cyst in a Child: A Case Report and Review of the Literature.

BACKGROUND: Spinal extradural arachnoid cyst is an uncommon cause of spinal cord compression. It results from a small dural defect that leads to cerebrospinal fluid (CSF) accumulation in the cyst and subarachnoid space, and the cyst can compress the spinal cord and nerve roots. Surgery is the treatment of choice in symptomatic patients, and most cases have an immediately satisfying outcome after surgery. CASE DESCRIPTION: A 10-year-old Thai boy presented with progressive weakness in both legs. Magnetic resonance imaging (MRI) demonstrated a giant cystic lesion 23 cm in length from T1-L2 level. To our knowledge, this is the longest arachnoid cyst that has been reported in children. The operation included unilateral paraspinal muscle dissection with spinous process translation techniques, T1-L4 laminectomy, total cyst excision, and dural defect repair at the T4 level. The symptoms were fully resolved within 2 months after surgery. However, thoracic kyphosis was slightly increased, but the patient still has a normal sagittal profile. CONCLUSIONS: Spinal arachnoid cyst is rare, especially in children. Early diagnosis and treatment are essential for improving the chance of full recovery, and for avoiding complication and irreparable defect. Total cyst removal with dural repair remains the best treatment alternative; however, potential complications, especially spinal malalignment after extensive laminectomy, must be considered. Postoperative MRI showed normal CSF flow and no spinal cord compression. The muscle-sparing technique with multiple-level laminectomy without spinal fusion that we used in this case provided a satisfying outcome.

Erratum: Missing Sentence and Word.

[This corrects the article on p. 54 in vol. 7.].

Bilateral Femoral Neck Fractures in Cerebrotendinous Xanthomatosis Treated by Hip Arthroplasties: The First Case Report and Literature Review.

INTRODUCTION: Cerebrotendinous xanthomatosis (CTX) is a rare autosomal recessive lipid storage disease caused by mutations of the CYP27A1 gene and deficiency of the sterol-27-hydroxylase enzyme in bile acid biosynthesis. It is characterized by the accumulation of cholestanol and bile alcohols in plasma, the formation of xanthomatous lesions in various tissues, and organ degeneration. This disorder is also associated with osteoporosis and increased risk of fracture. To date, only two CTX patients with femoral neck fractures have been reported. Neither was treated by arthroplasties, and the operative outcomes are lacking. CASE REPORT: We report the case of a 46-year-old Thai female who presented with consecutive bilateral femoral neck fractures following minor trauma within a 3-year period and received cementless bipolar hemiarthroplasties. Her phenotypic expression included Achilles tendon masses, childhood-onset cataracts, intellectual disability, and cerebellar ataxia. A brain computed tomography showed non-enhancing hypodense lesions in the bilateral cerebellar hemispheres with mild brain atrophy. Histopathology from an Achilles tendon biopsy revealed tendinous xanthoma and molecular analysis confirmed a homozygous nonsense mutation, c.1072C>T (p.Gln358Ter), in exon 6 of the CYP27A1 gene. The intra-operative crack of a calcar femorale was a major complication during both prosthetic insertion surgeries and warranted cerclage wiring. At the 7-month follow-up of the right hip and the 41-month follow-up of the left hip, postoperative radiographs showed well-fixed and well-aligned prostheses. Independent household ambulation could be resumed with Harris hip scores of 81 points equally. CONCLUSION: CTX is associated with osteoporosis, and middle-aged patients could present with femoral neck fracture following minor trauma. Cementless bipolar hemiarthroplasty for a totally displaced fracture is justified for a patient who has cognitive impairment. Intra-operative fracture is a major complication during prosthetic insertion and warrants cerclage wiring to achieve predictable bone healing and a satisfactory result.