Spinal osteotomy in ankylosing spondylitis: radiological,clinical, and psychological results

Background contextLittle is known about the psychological status in patients with ankylosing spondylitis (AS) before and after correction of fixed sagittal imbalance.PurposeThe aim of this study was to evaluate the changes in patients' psychological status after surgical correction and the existence of a correlation between psychological state and the angle of correction.Study designA retrospective study was performed to assess radiological and clinical results, and psychological status in patients with AS with fixed kyphotic deformity.Patient sampleThe sample comprises 24 patients with AS with fixed sagittal imbalance who underwent one-stage corrective osteotomies at our hospital between March 2006 and May 2010. All of the patients included in this study demonstrated an inability to look straight forward because of severe kyphotic deformities.Outcome measureThe radiologic analysis included evaluation of thoracic kyphosis, lumbar lordosis, and the sagittal vertical axis (SVA) of the spine. Clinical assessments were performed with Short Form 36 (SF-36), the Bath Ankylosing Spondylitis Function Index (BASFI), and the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). Patient psychological status was assessed using the Hospital Anxiety and Depression Questionnaire (HADS) and the Health Locus of Control-Form C Questionnaire (HLC-C).MethodsEach of the above measurements was recorded before and 1 year after the surgery. The changes derived from each measurement before and after the surgery were evaluated. We also analyze the correlations among the radiological, clinical, psychological, and mental evaluations.ResultsMean thoracic kyphosis changed from 38.5° to 33.3°. Mean lumbar lordosis was corrected from 13.8° to 26.1°, and the SVA was improved from 110.8 mm to 49.7 mm. There was significant improvement in the SF-36, BASDAI, BASFI, HADS, and HLC-C scores. The SVA changes were closely linked to BASFI and psychological status, especially anxiety and depression.ConclusionsThe scores of disease status, general health, and psychological status were improved significantly after correction of kyphotic deformity. And the correction of sagittal imbalance was correlated significantly with anxiety and depression.     

Dorsal closing wedge calcaneal osteotomy for the treatment of Insertional Achilles Tendinopathy: A technical tip to optimize its results and reduce complications

Background

Dorsal closing wedge calcaneal osteotomy is a technique for the treatment of Haglund’s triad, which is considered a safe procedure with good results. However, one of the complications that could lead to revision operation is the nonunion of the osteotomy and failure of osteosynthesis. This is attributed to instability of the osteotomy site and proximal migration of the posterior calcaneal process due to breakage of plantar bone-bridge at the apex of the wedge osteotomy.

Tibial condylar valgus osteotomy (TCVO): Surgical technique and clinical results for knee osteoarthritis with varus deformity

Tibial condylar valgus osteotomy (TCVO) is an intra-articular proximal tibial osteotomy developed in 1989 and has since been used for the treatment of knee osteoarthritis (OA) associated with genu varum. This article describes the surgical technique and clinical results of TCVO. TCVO can be used for all grades of varus knee OA in patients of any age. he preoperative range of movement should be at least 90°. Preoperative screening showed varus-valgus instability due to an intra-articular deformity of the proximal tibia. Using intraoperative image intensification, a sagittally oriented “L”-shaped osteotomy is made from the medial to the tibial tuberosity to the center of the tibial plateau between the medial and lateral tibial spines. The separation of the osteotomy using the lamina spreader is gradually increased using an image intensifier guidance until the articular surface of the lateral tibial plateau comes in contact with the articular surface of the lateral femoral condyle. Adequate correction is indicated by parallelism of the lateral tibial plateau and a line tangential to the distal convexity of the lateral femoral condyle on an anteroposterior (AP) image and the elimination of the valgus instability with the knee in extended position. A “T”-plate (locking or non-locking plate or circular external fixator) is used to fix the osteotomy in the corrected position. Synthetic or autologous bone grafts can be used. We used the Japanese Orthopaedic Association score to evaluate the patient's function and also measured the %MAD, medial plateau opening angle, medial plateau angle, and lateral plateau opening angle on an AP view of the long length roentgenogram of the lower limb (standing position). The JOA score, radiologically measured values, and instability of the knee joint remarkably improved.     

Mid-term results of cardiac autotransplantation as method to treat permanent atrial fibrillation and mitral disease

Objectives: The results of current surgical options for the treatment of permanent atrial fibrillation (AF) associated with mitral surgery are widely different, particularly in very enlarged left atria. The aim of this study was to assess the mid-term efficacy of cardiac autotransplantation for this goal, through a consistent reduction of left atrium volume and a complete isolation of the pulmonary veins. Methods: From April 2000 to September 2002, 30 patients (male/female 5/25) underwent cardiac autotransplantation for the treatment of mitral valve disease and concomitant permanent AF (>1 year). Surgical technique of bicaval heart transplantation was modified maintaining the connection of inferior vena cava in all but three cases. Twenty-eight patients had mitral valve replacement and two had mitral valve repair. Associated procedures were: aortic valve replacement (6 cases), tricuspid valve repair (2 cases), coronary re-vascularization (2 cases) and right atrium volume reduction (4 cases). Results: No hospital death occurred; 1 patient died 3 months post-operatively for pneumonia. At a mean follow-up of 21.1±7.7 months (range 6–35), 26 patients (89.7%) were in sinus rhythm and 3 (10.3%) in AF. Santa Cruz Score was 0 in 3 patients, 2 in 2 patients and 4 in the remaining 24 patients (82.7%). Mean left atrial diameter and volume decreased from 65.1±16.4 mm (range 50–130 mm) to 49.9±8.4 mm (range 37–78) (P<0.001) and from 118.3±68.4 ml (range 60–426) to 69.4±34.1 ml (range 31–226) (P=0.001), respectively, after the operation. Conclusions: Cardiac autotransplantation is a safe and effective option for the treatment of permanent AF in patients with mitral valve disease and severe dilation of left atrium.     

The Zadek calcaneal osteotomy in Haglund's syndrome of the heel: Clinical results and a radiographic analysis to explain its efficacy

Local debridement or decompression of the posterior heel in Haglund's syndrome yields variable results. This condition is sometimes due to an excessively long calcaneus rather than simply a large posterosuperior bony prominence. Failure to address this abnormality may explain the poor results in some series. We recently published a new measurement (the X/Y ratio) which, combined with the calcaneal pitch angle, assesses the abnormality of the shape of the calcaneus. The Zadek osteotomy strongly modifies that shape. We retrospectively reviewed 50 patients treated by a Zadek osteotomy at a mean 7 years follow-up using the AOFAS ankle-hindfoot score, the VISA-A score and Tegner scale. We measured only the X/Y ratio and the calcaneal inclination angle, as the classically described radiographic measurements in Haglund's syndrome are unreliable. We then assessed the condition of the distal end of the Achilles tendon with an MRI. Our results demonstrate excellent outcomes(40/50, 80%) following Zadek osteotomy and correspond to the change in pre- and post-operative measurements, especially the X/Y ratio. An algorithm using those geometrical measurements of the calcaneus is proposed for decision making in Haglund's syndrome.Level of clinical evidence: Level 3.     

Modified transanal rectosigmoidectomy for Hirschsprung's disease: clinical and manometric results in the initial 20 cases

Purpose

The authors describe a modified technique of primary transanal rectosigmoidectomy for Hirschsprung’s disease (HD), using a Swenson like procedure to perform the anastomosis between the colon and the rectum, and the preliminary results from this in children.

Methods

Twenty children, of whom, 90% were boys and 10% girls, 50% white and 50% nonwhite, aged 15 days to 10 years and with HD proven via biopsy, underwent a transanal pull-through procedure over a 29-month period. Postoperative follow-up ranged from 29 to 5 months. The proximal cut edge of the mucosal and submucosal cuff was tagged with multiple polypropylene 4-0 sutures, which were used for traction of the intestinal layers outside. The rectal mucosa was incised circumferentially using cautery, to perform rectal dissection approximately 1.5 cm from the dentate line, except in newborn case, in which the proximal cut edge was 0.5 cm from the dentate line. The dissection extended in an upward direction around the entire rectal circumference as far as the opening of the peritoneal reflection. The full thickness of rectum and sigmoid were mobilized outside through the anus, with division and coagulation of the rectal and sigmoid vessels using cautery or ligatures with cotton 4-0. The dissected colon then was divided above the transition zone, which was confirmed via full-thickness biopsy sections and with frozen section confirmation of ganglion cell presence. The authors performed a modified Swenson anastomosis technique, using a seromuscular polyglactin 4-0 separate-stitch suture. No drains were used.

Results

Normal bowel movements were displayed by all patients at the follow-up. All patients underwent a defecogram and anorectal computerized manometry at 3 months after surgery that showed an absence of stenosis and good anorectal sphincter muscle complex function. The incidence of complications in our series was 10%.

Conclusions

During the follow-up period of 29 months, all patients had normal bowel movements and normal anorectal manometric pressure profiles.     

Bone‐anchored sling using the Mini Quick Anchor Plus and polypropylene mesh to treat post‐radical prostatectomy incontinence: Early experience

Herein we describe our experience with a bone‐anchored sling using a suture anchor and polypropylene mesh for the treatment of post‐radical prostatectomy urinary incontinence. Eight patients with urinary incontinence as a result of intrinsic sphincter deficiency after radical prostatectomy were included in the analysis. The procedure involved piercing the pubic bone with a bone drill, inserting the suture anchor and fixing a soft or rigid polypropylene mesh to press firmly on the bulbar urethra. Urinary incontinence was significantly improved according to changes in the daily number of pads used at 1, 3 and 6 months postoperatively in comparison with preoperatively. However, no meaningful improvement at 6 months postoperatively was seen with the soft mesh. Complications included perineal pain in four cases, but pain control was achieved using non‐steroidal anti‐inflammatory drugs. The bone‐anchored sling with a suture anchor and polypropylene mesh appears to be safe and effective for the treatment of post‐radical prostatectomy urinary incontinence. Soft mesh appears inappropriate as material for the bone‐anchored sling because of the progressive likelihood of worsened urinary incontinence.     

Acetabular reconstruction using a cementless cup and hydroxyapatite granules: 3- to 8-year clinical results

We investigated 17 patients undergoing consecutive revision or conversion total hip arthroplasties with a cementless cup for acetabular bone defects. Patients were all women and the average age at the time of surgery was 61.2 years. All bone defects were filled and packed with porous hydroxyapatite (HA) granules. The average follow-up was 5.6 years (range, 3-8 years). The average Merle d'Aubigné functional hip score was 15.6 at the latest follow-up vs 11.6 before surgery. No patients needed additional revision surgery. In 4 cases in which a superior deficiency had been covered with HA granules, the cup migrated superior to the host bone but without any detrimental effect. The remaining 13 cases showed no migration of the cup. We conclude that acetabular reconstruction with a cementless cup and HA granules seems to provide encouraging intermediate results.     

Phosphate in early chronic kidney disease: associations with clinical outcomes and a target to reduce cardiovascular risk

There is an intimate association between mineral and bone disorders in chronic kidney disease (CKD) and the extensive burden of cardiovascular disease (CVD) in this population. High phosphate levels in CKD have been associated with increased all-cause mortality and cardiovascular morbidity and mortality. Observational studies have also shown a consistent relationship between serum phosphate in the normal range and all-cause and cardiovascular mortality, left ventricular hypertrophy (LVH) and decline in renal function. Furthermore, fibroblast growth factor-23 (FGF-23), a phosphaturic hormone, increases very early in the course of CKD and is strongly associated with death and CVD, including LVH and vascular calcification. Few studies have addressed outcomes using interventions to reduce serum phosphate in a randomized controlled fashion; however, strategies to address cardiovascular risk in early CKD are imperative and phosphate is a potential therapeutic target. This review outlines the epidemiological and experimental evidence highlighting the relationship between excess phosphate and adverse outcomes, and discusses clinical studies required to address this problem.     

Presence of spondyloarthritis associated to higher disease activity and HLA-B27 positivity in patients with early Crohn's disease: Clinical and MRI results from a prospective inception cohort

ObjectiveTo determine the SpA prevalence and identify its associated factors in Crohn's disease (CD) patients receiving a systematically rheumatological and imaging assessment, including magnetic resonance imaging (MRI) of the sacroiliac joints and spine.MethodsCD patients either naive to biologics or without them for three months prior enrollment were recruited in a subgroup of the German Spondyloarthritis Inception Cohort (GESPIC-Crohn). A structured assessment of SpA manifestations was performed by a rheumatologist, including MRI of sacroiliac joints and spine. Demographic and clinical parameters including disease activity in CD (Harvey Bradshaw Index-HBI) and SpA (C-reactive protein – CRP, Bath Ankylosing Spondylitis Disease Activity Index, and Ankylosing Spondylitis Disease Activity Score) were collected. Univariable and multivariable logistic regression analyses were performed to identify factors associated with the presence of SpA.ResultsA total of 103 patients with CD were included in the cohort. The mean CD disease duration was 1.3 ± 2.4 years and 95.1% were naïve to biologics. The most frequent musculoskeletal manifestation was back pain (65.0%), followed by chronic back pain (50.5%), and arthralgia (43.7%). Prevalence of SpA was 19.4% with slightly higher proportion of axial SpA than peripheral SpA, and higher proportion of radiographic axial SpA (7.4%) than non-radiographic axial SpA (2.8%). Changes in MRI compatible with axial SpA were found in 15 (14.7%) patients, of which 9 (81.1%) patients had the clinical diagnosis of axial SpA. HLA-B27 positivity (OR 9.02, CI 95% 2.29–35.55) and higher disease activity of CD as reflected by the HBI (OR 1.14, 95%CI 1.01–1.30) were significant and independently associated with the presence of SpA.ConclusionSpA was present in nearly one out of five patients with CD and it was associated with the expression of HLA-B27 and a higher clinical activity of CD. Our findings raise awareness to rheumatologists and gastroenterologists on the high concomitance between both diseases and may help to reduce the delay in SpA diagnosis.     

Modulation of the inflammatory response and apoptosis using epidermal growth factor and hepatocyte growth factor in a liver injury model: a potential approach to the management and treatment of cholestatic liver disease

Background/Purpose

The major side effect of total parenteral nutrition is liver injury leading to liver failure. This study was designed to assess specific growth factors in modulating the hepatic response in an ANIT-induced liver-injury model.

Methods

Sprague-Dawley rats were divided into four groups: control (n = 5), liver-injury control (α-naphtylisocyocyanate [ANIT], 100 mg/kg, n = 8), ANIT + epidermal growth factor (EGF, 150 μg/kg per day, n = 10), and ANIT + hepatocyte growth factor (HGF, 250 μg/kg per day, n = 9). Rats were given intraperitoneal injections of saline (control) or ANIT and implantation of an osmotic mini-pump for 7 days of continuous intravenous saline (liver injury control), EGF, or HGF. Seven and 14 days later, liver biopsies were obtained and evaluated for interleukin (IL)-6 and tumor necrosis factor α expression by immunofluorescent staining, and for apoptosis, by the terminal transferase dUTP nick end labeling (TUNEL) technique. All animals were euthanized at 14 days.

Results

Epidermal growth factor (P < .025) and HGF (P < .001) groups induced less IL-6 expression at day 14 compared to liver-injury controls. In addition, the interval decrease in IL-6 expression between days 7 and 14 was greater in EGF (P < .001) and HGF (P < .001) groups compared to liver-injury controls. At day 14, HGF also demonstrated decreased tumor necrosis factor α expression (P < .005). Apoptotic activity was significantly less for the EGF (P < .011) and HGF (P < .0012) groups.

Conclusion

Epidermal growth factor and HGF modulated the hepatic inflammatory response and apoptotic index in this established liver-injury model and may diminish or prevent liver damage in patients with total parenteral nutrition-induced liver injury.