Post-traumatic Brodie's Abscess of the Tarsal Cuboid: A Case Report and Review of the Literature.

Brodie's abscess of the tarsal cuboid is a relatively rare presentation of this disease. In this study, we present the case of a 20-year-old male with post-traumatic Brodie's abscess of the tarsal cuboid that was left untreated for three years after the traumatic episode (penetrating injury with a sharp piece of wood). The patient presented pain over the injured area, limping, while plain foot radiographs showed a small lytic cavitary area in the cuboid. The magnetic resonance imaging revealed the presence of the abscess in a 2-cm diameter cavity in the cuboid bone and chronic inflammation of the surrounding plantar musculature. The treatment regime included curettage of the cavity, debridement of the inflammatory tissues, and administration of antibiotics, according to the cultures harvested intraoperatively, for six weeks. During this period, symptoms completely resolved.

Heterotopic Ossification around the Elbow Revisited.

Heterotopic ossification (HO) is the process of ectopic bone formation in the periarticular soft tissues and is usually formed in the elbow, hip and knee joint as a complication of trauma, burns, brain injury or surgical procedures. The development of HO around the elbow joint can cause a severe limitation of range of motion (ROM) and may affect daily activities of the patient. Treatment of ectopic bone formation around the elbow is a challenge for many surgeons. Non-operative treatment usually fails to restore the ROM of the elbow joint; thus, surgery is necessary to restore the function of the joint. In the past, many surgeons suggested that a delayed excision of HO, until maturation of the ectopic bone, is the best option in order to avoid any possible recurrence. However, many authors now suggest that this delay may lead to complications such as muscular atrophy and formation of soft tissue contractures that can cause a greater impairment of elbow function; thus, early excision is a better option and can better restore the elbow ROM. We performed a literature research of articles that investigated which is the best time of HO excision and we also evaluated if the tethering effect of HO can lead to a greater impairment of the elbow function. We found numerous studies suggesting that a limitation in ROM of the elbow can appear from the tethering of the ectopic bone formation and not only from primary HO. Concerning the HO excision, there were no significant differences between patients who underwent delayed and early excision, concerning the recurrence rate of HO around the elbow. Patients who underwent early excision had better restoration of elbow ROM; thus, early excision, combined with a rehabilitation program, is reported to be the best option for these patients.

Topical use of tranexamic acid: Are there concerns for cytotoxicity?

Tranexamic acid (TXA) has revolutionized modern blood management in orthopaedic surgery, especially in total joint arthroplasty, by significantly reducing blood loss and transfusion rates. It is an antifibrinolytic agent and a synthetic derivative of the amino acid lysine, which can inhibit the activation of plasminogen and the fibrin breakdown process. The administration of TXA can be intravenous (IV), topical, and oral. In patients where the IV administration is contraindicated, topical use is preferred. Topical administration of the drug theoretically increases concentration at the operative site with reduced systemic exposure, reduces cost, and gives the surgeon the control of the administration. According to recent studies, topical administration of TXA is not inferior compared to IV administration, in terms of safety and efficacy. However, there are concerns regarding the possible toxicity in the cartilage tissue with the topical use of TXA mainly in hemiarthroplasty operations of the hip, unilateral knee arthroplasties, total knee arthroplasties where the patella is not resurfaced, and other intraarticular procedures, like anterior cruciate ligament reconstruction. The purpose of the present review is to present all the recent updates on the use of TXA focusing on the toxicity on chondrocytes and the articular cartilage that may or may not be provoked by the topical use of TXA.

Lumbar Intervertebral Disc and Discovertebral Segment, Part 1: An Imaging Review of Normal Anatomy.

The intervertebral disc is designated the most important cartilaginous articulation of the vertebral column that functions to withstand compressive biomechanical forces and confer strength and flexibility to the spine. A thorough study of the complex fine structure and anatomic relationships of the intervertebral disc is essential for the characterization of the integrity of each individual structure in the discovertebral segment. This elaborate work in human cadavers explores the sophisticated internal structure of the normal intervertebral disc and the discovertebral segment, providing detailed data derived from the dissection of specimens through imaging and close anatomic-histologic correlation. Familiarity with the normal appearances and basic functional properties of the lumbar intervertebral disc and discovertebral segment is fundamental for the recognition of aberrations that may have important clinical implications in patients with low back pain. In Part I of this article, the anatomic structure and features of the discovertebral complex in adults will be described.

Lumbar Intervertebral Disc and Discovertebral Segment. Part 2: An Imaging Review of Pathologic Conditions With Anatomic Correlation.

The lumbar intervertebral disc is a complex anatomic structure that can be affected by a number of distinct pathologic processes. Categories of the disease include degenerative changes, subclinical or overt trauma, infectious lesions, inflammatory insults, metabolic disease, and tumors. Abnormalities affecting the intervertebral disc may assume atypical appearances or alterations may as well mimic pathologic processes related to degeneration that can be asymptomatic. Although the imaging findings of degenerative diseases of the vertebral column have been emphasized extensively, the assembly of pathologic conditions associated with the discovertebral segment has not received adequate attention. This manuscript reviews and illustrates a range of abnormalities affecting the discovertebral segment, providing a detailed analysis of postmortem material, in the realm of a close anatomic-imaging correlation. Knowledge of the characteristic morphology and patterns of abnormal conditions affecting the intervertebral disc and discovertebral segment can help radiologists narrow the differential diagnosis in a broad spectrum of disease processes.

Postoperative Delirium and Postoperative Cognitive Dysfunction in Patients with Elective Hip or Knee Arthroplasty: A Narrative Review of the Literature.

Postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) are common complications following total knee arthroplasty (TKA) and total hip arthroplasty (THA), affecting the length of hospital stay and increasing medical complications. Although many papers have been published on both conditions in this setting, no reviews have currently been written. Thus, the purpose of our study is to summarize the current literature and provide information about POD and POCD following elective THA or TKA. Our literature search was conducted in the electronic databases PubMed and the Cochrane library. We found that POD is a common complication following elective THA or TKA, with a median incidence of 14.8%. Major risk factors include older age, cognitive impairment, dementia, preoperative (pre-op) comorbidities, substance abuse, and surgery for fracture. Diagnosis can be achieved using tools such as the confusion assessment method (CAM), which is sensitive, specific, reliable, and easy to use, for the identification of POD. Treatment consists of risk stratification and the implementation of a multiple component prevention protocol. POCD has a median incidence of 19.3% at 1 week, and 10% at 3 months. Risk factors include older age, high BMI, and cognitive impairment. Treatment consists of reversing risk factors and implementing protocols in order to preserve physiological stability. POD and POCD are common and preventable complications following TKA and THA. Risk stratification and specific interventions can lower the incidence of both syndromes. Every physician involved in the care of such patients should be informed on every aspect of these conditions in order to provide the best care for their patients.

Posterior and anterior epidural and intradural migration of the sequestered intervertebral disc: Three cases and review of the literature.

Context: Dorsal migration of the sequestered lumbar intervertebral disc is an unusual and underrecognized pattern of lumbar disc herniation associated with pain and neurological deficit.Findings: Three patients presented with lower limb- and low back pain. MR imaging showed intracanalicular mass lesions with compression of the spinal cord and allowed precise localization of lesions in the extradural or intradural space. Diagnosis was straightforward for the patients with the posterior and anterior epidural disc fragments, whereas various differential diagnostic considerations were entertained for the patient with the intradural mass lesion. All patients underwent surgical removal of the sequestered disc fragments, and recovered full motosensory function. Surgical repair of the dura mater due to CSF leak was required for the patient with intradural disc herniation.Conclusion/clinical relevance: Posterior and anterior epidural, and intradural disc migration may manifest with clinical symptoms indistinguishable from those associated with non-sequestered lumbar disc hernias. Missed, migrated disc fragments can be implicated as a cause of low back pain, radiculopathy or cauda equina syndrome, especially in the absence of visible disc herniation. A high index of suspicion needs to be maintained in those cases with unexplained and persistent symptoms and/or no obvious disc herniation on MR images.

Advanced ankylosing spondylitis: a multisite, multimodality densitometric analysis for investigation of bone loss in the axial and appendicular skeleton.

OBJECTIVE: The aim of this study was to investigate if there is a bias in bone mineral density measurements among major densitometric techniques across multiple skeletal sites. METHODS: In 25 advanced ankylosing spondylitis patients, bone mineral density measurements were acquired in the lumbar spine, the hip, and the forearm. RESULTS: In total, 60% of patients had a bone mineral density Z-score of -2 or less at one or more skeletal sites. Dedicated loss of cortical bone was identified at the distal forearm (60% of patients). Differences in bone mineral density measurements across all densitometric techniques were highly significant (p≤0.001). Bone loss was more striking in spinal trabecular bone by three-dimensional quantitative computed tomography [Z-score -2.1] versus dual-energy X-ray absorptiometry [Z-score 0]. A trabecular bone loss quantified by quantitative computed tomography was about twice as much as a cortical bone loss by single-energy X-ray absorptiometry (p=0.001). CONCLUSIONS: Low bone mineral density is prevalent in advanced ankylosing spondylitis patients, predominating in the spine. Bone mineral density measurements have systematic differences when compared to each other. Knowledge of these offsets is useful for improved diagnosis of regional bone loss that allows for targeted treatment of osteoporosis. Three-dimensional quantitative computed tomography is more suitable for evaluating spinal osteoporosis in advanced ankylosing spondylitis than dual-energy X-ray absorptiometry, which rather underestimates bone loss.

Gait Kinetic and Kinematic Changes in Chronic Low Back Pain Patients and the Effect of Manual Therapy: A Randomized Controlled Trial.

Patients with chronic back pain as a result of degenerated disc disease, besides pain, also present with impaired gait. The purpose of the article was to evaluate kinetic and kinematic characteristics during gait analysis in patients with chronic low back pain as a result of degenerated disc disease, before and after the application of physiotherapy, including manual therapy techniques. Seventy-five patients suffering from chronic low back pain were randomly divided into 3 groups of 25 each. Each group received five sessions (one per week) of interventions with the first group receiving manual therapy treatment, the second a sham treatment and the third, classic physiotherapy (stretching exercises, TENS and massage). The effectiveness of each treatment was evaluated using an optoelectronic system for recording and analysis of gait (kinetic and kinematic data). Patients overall showed an impaired gait pattern with a difference in kinetic and kinematic data between the left and the right side. Following the application of the above-named interventions, only the group that received manual therapy showed a tendency towards symmetry between the right and left side. In patients suffering from chronic low back pain as a result of degenerated disc disease, the application of five manual therapy sessions seems to produce a tendency towards symmetry in gait.

Neonatal brachial plexus injuries and their impact on growing bone. An experimental study.

Neonatal brachial plexus palsy remains a problem, even in light of current advances in perinatal care. While many cases resolve spontaneously, the concern remains on the best means of surgical management for restoration of elbow flexion and shoulder reanimation. The present experimental study in an animal model examines the evidence that supports that neonatal brachial plexus injuries result in structural changes in the affected bone. The study suggests that if the microsurgical reinnervation takes place early enough, these changes may be diminished. On the other hand there is no way to identify at birth, which injuries will be permanent and will need surgical repair and which will spontaneously improve.

Is TKA with computer-assisted navigation associated with less blood loss? A comparative study between computer-navigated and conventional method.

The aim of this study is to evaluate whether computer-assisted navigated TKA reduces perioperative blood loss. Patients were randomly divided into 2 groups and underwent either a conventional TKA (n = 40) or a TKA with computer-assisted navigation (n = 40). Perioperative blood loss was evaluated by laboratory parameters, postoperative drain output and number of required transfusions. Change in hemoglobin concentration and in hematocrit levels was similar. Also, there was no statistically significant difference in drain output and in the number of transfused units. The results of this study showed that TKA with computer-assisted navigation is similar to the conventional TKA regarding perioperative hemorrhage.

Bilateral Total Knee Arthroplasty for Charcot Arthropathy After Cauda Equine Syndrome: A Case Report.

Charcot arthropathy of the knee is a relatively rare and poorly understood condition. Diagnosis requires detailed history of the patient, radiological investigation and exclusion of other causes of arthropathy. Conservative treatment is sufficient only in early stages. In late stages, either arthrodesis or total knee arthroplasty is the treatment of choice. We report a case of a 65-year-old woman who presented with Charcot arthropathy in both knees, after a spinal fracture 35 years ago, which caused cauda equine syndrome with diminished sensation of both legs. She underwent bilateral total knee arthroplasty using hinged knee prosthesis.

Is prophylaxis for heterotopic ossification with radiation therapy after THR associated with early loosening or carcinogenesis?

INTRODUCTION: Heterotopic ossification may develop after major hip surgeries, thus preventive strategies including radiation therapy and non steroid anti-inflammatory drugs are commonly employed. There are certain concerns regarding the effects of radiation therapy on implant loosening and carcinogenesis. Our study aims to evaluate whether radiation therapy results in implant loosening or radiation-induced tumours in the long term. PATIENTS AND METHODS: This was a prospective study including 97 high-risk patients for heterotopic ossification who underwent total hip arthroplasty. Patients were divided into 2 groups and received either a combination of radiation therapy and indomethacin (Group A), or indomethacin alone (Group B). Evaluated outcomes included implant loosening or development of radiation-induced tumours during the follow-up period. RESULTS: The follow-up period of the study was 10 years. Group A consisted of 50 patients, while Group B consisted of 47 patients. 3 patients died during the follow-up. There were 2 cases of implant loosening, 1 from each of the 2 groups at 9 and 10 years after surgery respectively; thus, no statistically significant difference regarding implant loosening was found (p < 0.05). During the follow-up period no cases of radiation-induced tumours were identified. CONCLUSION: Our results are consistent with those of other studies supporting the safety of radiation therapy as a preventive strategy for heterotopic ossification following major surgeries in high risk patients. Further studies with even longer follow-up may be required to definitely exclude the possibility of adverse outcomes linked with radiation therapy.

Association between MRI findings and clinical outcomes in a period of 5 years after lumbar spine microdiscectomy.

BACKGROUND: To evaluate the associations between magnetic resonance imaging (MRI) findings and pain, disability and quality of life before surgery and up to 5 years after lumbar microdiscectomy. MATERIALS AND METHODS: Sixty-one patients who underwent one-level lumbar microdiscectomy by the same surgeon participated in this analytic, observational, prospective study. Lumbar spine MRI was performed preoperatively and 5 years postoperatively. Pain, disability and quality of life were measured with VAS, ODI, Roland Morris and SF-36 pre- and up to 5 years postoperatively. Subsequently associations between radiological findings and clinical outcomes were recorded. RESULTS: Before surgery patients with disc extrusion or sequestration, with increased thecal sac compression (d > 2/3), with Modic changes (MC) 2 and 3 on the operated level and Pfirrmann grades IV and V on the operated and both adjacent discs presented the worst preoperative clinical outcomes. MC preoperatively were not related with postoperative results, in contrast with the type of disc herniation and thecal sac compression. Preoperative Pfirrmann grade IV and V on the operated and both adjacent discs and postoperative MC 2 and 3 on the operated level were related to poor clinical outcomes 36-60 months post-discectomy. CONCLUSIONS: Extrusion or sequestration of the operated disc, increased compression of thecal sac, MC 2 and 3 on the operated level and Pfirrmann grades IV and V on the operated and adjacent discs were associated with the worst clinical outcomes. Nerve root impingement, facet joint arthritis, perineural fibrosis and disc granulation tissue had no effect on clinical scores.