First presentation of a Nora-lesion of the talus in a paraossal fasciitis.

Nora-Lesion is a proliferation that normally develops out of an intact corticalis. The entity of this fibroostotic pseudotumor, as discussed in literature, is triggered from repeating trauma or reactive periosteitis. In the literature, there are more than 200 cases defined as Nora lesion. In the daily routine of medical offices or ambulances, the Nora- Lesion should be established as a differential diagnosis for a swelling of the foot. Our case report of a 49-year-old patient is the worldwide first description of a Nora lesion of the talus, as well as secondary of the calcaneus. In the immense differential diagnosis discussion for bony pathologies of the hindfoot the Nora-lesion should be now added.

Primary leiomyosarcoma of the distal fibula: A case report and review of the literature.

We describe a primary leiomyosarcoma of bone located in the distal fibula in a 67- year-old man. Plain radiographs and computer tomography scan revealed a lytic destructive lesion in the distal metaepiphyseal region of the left fibula with little involvement of the surrounding soft tissues. The lesion was composed of proliferating spindle-shaped cells with very slim cytoplasm and narrow oval cigar shaped nuclei. Immunohistochemistry studies demonstrated a strong positivity for actin and desmin, and weak positivity for caldesmon.

Posterior interbody grafting and instrumentation for spondylodiscitis.

PURPOSE: To report outcomes of 7 patients with bacterial spondylodiscitis treated through a posterior approach. METHODS: Five men and 2 women aged 40 to 80 years underwent one-stage posterior interbody debridement and instrumentation for single-segment bacterial spondylodiscitis of lumbar (n=5) or thoracic (n=2) vertebrae. The Oswestry Disability Score, the Frankel classification, the Cobb angle, and the visual analogue scale (VAS) for pain as well as bone union on radiographs were assessed. RESULTS: Patients were followed up for 19 to 36 months. None had relapses or complications. Postoperatively, 5 patients had no pain or used analgesics only occasionally; their VAS scores varied from 0 to 20. The remaining 2 patients had residual symptoms and received regular peripheral pain medication and opiates; their VAS scores ranged from 30 to 50. The mean Oswestry Disability Score improved to 21 (range, 12-38). The mean Cobb angle improved from 13.1 to 11.1 degrees. The segments were probably fused in 5 patients and questionable in 2. CONCLUSION: Posterior debridement and instrumentation was adequate for single-segment spondylodiscitis and achieved good outcomes.

Efficacy of tranexamic acid in reducing blood loss in posterior lumbar spine surgery for degenerative spinal stenosis with instability: a retrospective case control study.

BACKGROUND: Degenerative spinal stenosis and instability requiring multilevel spine surgery has been associated with large blood losses. Factors that affect perioperative blood loss include time of surgery, surgical procedure, patient height, combined anterior/posterior approaches, number of levels fused, blood salvage techniques, and the use of anti-fibrinolytic medications. This study was done to evaluate the efficacy of tranexamic acid in reducing blood loss in spine surgery. METHODS: This retrospective case control study includes 97 patients who had to undergo surgery because of degenerative lumbar spinal stenosis and instability. All operations included spinal decompression, interbody fusion and posterior instrumentation (4-5 segments). Forty-six patients received 1 g tranexamic acid intravenous, preoperative and six hours and twelve hours postoperative; 51 patients without tranexamic acid administration were evaluated as a control group. Based on the records, the intra- and postoperative blood losses were measured by evaluating the drainage and cell saver systems 6, 12 and 24 hours post operation. Additionally, hemoglobin concentration and platelet concentration were reviewed. Furthermore, the number of red cell transfusions given and complications associated with tranexamic acid were assessed. RESULTS: The postoperative hemoglobin concentration demonstrated a statistically significant difference with a p value of 0.0130 showing superiority for tranexamic acid use (tranexamic acid group: 11.08 g/dl, SD: 1.68; control group: 10.29 g/dl, SD: 1.39). The intraoperative cell saver volume and drainage volume after 24 h demonstrated a significant difference as well, which indicates a less blood loss in the tranexamic acid group than the control group. The postoperative drainage volume at12 hours showed no significant differences; nor did the platelet concentration Allogenic blood transfusion (two red cell units) was needed for eight patients in the tranexamic acid group and nine in the control group because of postoperative anemia. Complications associated with the administration of tranexamic acid, e.g. renal failure, deep vein thrombosis or pulmonary embolism did not occur. CONCLUSIONS: This study suggests a less blood loss when administering tranexamic acid in posterior lumbar spine surgery as demonstrated by the higher postoperative hemoglobin concentration and the less blood loss. But given the relatively small volume of blood loss in the patients of this study it is underpowered to show a difference in transfusion rates.

Instrumented intervertebral or posterolateral fusion in elderly patients: clinical results of a single center.

BACKGROUND: Data on the clinical outcome after spinal fusion in the elderly patient are rare. To our knowledge there has been no clinical outcome assessment for instrumented spinal fusion in elderly patients comparing posterolateral fusion with intervertebral fusion. Aim of the current study was to evaluate the clinical outcome of elderly patients who underwent a spinal fusion procedure for degenerative spinal stenosis with instability. Main hypothesis was to test whether it is necessary to force an intervertebral fusion for a better clinical outcome in spinal fusion surgery of the elderly or not. METHODS: Two subgroups - posterolateral fusion versus intervertebral fusion (cage vs. non-cage) were compared with regard to functional outcome, fusion rates and complications after a mean follow up of 3.8 years. Questionnaires were completed by the patients before surgery and at final follow-up. Changes in mean VAS and ODI scores (decrease from the baseline VAS and ODI scores) were compared. RESULTS: The mean final follow up for all subjects was 3.8 years. Of the 114 patients, 2 patients were deceased at the time of the follow-up, 5 patients didn't want to participate and 107 patients completed the questionnaires. This resulted in an overall follow-up rate of 93%. At final follow-up, the patients demonstrated significant improvement in the VAS and ODI- compared with the preoperative scores in both groups. But overall there were no significant differences between both groups regarding the outcome assessment using the ODI and VAS. CONCLUSIONS: The results of this study shows that elderly patients aged over 75 benefit from instrumented lumbar fusion. The study suggests that there is no need to force an intervertebral fusion because elderly patients do not seem to benefit from this procedure.

A 10 year follow-up study after Roux-Elmslie-Trillat treatment for cases of patellar instability.

BACKGROUND: A retrospective study concerning patients presenting with patella instability, treated using a Roux-Elmslie-Trillat reconstruction operation and followed up for 10 years following surgery, is presented. METHODS: Pre-operative and follow-up radiographic evaluation included the weight-bearing anteroposterior and merchant views. Evaluation was carried out using the Insall-Salvati index, sulcus and congruence angle. The Roux-Elmslie-Trillat reconstruction operation was performed on 18 patients. The clinical evaluation at follow-up was performed using the Knee-Society-Score (KSS) and Tegner-Score. RESULTS: Subjective results of the operation were classed as excellent or good in 16 of the 18 patients ten years after surgery; persistent instability of the patella was recorded in only one of the 18 patients. The majority of patients returned to the same level of sporting activity after surgery as they had participated in before injury. CONCLUSIONS: The Roux-Elmslie-Trillat procedure could be recommended in cases presenting with an increased q-angle, trochlea dysplasia or failed soft tissue surgery. In the present study the majority of patients report a return to previous sporting activity ten years after surgery.

Early experience with the NexGen® CR-Flex Mobile knee arthroplasty system: results of 2-year follow-up.

We evaluated our initial results in 57 patients who received the NexGen® CR-Flex Mobile knee system using the standard anterior approach in a prospective study. The bicondylar surface implant was cemented in position (Palacos®) without posterior patellar resurfacing. The clinical outcome and perioperative and post-operative complications were documented over 24 months of its use. Overall, after two years, good results were obtained for the categories of pain and ROM (range of motion), and for the HSS (knee society score) (pre-operative: 42/57; post-operative: 87/80). No pathological radiological findings were made during this period. Two patients, however, felt that the primary operation had not been successful because of lateral patellar tilt. This was corrected with revision surgery. It was remarkable that our patients achieved greater than 100° flexion within the first 14 days of the immediate post-operative period. Evaluation and comparison of the scores with those of conventional bicondylar surface replacement systems showed no relevant differences.

Fibrous dysplasia - differential diagnosis of cystic lesions in the proximal femur:a case report.

BACKGROUND: We are reporting about the case of a 22-year old woman, who made a first visit as an outpatient with pain that arose in acute form in the area of the left groin. The patient history did not indicate a preceding trauma, or an inflammatory or malignant disease. CASE PRESENTATION: Conventional X-ray showed the image of a cystic lesion in the area of the neck of the thigh [collum femoris] with pathological fracture in the area of the calcar. The MRT produced the diagnosis of an aneurismal bone cyst, in which the presence of juvenile bone cyst or a giant cell tumor could be taken into consideration by differential diagnosis.Owing to the pathological fracture, repair by operation of the lesion was carried out by means of spongioplastic surgery and internal fixation (DHS). CONCLUSION: Histology produced characteristic findings fitting the condition of fibrous dysplasia, which was not included among the primary causes in the considerations offered by differential diagnosis.Therefore, this case is a good example of the fact that fibrous dysplasia must be taken into account when using differential diagnosis as one of the cystic lesions.

Extracorporeal shock-wave therapy in the treatment of pseudoarthrosis: a case report.

We describe the case of a of a 23 year old man (european) with a complicated fibular-tibial shaft fracture with subsequent pseudoarthrosis formation, which was unable to be corrected by surgery, but which we were finally able to heal using Extracorporeal shock-wave therapy.

Polyethylene and cobalt-chromium molybdenium particles elicit a different immune response in vitro.

Periprosthetic osteolysis is a major clinical problem that limits the long-term survival of total joint arthroplasties. Particles of prosthetic material stimulate immune competent cells to release cytokines, which may cause bone loss and loosening of the prosthesis. This study examined the following hypothesis. Polyethylene and titanium particles elicit a different immune response in vitro. To test these hypotheses, we used the human bone marrow cell culture model that we have established and previously used to examine particle associated cytokine release. Ultra high molecular weight polyethylene (UHMW-PE) induced a proliferation of CD14 positive cells (monocytes/macrophages) whereas cobalt chromium molybdenium (CoCrMb) particles demonstrated an increased proliferation of CD66b positive cells (granulocytes). Light and scanning microscopic evaluation revealed that the UHMW-PE particles, which have built large clusters of particles (Ø7, 5 microm), were mainly surrounded by the cells and less phagocytosed. On the other hand the smaller particles from CoCrMb have been phagocytosed by the cells. These results provide strong support for our hypothesis: that wear particles derived from prosthetic materials of different material can elicit significantly different biologic responses. In summary the results suggest that the "in vitro" response to wear particles of different biomaterials should be investigated by culture systems of various lineages of cells.

Correlation of in vitro and in vivo results of vacuum plasma sprayed titanium implants with different surface topography.

Research has proven that rough surfaces improve both biologic and biomechanical responses to titanium (Ti) implants. The purpose of this study was to evaluate the correlation between the expression of bone cell-associated proteins to Vacuum Plasma-Sprayed Titanium implants (VPS-Ti) with different surface textures in vitro and the bone integration in vivo. The biological performances of the surfaces were evaluated over a period of 8 weeks using human bone marrow cell cultures and Göttinger mini pigs. Cells were cultured on VPS-Ti with two respectively different surface-roughnesses (Ra). The level of Osteoprotegerin (OPG), Osteocalcin (OC) and alkaline phosphatase activity (ALP) were evaluated. The bone integration in vivo was evaluated by histomorphological analyses. A cancellous structured titanium (CS-Ti) construct was used as reference material in both study designs. Comparison of data was conducted using the Scheffé tests and the paired t-test with Bonferroni's correction. A comparative analysis was done to measure the degree of association between the in vitro and in vivo data. A total amount of OC was significantly increased for VPS-Ti for cells cultured on both VPS-Ti and CS-Ti, while OPG was only detectable after 8 weeks without any significant differences. The ALP activity on all surfaces was not statistically increased. For VPS-Ti with Ra ranging from 0.025 mm up to 0.059 mm, bone integration response was increased, but there was no statistical difference between the VPS-Ti. Expression of OPG, OC and ALP correlated with the histomorphological data over the 8-week period. The in vitro data suggest the superiority of VPS-Ti over CS-Ti, but more importantly, the biocompatibility of testing an in vitro model to predict the outcome and possible integration of implants in vivo.

TTM-based counselling in physiotherapy does not contribute to an increase of adherence to activity recommendations in older adults with chronic low back pain--a randomised controlled trial.

AIMS: The present study examines the outcome of counselling in physiotherapy based on the Transtheoretical Model (TTM) in a sample of elderly individuals with chronic low back pain. METHODS: In a prospective randomised trial with concealed assignment, elderly individuals with chronic low back pain were allocated to two treatment conditions. Both contained 10 sessions of physiotherapy, each of 20min duration. In addition, the experimental group (EG) received 10min counselling prior to every session based on the TTM, also provided by the physiotherapist, and the control group (CG) underwent a placebo ultrasound treatment with an inactivated device to control for the additional attention given to the EG. Assessments took place prior to the treatment (t1), immediately after termination of the treatment (t2), and at a 6-months follow-up. Outcome measures were physical activity calculated from one-week activity diaries, self-reported functional capacity, and range of motion measured by ultrasound topometry. RESULTS: A total of 170 individuals (64% female) with a mean age of 70.3 years (SD=4.4, range 65-84) participated in the study. The retention rate was 90%. At t3, both EG and CG showed increased physical activity and functional capacity, but no change in range of motion. Effect sizes were large. Contrary to our hypothesis, however, motivational training did not result in a better outcome compared with placebo treatment. CONCLUSION: The study does not provide evidence that a short TTM-based motivation programme is superior to placebo treatment regarding adherence to activity recommendations.

Intradiscal application of hyaluronic acid in the non-human primate lumbar spine: radiological results.

Prospectively, with randomized segment-treatment assignment, and with blinded evaluators, lumbar motion segments in Cercopithecus monkeys were analyzed for macroscopic and radiological changes 24 weeks after nucleotomy and nucleotomy with additional intradiscal application of different hyaluronic acid formulations versus untreated control segments. The objective was to find out whether hyaluronic acid is able to influence the degenerative cascade in nonhuman primates after nucleotomy. In a similar procedure, hyaluronic acid has proven to decrease degeneration after nucleotomy in a Minipig model. This is the first such study ever undertaken in primates, thus trying to overcome the known limitations of non-primate spine models. Twenty monkeys with four segments each obtained nucleotomy in three segments and solely exposure of another control segment. Nucleotomy was performed from a transpsoatic retroperitoneal approach. Preoperative radiographs and follow-up radiographs, magnetic resonance imaging (MRI), computed tomography (CT), Q-CT with bone mineral density measurements and three-dimensional reconstruction were obtained and analyzed qualitatively and quantitatively. Segments with high-molecular-weight hyaluronic acid (Hylan G-F 20) application proved to be significantly superior over those with a standard nucleotomy in radiographs, MR images, CT scans, and macroscopic appearance at follow-up. Control segments remained unaffected. Interdependence between the different methods validated the utilized methods of quantitative radiological assessment of degeneration. Hylan G-F 20 appears to be a possible adjunct in reducing postoperative degeneration in an animal nucleotomy model. It deserves further evaluation, despite the fact that the mechanisms of its effects are still speculative.