VERTEBROPLASTY IN THE TREATMENT OF VERTEBRAL FRACTURES CAUSED BY PLASMACYTOMA.

The aim of this study was to compare and evaluate clinical results before and after vertebroplasty in the treatment of myeloma-induced vertebral fractures. Success of the surgery was defined by increased or reduced pain intensity before and after the treatment, as assessed using the visual analog scale (VAS). The study was designed as a retrospective-prospective study. The study included 26 patients, 14 women and 12 men. Data on patients treated for myeloma-induced vertebral fractures were collected at the Department of Orthopedics, Osijek University Hospital Centre. The following data were analyzed: gender, duration of illness, intensity of pain before and after treatment (using VAS), radiological changes before and after treatment, grade of vertebral fracture, and extracorporeal cement leakage from the vertebral body to the surrounding tissue during the procedure. Difference in pain intensity before and after the surgery was statistically significant. All patients complained of pain before the surgery (pain intensity median 8), whereas after the surgery, pain intensity decreased in all patients (pain intensity median 2). In conclusion, improvement in clinical results of the treatment of myeloma-induced vertebral fractures with vertebroplasty proved to be significant.

Quality of Life in Patients Following Vertebroplasty.

AIM: To examine the quality of life in patients who underwent vertebroplasty treatment and compare it to the preoperative quality of life. STUDY DESIGN: The Cross-sectional study conducted at the Department of Orthopaedics, Clinical Hospital Centre Osijek. PATIENTS AND METHODS: The research included 50 patients under stationary treatment in hospital at the Department of Orthopaedics. The research instruments include a questionnaire containing demographic data and the standardised EuroQuol Research Foundation Questionnaire (EQ-5D-5L) consisting of five dimensions which include mobility, self-care, usual activities, pain level and anxiety. RESULTS: The average score of the current health status before surgery was 67.5 whereas post-operative health was rated 80 (p < 0.001). After the procedure, a significantly higher number of respondents reported greater mobility levels, and lower pain intensity; fewer respondents reported feeling anxious or depressed (p < 0.001), more respondents rated their self-care abilities higher (p = 0.003), and felt improvements when performing usual activities (p = 0.031). CONCLUSION: After the vertebroplasty, a significantly higher number of respondents reported higher levels of mobility, lower pain or discomfort levels, and a smaller number of respondents felt anxious or depressed, more respondents felt they can take better care of themselves, and are better at performing usual activities when compared to the preoperative status.

Application of high viscosity bone cement in vertebroplasty for treatment of painful vertebral body fracture.

Aim To evaluate the effectiveness and complication of vertebroplasty with high viscosity cement (HVC). Methods The patients with intensive pain caused by a fractured vertebrae were treated by application of HVC into the vertebral body, through unilateral transpedicular approach. The application was performed in 422 patients (221 were treated for osteoporosis and 201 for malignancy) on 846 vertebrae. Results Preoperative Visual Analogue Scale (VAS) score was 8.35 and 2.21 (p<0.00001) 24 hours after surgery and 3 months later, respectively. There was no serious intra- and post-surgery complication. By diascopy during the surgery in 121 (14.3%) vertebrae cement leakage from the fractured vertebral body was evidenced, which did not cause any aggravation of patients' clinical status. Conclusion Vertebroplasty with HVC is a method that successfully combines all advantages of this method but it also minimizes the risk of extra-ossal cement leakage which makes it significantly safer for the surgeon and for the patient as well.

Histological analysis of cross-sectional area of quadruple hamstring tendons and patellar ligament samples in relation to age and gender.

AIMS: The middle of the patellar ligament and the quadruple hamstring tendons (gracilis and semitendinosus) are two types of graft predominantly used in anterior cruciate ligament (ACL) reconstruction. The aim of this study was to determine the morphometric characteristics of patellar ligament grafts and hamstring tendon grafts and to compare the results according to subject age and gender. MATERIALS AND METHODS: The study was conducted on a total of 120 samples: 40 of gracilis tendon, 40 of semitendinosus tendon and 40 of patellar ligament, distributed equally according to gender, age (50-75 years) and the side of the body from which the sample was harvested. RESULTS: Morphometric and histological analyses showed that patellar ligament samples had less cross-sectional area than quadruple tendon samples (49.29 mm(2) compared with 51.46 mm(2), respectively). Sexual dimorphism was noticed in distal cross-sections of gracilis tendons (p=0.09), cross-sections of quadruple tendons (p=0.07) and patellar ligament samples (p=0.01) because of different muscular build. CONCLUSIONS: All samples obtained from male subjects had larger cross-sectional areas compared with the samples taken from females. Furthermore, samples obtained from subjects aged 60 years or under had larger cross-sectional areas than samples obtained from subjects aged at least 61 years for all types of graft.

Analysis of biomechanical properties of patellar ligament graft and quadruple hamstring tendon graft.

INTRODUCTION: Two types of transplant are commonly used in the surgical management of anterior cruciate ligament lesions: the central part of the patellar ligament and quadruple tendons of the gracilis muscle and semitendinosus muscle. AIMS: The aim of this study was to determine the biomechanical characteristics of patellar ligament transplants and transplants of the quadruple tendons of the hamstring muscles under tensile force in the laboratory, and to compare the results in each group of samples. MATERIALS AND METHODS: The study comprised 160 specimens: 40 specimens of gracilis muscle tendons, 40 of semitendinosus muscle tendons, 40 of quadruple tendons and 40 of the patellar ligament, approximately equally distributed according to sex, age (50-70 years) and the side of the body from which the specimen had been taken. RESULTS: The working curve analysis of the specimens under tensile load of a maximum force of 30N showed the least elongation (0.31%) in the quadruple tendon, followed by the gracilis muscle tendon (1.48%) and patellar ligament tendon (3.91%). CONCLUSIONS: The quadruple tendon specimen showed greater strength and higher elasticity compared with the patellar ligament specimen, which proved the starting hypothesis.

Cystic fibrosis: model of pathogenesis based on the apical membrane potential.

A simple model of cystic fibrosis (CF) is proposed, based on the apical membrane (ApM) potential. The ApM of epithelial cells is highly permeable to sodium and activation of CFTRs makes it permeable to chloride. Calculated ApM potentials of cells with activated cystic fibrosis transmembrane conductance regulators (CFTRs) are between the sodium and chloride Nernst values and thus allow rapid absorption of both ions in exocrine glands. In CF patients the potential is near the sodium Nernst value and thus more salt is left in the ducts. Simulation predicts that the sodium driving force increases more than 3.5 times if the ApM permeability for Cl- increases from 5-94% of the sodium permeability. In pancreatic ductal cells basolateral sodium bicarbonate cotransporters (pNBC1) allows influx of bicarbonates with sodium. Bicarbonates are exchanged for intraductal chloride by anion exchanger 1 (AE1) in the ApM. Activated CFTRs let some chloride to leak back to ducts, followed by water that dilutes ductal proteins. Replenished intraductal chloride allows more bicarbonate secretion. In CF patients, pancreatic water and bicarbonate secretion is limited by the intraductal chloride pool.

Detection of coxarthrosis in femoral head radiographic images seems limited mainly to vertically oriented pattern features.

Out of 120 conventional hip joint X-rays, two indepenendent examiners have chosen 27 healthy and 62 coxarthrotic joints. Central parts of femoral head images were digitalized (300 points/inch) and pixel density values analysed. Two methods were applied separately to horizontal rows and to vertical columns: variance coefficient calculation and power coefficients of Fourier harmonics. The arithmetic mean and median of variance coefficient for 256 pixel columns were both significantly higher in data of osteoarthrotic femurs (Mann-Whitney U-test, p = 0.0046 and p = 0.0011, respectively), while no difference was found for horizontal rows. The arithmetic mean and median of variance coefficient for 128 pixels long columns were significantly lower in data of osteoarthrotic femurs (p < 0.001) with wider standard deviation (p = 0.0274), while standard deviation was significantly lower in rows of coxarthrotic heads (p < 0.001). Fourier analysis of 128 pixel vertical columns showed significantly higher values in coxarthrotic femoral heads (from 1st harmonic, wave length of 10.8 mm to 33rd harmonic, wave length of 0.328 mm, p < 0.05). Fourier analysis of 128 pixel horizontal rows did not differ much between coxarthrotic and normal femoral heads. Only valuds for the 60th and 61st harmonic (wavelength near 0.2 mm) showed significantly lower power in coxarthrotic images than in controls (p < 0.01). Results suggest that in the analyzed set of digitalized x-ray femoral head images, information regarding osteoarthrotic changes in the central part of femoral head is detectable mainly through mathematic postprocessing of vertically oriented patterns.

Treatment of infected tibial nonunion with bone defect using central bone grafting technique.

Treatment of infected tibial nonunion with bone defect represents a challenge for every orthopaedic surgeon. Various methods of treatment have been described for nonunions with infection, bone loss or both. One of them is the central bone grafting technique, which is a safe and effective treatment for nonunions of the tibia. The technique involves placement of autogenous cancellous bone from the iliac crest on the anterior surface of the interosseous membrane with the aim of creating a tibiofibular synostosis. We present the results of uncontrolled, retrospective and continuous series of ten patients treated by a central bone grafting technique for infected tibial nonunion with bone loss. Mean follow-up period was 12 (10-15) years. Most injuries were a result of war injuries. Clinically and radiologically confirmed bony healing with total consolidation of the graft was achieved in all patients within a period of 10-12 months without further bone grafting. The newly-formed bone mass was able to fulfil the mechanical and functional demands of everyday life activities. Once again, the central bone grafting technique has shown to be a safe, reliable and effective method of treatment for infected tibial nonunion with bone defect.

Hemiarthroplasty is an effective surgical method to manage unstable trochanteric fractures in elderly people.

Trochanteric femoral fractures are a major problem in the elderly because of higher bone fragility due to osteoporosis. Numerous chronic illnesses, which usually affect the elderly, aggravate and complicate their surgical treatment. Trochanteric femoral fractures results in high morbidity and mortality in elderly patients. The aim of our study is to evaluate the effectiveness of hemiarthroplasty in the treatment of unstable trochanteric femoral fractures in elderly patients. Between 2000 and 2005, 50 patients with unstable trochanteric femoral fractures (41 women) aged 75 to 92 years (mean 86 years) underwent cemented hemiarthroplasty. The surgical procedure was performed within first 48 hours after the fracture (out of which 14 in the first 12 hours, 27 in the first 24 hours and 9 in the first 48 hours), with minimal blood loss. Hemiarthroplasty was indicated in patients where stability was important to allow early mobilization. In forty patients (80%) early ambulation with full weight bearing was achieved during the short period of hospitalization (9-14 days). Given that the affected population is predominantly the elderly, who are less mobile and demanding and thus put less strain on the endoprosthesis, we believe that this kind of treatment is the treatment of choice for unstable trochanteric femoral fractures in these patients. This assumption is corroborated by the fact that we did not have any endoprosthesis luxation, apparent acetabular protrusion or instability during the mean follow up period of 15 months (range 12-18 months).

Spontaneous regression of intervertebral disc herniation--case reports.

Lumbar disc hernia (LDH) is a common cause of low back pain and radicular leg pain. It is well known that the majority of LDH patients recover spontaneously. Since the advent of MRI, a spontaneous regression of fragment size of disc hernia occurs, as well as mitigation of subjective difficulties and neurological disorders. Therefore, surgical treatment is not always method of choice in this disease. Two cases of conservatively treated large disc extrusion which result in significant reduction of difficulties, with simultaneous reduction in fragment size of hernia which is documented by MR.

Transforaminal lumbar interbody fusion (TLIF) and unilateral transpedicular fixation.

TLIF (transforaminal lumbar interbody fusion) is a method of interbody fusion, which is alternative to other vertebral fusion wherein, with an approach through intervertebral foramen, through lateral segment of intervertebral space, complications occurring with other methods are reduced. Today, there are numerous versions of this method in terms of implants and transplants. At our Department patients with axial pain resistant to conservative treatment of minimum six months underwent TLIF method with unilateral transpendicular fixation with polyaxial screws, CAGE filled with autologous transplant obtained by lamina resection, and posteromedial contralateral fusion. 22 procedures were performed at 22 levels, 10 for relapsing hernia, and 12 for disc herniation combined with degenerative changes on the same level. Pain reduction was significant; according to VAS score, lumbar pain was reduced from preoperative 8.5 +/- 0.8 to 2.4 +/- 0.85 (-72.63%) a year after, and leg pain was reduced significantly from preoperative 8.45 +/- 0.91 to 2.072 +/- 0.81 (71%) 12 months after surgery. The Wilcoxon paired test demonstrated a significant difference between preoperative VAS score and the value measured 12 months after surgery (n = 22, Z = 4.1, p < 0.001) leg and back, respectively. In 15 (68.2%) patients fusion was evidenced on standard X-ray of lumbar spine, and in 4 patients, with aggravated clinical presentation, fusion in 2 patients and pseudoarthrosis in 2 patients were evidenced by CT. Total 17 patients (77.3%) showed signs of fusion. In our study we demonstrated that unilateral ipsilateral transpedicular fixation, with positioning of one CAGE filled with local autologous transplant represents a reliable and successful method of treatment of axial lumbar pain.

Arthroscopic removal of metal foreign bodies from the knee joint after explosive war injuries.

The results of arthroscopic removal of metallic fragments from knee joint due to explosive war injuries are presented. In period from 1991-1995 during war in Croatia we have operated 25 knee joints. Indications for arthroscopy were based on radiographic and clinical findings. The foreign bodies in the joint were found in 19 patients while additional 6 had foreign bodies in the periarticular soft tissues. Arthroscopies were performed on average one month after wounding. The foreign bodies were placed in different parts of the joint with no prediction sites. In 8 knees foreign bodies were freely mobile, and in 11 were anchored to different intraarticular structures. There were no complications during early postoperative period as well as in follow up period.

Vertebroplasty for vertebral compression fracture.

The patients with intensive pain caused by the vertebra body fracture were treated by application of bone cement under local or general anesthesia, by means of diascopy through unilateral transpedicular approach. The intensity of pain was followed-up on the VAS scale before surgery, 24 hours after surgery and three months after surgery. The cement was applied in 55 patients (43 women, 12 men). The average age of the tests was 68.43 years (38 to 82 years). Fifty five procedures were implemented on 85 vertebrae, i.e. 32 metastatic fractures and 23 osteoporotic fractures. The procedures were applied on 28 thoracal and 57 lumbar vertebrae. The average VAS before surgery was 8.36 and 2.23 (p < 0.005) 24 hours after surgery, and it remained almost unchanged three months later. There were 1 serious complication, a paraparesis caused by the leakage of cement into the spinal canal, which was partially recovered after decompression and rehabilitation treatment, and 2 superficial infections with S. epidermidis which were cured by means of antibiotics. By means of Wilcoxon paired test a significant difference was found between the preoperative VAS and the value 24 hours after surgery (n = 55, Z = 6.451, p < 0.00001) and 3 months after surgery (Z = 6.45, p < = 0.00001), while there was a compliance between two VAS measurements after surgery (Z = 1.308, p = 0.191) which indicates that the fast pain reduction remained stable during the 3 month follow-up. The vertebroplasty is a safe and efficient surgical method in treatment of compressive vertebrae fractures which do not react to the conventional method of treatment. The achieved analgesic effect 24 hours after surgery is a good predictor of pain intensity 3 months after surgery.

Open total talar dislocation with extrusion (missing talus).

Open total dislocation of a talus with extrusion (missing talus) is an extremely rare injury. We present a case of a 63-year-old male who sustained an open total lateral dislocation of the right talus with extrusion and without a concomitant fracture after a fall from a small height. Tibiocalcaneonavicular arthrodesis was performed. Arthrodesis failed, and due to painful and unstable ankle, rearthrodesis was performed two years later, successefully. Because of rarity of this kind of injury, hers importance for foot function, previously described various treatment options and absence of guidelines, herewith we propose, according to our experience and review of literature, the algorithm for the treatment of this rare injury.

The analysis of the unstable tibia fracture treatment applying internal stabilization method.

The study included 51 patients with tibia fractures, who underwent percutaneous bone reposition and stabilization with unrimed tibial locking nail. The results obtained using this method were compared with those obtained by standard fracture treatment where flat and anatomic plates were applied (n = 64). In patients who had osteosynthetic material implanted percutaneously (using unrimed tibial locking nail) there was no incidence of post surgical osteitis or any pseudarthrosis. The healing callus of the fracture was of lesser quality and spindle shaped, suggesting that fracture stabilization using this method was less efficient. In patients with fractures stabilized by the open method using flat and anatomic plates (n = 64), we noticed 3.1% (n = 2) cases of osteitis and 4.7% (n = 3) cases of pseudarthrosis. Due to lesser incidence of postoperative osteitis, our method of choice in tibia fractures would be percutaneous stabilization with unrimed tibial locking nail. However, this treatment method has its disadvantages, too. Fracture callus is of lesser quality and it is spindle shaped. Furthermore, there are problems with adequate percutaneous reposition in some cases, as well as necessity for radiological checking.