Objectives: Skeletal muscle relaxants are frequently used to treat low back pain with spasm of paravertebral muscles. However, there is little comparative efficacy and safety data of different muscle relaxants. A randomized, doubleblind study was conducted to evaluate and compare the efficacy and safety of mephenoxalone and tizanidine in the 7-day treatment of adult patients suffering from acutely painful and moderately severe spasm of paravertebral muscles. Methods: A total of 41 Taiwanese patients were randomly allocated into mephenoxalone and tizanidine groups. Primary (muscle spasm severity, treatment responses) and secondary efficacy variables were obtained before and after treatments. Adverse events and several safety assessments were also recorded. Results: In a three item scale, muscle spasm severity was reduced by 0.90±0.55 and 0.95±0.67 points in the mephenoxalone and tizanidine groups, respectively. There was no significant difference between the two treatment groups in all variables for primary and secondary efficacy assessments. Nine mild to moderate adverse events were reported and one tizanidine-treated patient stopped the medication due to drug-induced urticaria. Transient slight drowsiness experienced in four mephenoxalone-treated patients did not hinder the treatment effect. Conclusion: This randomized, double-blind study demonstrates equivalent treatment efficacies of mephenoxalone and tizanidine in alleviating symptoms of acute painful paravertebral muscle spasms in Taiwanese patients. Both drugs with generally well tolerated.
Patella fractures are rare in children and the sleeve fractures are most common. Diagnosis may be difficult if there is no bony fragment on the X-ray. In this report, we present a case of 12-years-old boy who had sleeve fracture of the right patella. Diagnosis and treatment were discussed.
Purpose: Percutaneous kyphoplasty is widely used in treating Vertebral Compression Fracture (VCF), as a minimally invasive surgery, which provides effective and safer treatment for patients who are suffering painful osteoporotic VCF s. Although pain-relief is usually effective after the treatment, there are still a few patients who respond to the initial percutaneous kyphoplasty only for a very short period of time. Several pathologies might be responsible for the pain. One of them proposed here are due to cement block loosening in the vertebral body, resulting in intolerable back pain again. There are several discussions in repeat vertebroplasty but rarely in repeat kyphoplasty.5 Material and methods: Here we conducted an alternative treatment to solve the problem instead of operating a Corpectomy procedure, which brought patients to experience a shorter recovery time. Result: In this report, three patients with vertebral compression fractures, with the average age of 80 years, were treated with repeat kyphoplasty at the focal vertebrae and had their VAS scores evaluated. Conclusions: The outcome of this study suggested this alternative approach could effective solve the pain from second vertebral instability by stabilizing the original cement block in the vertebral body which previously underwent percutaneous kyphoplasty. The VAS scores dropped from 9 to 3 on average. The technique of the procedure was described and clearly illustrated.
Purpose: Pullout of the coracoclavicular screw sometimes develops after surgical treatment of acromioclavicular dislocation with only one coracoclavicular screw. This fixation method may not tolerate postoperative physiotherapy. The augmented technique was therefore developed to provide an alternative surgical method in treating Rockwood type Ⅲ acromioclavicular dislocation. Materials and Me thods: There were seven patients with seven acromioclavicular dislocation treated with open reduction and internal fixation with a coracoclavicular screw and tension band wires from July 2000 to June 2005. The surgical indications were active, heavy manual workers with Rockwood type Ⅲ acromioclavicular dislocation. Arm sling protection of the involved shoulder was immediately applied postoperatively and lasted for 6 weeks. Both of the passive and active range of motion exercise of the injured shoulder were initiated 6 weeks after the surgery. The implants were removed about 3 months after the surgery. Results: All seven patients with complete follow-up achieved painless full motion of the involved shoulder. No pullout of the coracoclavicular screw was noted postoperatively. No redislocation of acromioclavicular joint developed after removal of the implant. All patients returned to their pre-injury status of work, and all returned to their previous sporting activities, including overhead sports. Conclusions: This modified surgical method for treatment of Type Ⅲ AC dislocation may be a safe alternative procedure, especially in the young, active, and heavy manual workers.
Surgical treatment of a giant-cell tumor (GCT) locating the proximal fibula is a formidable challenge to an orthopedic surgeon because its proximity to the peroneal nerve. If the tumor volume is larger than 250 ml with cortical breakthrough, complete resection of the tumor is detrimental to the peroneal nerve. We report on a case of 27-year-old man who had a large GCT of the proximal fibula with tumor volume of 282 ml. The tumor was removed by excision and curettage with meticulous preservation of the peroneal nerve. At 47-month follow-up, he was free of tumor recurrence and had a normal knee function and no limitation of activities.
Purpose: Bone grafting is widely used in clinical orthopedic surgery. In order to avoid the complications associated with autogenous bone grafting, many kinds of bone substitutes have been developed. We developed an MSC carrier comprising a hot compression-molded polylactide/polyglycolide (PLGA), a porous calcium phosphate product that is used clinically and commercially (Interpore; Pro-Osteon 500R, Irvine, California) and a type I collagen composite for use in bone grafting. The purpose of this study was to evaluate the osteoblastic differentiation ability of rabbit MSC s loaded on this PLGA /Interpore/type I collagen carrier system in vitro. Materials & Methods: MSC s aspirated from rabbit bone marrow were cultured in induction medium and loaded onto the PLGA /Interpore/type I collagen carrier system. After culture for 7 and 14 days, the osteoblastic differentiation ability was tested using histological analysis and reverse transcription polymerase chain reaction (RT-PCR ) and by measuring the calcium and alkaline phosphatase levels. Results: After culture in the induction medium for 7 and 14 days, both the calcium and alkaline phosphatase levels were significantly higher than those in the control group. RT -PCR revealed mRNA expression of osteopontin, core binding factor alpha 1 (Cbfa1), and type I collagen. Optical micrographs of the MSC-loaded PLGA /Interpore/type I collagen carrier surface were obtained. After culture in osteogenic medium for 14 days, the carrier surface was almost entirely covered by cells and a dense collagenous extracellular matrix. Conclusions: The results of the study suggest that the biodegradable PLGA / Interpore/type I collagen MSC carrier system possesses potential osteoblastic differentiation ability.
Purpose: Because of the concern of donor site-related complications of autografts and the fusion rate of allografts, the substitute of the titanium mesh cages (TMC) in spinal surgery has been reported. Here we present our preliminary results of anterior interbody fusion using TM Cs for patients with multilevel cervical spondylotic myelopathy. Materials and Methods: Fifteen patients (6 females, 9 males) with multilevel cervical spondylotic myelopathy were enrolled. Patients underwent anterior reconstruction using TM Cs and local autologous bone grafts for corpectomy decompression and associated cervical plate fixation. Radiography, magnetic resonance imaging (MRI), and computed tomography (CT) scanning were used for imaging studies. The Nurick Function Disability (Nurick) score was used to assess myelopathy severity, while the Japanese Orthopedic Association (JOA) score was adopted to compare clinical outcomes before and after surgery. Results: The mean postoperative follow-up was 35.1 months (range, 18-55). No major surgery-related complications were observed. The implant-related complication rate was 13.3%. All patients experienced functional improvement of at least 2 in Nurick score after surgery. The mean JOA score increased significantly from a mean of 9 (range, 7-13) before surgery to 14 (range, 11-16) at the final follow-up. The bony continuum between the vertebral body and TM C was verified by cervical CT in all patients 12 months postoperatively. Conclusion: TM C with concomitant use of an anterior cervical plate has value in the treatment of patients with multilevel cervical spondylotic myelopathy. It provides immediate strong anterior column support, correct kyphotic deformity, and avoids donor site morbidity. Purpose: Because of the concern of donor site-related complications of autografts and the fusion rate of allografts, the substitute of the titanium mesh cages (TMC) in spinal surgery has been reported. Here we present our preliminary results of anterior interbody fusion using TM Cs for patients with multilevel cervical spondylotic myelopathy. Materials and Methods: Fifteen patients (6 females, 9 males) with multilevel cervical spondylotic myelopathy were enrolled. Patients underwent anterior reconstruction using TM Cs and local autologous bone grafts for corpectomy decompression and associated cervical plate fixation. Radiography, magnetic resonance imaging (MRI), and computed tomography (CT) scanning were used for imaging studies. The Nurick Function Disability (Nurick) score was used to assess myelopathy severity, while the Japanese Orthopedic Association (JOA) score was adopted to compare clinical outcomes before and after surgery. Results: The mean postoperative follow-up was 35.1 months (range, 18-55). No major surgery-related complications were observed. The implant-related complication rate was 13.3%. All patients experienced functional improvement of at least 2 in Nurick score after surgery. The mean JOA score increased significantly from a mean of 9 (range, 7-13) before surgery to 14 (range, 11-16) at the final follow-up. The bony continuum between the vertebral body and TM C was verified by cervical CT in all patients 12 months postoperatively. Conclusion: TM C with concomitant use of an anterior cervical plate has value in the treatment of patients with multilevel cervical spondylotic myelopathy. It provides immediate strong anterior column support, correct kyphotic deformity, and avoids donor site morbidity.
Metallic tibial baseplate fracture is an infrequent complication after total knee arthroplasty (TKA). From our clinical experience and literature review, baseplate fractures were occasionally found in fixed bearing knees, but no case was found in mobile bearing knees so far. We present a case of baseplate fracture in Low-Contact-Stress Meniscal-Bearing total knee prosthesis after twelve-years of implantation. Clinical examination, retrieval analysis, scanning electron microscopy (SEM) and Energy Dispersive Spectrometer (EDS) were comprehensively applied to speculate the possible factors resulting in metallic fracture. The tibial baseplate was fractured along the edge of medial track rail of meniscal bearing. Fatigue striations were observed near the posteromedial portion of the baseplate by SEM observation, indicating fracture initiation started surrounding the track rail. No material defects were detected by EDS.
Gauzoma is also called as gauze-induced granuloma, and it always grows rapidly. It is a familiar surgical complication although it is a rare orthopaedic condition. We described a 26-year-old male and he had ever received the operation of open reduction and internal fixation with interlocking nail under the diagnosis of fracture of left femoral shaft about 3 years ago. Removal of implant was performed about two years ago. Unfortunately, a huge mass over medial side of left thigh was found after operation. He received magnetic resonance imaging study and it showed a heterogenous tumor with clear margin. A well-capsuled tumor was resected and multiple-piece gauze retention was noted. It was proved by pathologic report later. Early detection and avoid surgical complication were necessary.
Purpose: Percutaneous vertebroplasty (PVP) has been used to treat patients with painful osteoporotic spinal compression fractures and benign spinal tumors such as hemangiomas. Patients with metastatic spinal tumor lesions may suffer from severe back pain due to destructive vertebral lesions associated with instability. We evaluated the clinical outcome of injecting polymethylmethacrylate (PMMA) into the vertebral body with metastatic tumor lesions. Materials and methods: Nineteen patients with metastatic spinal tumors received PVP over a total of 25 vertebrae for pain control. The follow-up periods were from September 2003 to August 2008 and ranged from 1 to 48 months. Pain levels were assessed using the visual analog scale (VAS) before the operation, on postoperative day 3, and at 1 and 6 months during follow-up. Patients self-recorded functional disability values were obtained using the Oswestry Disability Index (ODI). Results: Sixteen patients (84%) had moderate to marked improvement in pain on postoperative day 3. The mean VAS pain score decreased from 7.8 to 3.5 on postoperative day 3 and to 4.2 at 6 months postoperatively. The mean ODI score improved from 79 preoperatively to 53 at postoperative month 1. Seven patients (36.8%) with cement leakage had no further clinical symptoms. The majority of patients (73.7%) survived for more than 6 months after treatment. There were no postoperative neurological deficits or procedure-related complications. Conclusion: PVP is a palliative and safe surgery option that provides moderate to marked pain relief and reduces disability in patients with symptomatic metastatic spinal tumors.
Purpose: Metastatic lesions in proximal femurs are not uncommon. However, the influence of primary malignancy, effective surgical techniques, post-operative survival period, and surgical complications have not been well clarified. The aim of this retrospective study was to evaluate outcome after surgical treatment for metastatic lesions in proximal femurs. Methods: Seventy-eight patients with 81 metastatic lesions with or without pathologic fractures in proximal femurs were surgically treated and regularly followed-up until patient death. Patient demographics, primary malignancy, surgical methods, implant selection, survival period after surgery, and complications were recorded and analyzed. Results: The average life span for 78 patients was 8.8 months (range, 0.1-42.5 months). The overall survival rates in 1 year and 2 years were 28% and 9%, respectively. Female patients lived longer than male patients (11.1 versus 5.6 months, p= 0.002). Additionally, female patients with breast cancer had longer survival time than female patients with lung cancer (p=0.020). Three patients (3.8%) sustained systemic complications and seven lesions (8.6%) sustained implant-related complications. The complication rates for patients treated with dynamic hip screws and intramedullary nails were 5.9% and 4.2%, respectively (p=0.411). The complication rate for patients treated with hemiarthroplasty and other implants were 25% and 100%, respectively. Conclusions: Among patients with surgical treatment of metastatic lesions in proximal femurs, female patients live longer than male patients. Female patients with breast cancer live longer than those with lung cancer. Surgical treatment using intramedullary nails has similar implant-related complication rates as that using dynamic hip screws. Surgical treatment using intramedullary nails or dynamic hip screws for metastatic lesions in the proximal femur is a safe, economical, and reasonable method as compared with endoprosthesis.
Removing femoral intramedullary nail for a healed femur fracture is regarded as a low-risk procedure with little publications about its complications. We reported a case of a femoral shaft fracture which occurred while we were trying to remove the ZMS Femoral intramedullary nail from a healed femoral shaft fracture. A 32 year-old woman with a healed right femoral shaft fracture asked for ZMS intramedullary nail removal. When we attempted to extract the nail 8 years after insertion, incarceration of distal end at the healed fracture level was encountered. Forceful extraction of the nail caused fracture of the femoral shaft near the old fracture site. The specific design of ZMS First generation nail includes four flutes on the nail shaft for enhancement of fixation stability. However those flutes did not continue down the entire length of the nail, which makes the distal end relatively bulky. When the distal bulky end encountered the fracture site during nail extraction, the endosteal bone incarcerated into the flutes cause difficulty in nail extraction and possible femoral shaft fracture. Orthopaedic surgeons should be aware of the possibility of an incarcerated nail when attempt to remove this design of nail and should inform the patient for the possibility of this complication preoperatively.
Purpose: In this article, we highlight the unusual presentation of the gouty tophus that mimicking a tumorous mass of the wrist that causing digital flexion contracture of hand. We aim to emphasize the importance of considering this disease entity in the differential diagnosis of a wrist mass in a patient with digital flexion contracture of hand. Case report [Materials & Methods]: We reported a case of isolated gouty involvement of the flexor tendon of the wrist which was mimicking a tumorous mass that causing digital flexion contracture of the hand. In this case, the patient is a young-aged male with no known past history of gouty arthritis who presenting to clinic with a slowly-growing mass at his left wrist. His left middle finger was fixed in complete flexion position. Magnetic resonance (MR) imaging showed a well-defined space-occupying lesion with heterogenous intensity which was located at volar aspect of wrist. Results: Surgical exploration was performed and a tophaceous mass was found infiltrating the flexor tendon of wrist obstructing the passage of tendon through the carpal tunnel. The pathology report further confirmed the diagnosis of tophaceous gout. Conclusions: Tophaceous gout involving the wrist is an unusual condition, but is possible in chronic cases with long history of hyperuricemia. This unusual case raises awareness of a wrist mass causing digital flexion contracture as one manifestation of gout.
Purpose: We wanted to evaluate the outcome of retaining the syndesmosis screw after open reduction and internal fixation of ankle fractures with disruption of the syndesmosis. Materials & Methods: From 2006 to 2007, seven consecutive patients who had acute unilaterally closed ankle fractures with disruption of the syndesmosis were collected and evaluated prospectively. The fractures were managed with open reduction and internal fixation, with a one third tubular plate for a fracture of the lateral malleolus, two 3.5 mm cancellous screws for medial malleolus, and a syndesmotic screw (one 3.5 mm cortical screw in tricortical fixation) for disruption of the syndesmosis. After the operation, the patients were followed up regularly to evaluate the retention of the syndesmosis screw. The follow-up period was 24 months on average (range: 14-30 months). All the patients had a complete functional evaluation (functional score by Olerud and Molander) and radiographic assessments. Results: Syndesmosis screw breakage was noted in six out of seven patients and osteolysis around the syndesmotic screw was noted in two. All six patients asked to have the lateral section of the broken screw removed. All patients except one were satisfied with the results and the functional scores were noted to be excellent in four, good in two and fair in one patient. Conclusions: Although retaining the syndesmosis screw was said to not affect the functional results of the injured ankle, the incidence of screw breakage was found to be very high in this series. Removal of the screw prior to weight bearing is recommended to avoid such an eventuality.
We report two cases of unusual primary salmonella infection on bone tumor. No predisposing host susceptibility for occurrence of the infection was found in both patients. High clinical suspicion of the entity associated with bacterial culture and tissue biopsy was the most useful tools to achieve the correct diagnosis. The purpose of this article is to remind that it is possible to have an associated salmonella osteomyelitis in a tumoral tissue and the importance of tissue culture during all biopsy to provide an early recognition of this entity and accurate treatment of this medical condition.
There are many osteoid osteomas of the scaphoid reported in the literature, but most of them show typical sclerosis or a nidus on plain radiographies that are easily detected. We report on a young adult with unusual radiographic presentation of an osteoid osteoma of the scaphoid. He received surgical excision of this tumor and the pathology proved this diagnosis.
Radiation associated sarcomas are uncommon, constituting less than 5% of all sarcomas and generally associated with a poor prognosis. We are reporting a case of an 82-year-old male who had a history of hepatocellular carcinoma associated with a solitary metastasis over the proximal femur. The metastatic bone lesion was stabilized by a static interlocking nail and augmented with bone cement. Postoperative radiotherapy was given in divided dose in 3 years to the whole femur with a total dose of 79 Gy. No evidence of tumor recurrence or progression was found at the subsequent follow-up. However, bone destruction accompanied with a huge soft tissue mass developed over the irradiated area five years later. Intra-lesional excision and reconstruction with a tumor prosthesis were performed. The pathologic result revealed post-irriadiation osteosarcoma instead of local recurrence of metastatic carcinoma.
Purpose: This study evaluated an injectable, bioresorbable, calcium-based, bioceramic bone-substitute putty for the capacity to augment osteoporotic distal radius fracture fixation. Methods: Twenty patients (12 females; mean age, 72 ± 12 years) with osteoporotic fractures of the distal radius treated between July 2006 and July 2007 were included. Fractures, which were classified as AO type A1 and A2 extra-articular and type B1 and B2 simple intra-articular, were treated with closed reduction and internal fixation involving two Kirschner wires augmented with Cem-Ostetic bone-substitute putty. Wrist range-of-motion exercises were initiated 4 weeks after K-wire fixation and 6 weeks after short arm cast fixation. Clinical symptoms and radiographic findings were evaluated every 4 weeks and analyzed using SAS version 9.1. Measurements of volar tilt, radial height, and radial inclination performed postoperatively and at the final follow-up visit were compared using the Wilcoxon signed rank test. Results: A significant difference in volar tilt (p＜0.001), but not radial length or inclination, was observed. Follow-up radiographs revealed rapid fracture healing. Bone-putty was absorbed and solid bridging callus formation was evident 3 months postoperatively. When a visual analogue scale was used to evaluate clinical symptoms, major improvements were observed on the contralateral side. Use of a Gartland and Werley scoring system revealed that 14 (70%) patients recovered function completely; results were graded as excellent. No joint arthritic changes or related complications were observed. Conclusions: Cem-Ostetic bone putty provides initial osteoconduction in osteoporotic bone. However, the extent and rate of new bone formation following augmentation depend on the fracture pattern.
Purpose: The follower load tangent to the spinal curvature mimics the physiologic compressive loads for in vivo tests. In vitro tests for spinal implants have advanced from the traditional load-control method (LCM) to the displacement-control method (DCM). This study used a follower load in finite element (FE) models of fusion and non-fusion spinal implants to evaluate the differences of the LCM and DCM at each motion segment. Methods: A FE model of the intact L1-L5 (INT) was validated and used to implant artificial disc replacement (ADR), or anterior lumbar interbody fusion (ALIF) cage supplement with pedicle screws fixation at the L3-4 level. The follower load was applied by using thermo-isotropic link elements passing through the instantaneous center of rotation at each motion segment with the L5 bottom constrained. The LCM imposed 10 Nm moments of flexion, extension, bending and rotation with a 400 N follower preload. The DCM applied motion that matched the angular displacement noted in the LCM of the INT model. Biomechanical performance of the ADR and ALIF models was compared with the INT model. Results: At surgical level, the ALIF model had sufficient stability under four physiological motions when using the LCM and DCM. The ADR model maintained the same motion in flexion when using the LCM and DCM, but reduced motions of 20.6%, 8.6% and 9.9% in extension, bending and rotation, respectively, when using the DCM. At adjacent level, the ADR model approached the INT model under all motions (＜10%), when using the LCM and DCM. However, the ALIF model increased motions of 16.6%, 37.7%, 42.5% and 24.7% in flexion, extension, bending and rotation, respectively, when using the DCM, as compared with the LCM. Conclusions: This study confirmed the applicability of a follower load on the entire lumbar spine under various loading conditions. For the ALIF model, the DCM showed greater motion at adjacent levels than the LCM. For the ADR model, the LCM and DCM revealed similar motions at surgical level; while the DCM had prominent motion variations at adjacent level, as compared with the LCM.
Purpose: To compare clinical and functional outcomes of locked intramedullary nailing with plating in treating distal tibial shaft fractures. Methods: Fifty-one consecutive adult patients with 51 closed or type 1 open distal tibial shaft fractures were treated with either locked nails (35 tibiae) or plates (16 tibiae). The location of tibial fractures in this study was distal to the isthmus and 6 cm proximal to the articular surface of the ankle. Postoperatively, no supplementary devices were used to reinforce local stability. Results: Forty-five patients with 32 nails and 13 plates were followed-up for at least one year (range, 1-2.5 years; average, 1.9 years). The union rates of nailing and plating tibiae were 93.8% and 92.3%, respectively (p=0.45). The union periods were 17.2 weeks and 19.4 weeks, respectively (p=0.29). Complications included deep infection, nonunion, and malunion in patients with a rate of 9.4% and 23.1%, respectively (p=0.23). Ankle function was satisfactory in all 45 patients. Conclusions: Both techniques can achieve a high union rate and satisfactory ankle function. The locked nailing group has a lower complication rate compared to the plating group. We recommend locked nailing for treating distal tibial shaft fractures.
