Conservative management of thoracolumbar and lumbar spine compression and burst fractures: functional and radiographic outcomes in 136 cases treated by closed reduction and casting

Introduction  Both fractures of the lumbar spine and at the thoracolumbar junction are quite common. The treatment of these fracture types is discussed controversially. Some authors advocate surgical treatment even in fractures without neurologic compromise while other series report good results after non-operative treatment. Materials and methods  Between January 1997 and April 2004, 324 patients with spinal fractures were admitted to our institution. Hundred and thirty-six patients with compression and burst type fractures treated by closed reduction and casting were available for follow-up. Their medical records, radiographs and computer tomography scans were reviewed and their functional status was assessed. Results  94 male (69.1%) and 42 female (30.9%) patients with a mean age of 48.6 years (range 17–81) at time of injury were included. The thoracolumbar junction (T11-L1) was affected in 104 patients (76.5%). 23.5% had lumbar fractures. All of the burst type fractures with involvement of the posterior column affection were type A3.3. fractures according to the Magerl classification. Significant correction of radiographic parameters was achieved in the early postreduction period (P < 0.0001). Reduction could not be maintained at the final follow-up but still showed slight improvement compared to the initial presentation. Reduction could be maintained better in the thoracolumbar region than in the lumbar spine. Neurologic function was restored in all patients with unilateral radicular pain but only one patient recovered fully after cauda equina-syndrome. Patients after lumbar spine indicated a higher level of pain when compared to patients with fractures at the thoracolumbar junction. Discussion  Closed reduction and casting is a safe and effective method for treatment of compression and burst type fractures at the thoracolumbar junction and can restore neurologic function in patients with unilateral radicular pain. It is of limited value in lumbar fractures and in burst type fractures with posterior column involvement.     

Total posterior condylar separation in a juvenile knee: open fixation through a posterior arthrotomy

The authors report a case of separation involving the posterior aspect of the lateral femoral condyle in a 13-year-old boy. The patient presented with a 2-year history of vague knee discomfort and recurrent knee effusions in the absence of a single acute traumatic event. A large mobile osteochondral fragment involving most of the posterior aspect of the lateral condyle was refixed surgically with two screws via a posterolateral arthrotomy. The knee has recovered full function and the lesion is radiologically stable.     

Chilaiditi syndrome with eventration of the diaphragm: A rare coexistence

Simultaneous coexistence of Chilaiditi syndrome along with eventration of the diaphragm is a rare occurrence. We present a case of this rare occurrence in a 41 year old male patient who presented with respiratory distress.     

Distribution of thrombi in acute lower extremity deep venous thrombosis: implications for sonography and CT and MR venography

OBJECTIVE: Our objective was to determine the typical distribution of thrombi in acute lower extremity deep venous thrombosis as a means of evaluating the validity of imaging techniques that only include the common femoral and popliteal veins, but not the superficial femoral vein. MATERIALS AND METHODS: The results of 2704 lower extremity venous sonograms, obtained in 2026 consecutive patients over a 4-year interval, were reviewed retrospectively. The distribution of acute deep venous thromboses across various lower extremity venous segments was analyzed for this population, which consisted of both symptomatic and asymptomatic patients. RESULTS: Of 2704 lower extremities studied with duplex sonography, acute deep venous thrombosis was identified in 269 (9.9%). Of these 269 cases, acute deep venous thrombosis was isolated to the superficial femoral vein in 60 (22.3%). The remaining 209 cases (77.7%) showed thrombus that extended into the common femoral or popliteal veins (or both). CONClUSION: An abbreviated imaging study that evaluates only the common femoral and popliteal veins would fail to identify more than 20% of lower extremity acute deep venous thromboses in a population like ours. Although evaluation of the superficial femoral vein requires additional time and resources, evaluation of this segment may prevent a substantial number of thrombi from being missed.     

Prognostic factors in recurrent glioblastoma multiforme and anaplastic astrocytoma treated with selective intra-arterial chemotherapy

BACKGROUND AND PURPOSE: Factors predictive of primary brain tumor outcome have been studied extensively, although the prognostic value of radiologic data, such as MR imaging and angiographic characteristics, has not been studied in depth. The purpose of this study was to determine whether radiologic data were prognostic factors among patients with recurrent glioblastoma multiforme and anaplastic astrocytoma treated with selective intra-arterial chemotherapy. METHODS: Forty-six patients were enrolled in a Phase II study of intra-arterial chemotherapy with carboplatin and Cereport (Alkermes Inc.; Cambridge, MA), a bradykinin analog that selectively increases permeability of the blood-tumor barrier. MR imaging volumes of enhancing tumor, resection cavity, and T2 signal abnormality were measured with T1-weighted and T2-weighted sequences. Volumes were analyzed individually and in various combinations. Tumor vascularity was graded on angiograms. Outcome was measured by time to tumor progression and survival. RESULTS: Of 46 patients included in this study, 41 underwent evaluation. Thirty were male and 11 were female; mean age was 48.5 years. Karnofsky scores ranged from 70 to 100. Thirty-two patients had glioblastoma multiforme, whereas nine had anaplastic astrocytoma. Twenty-eight patients had tumor progression and 13 had stable disease. Twenty-three patients died after an average of 205 days; 18 were surviving at an average of 324 days from the start of intra-arterial chemotherapy. In multivariate analysis, time from diagnosis to intra-arterial chemotherapy was predictive both of time to tumor progression and survival. Net tumor volume and vascularity also were significant for survival. Age, Karnofsky performance status, histologic findings, gender, MR imaging area, resection cavity volume, T2 signal abnormality volume, and various combined volumes were not significant. CONCLUSION: If confirmed by further studies, radiologic factors such as tumor volume and angiographic vascularity should be considered in design and stratification of future chemotherapy trials.     

Prednisone dosing per body weight or body surface area in children with nephrotic syndrome—is it equivalent?

The current guidelines recommend a dosage of prednisone of 60 mg/m² body surface area per day (BSA PRED) for the initial therapy of nephrotic syndrome (NS). Alternatively, a dosage of 2 mg/kg body weight per day (W PRED) can be used. We hypothesized that the BSA PRED and W PRED are not equivalent and analyzed the differences between BSA PRED calculated with various formulas for body surface area (BSA), W PRED and the dose of prednisone prescribed for our patients. We performed a retrospective chart review of the patients at their initial presentation of NS. Thirty-three children were included, of median age 3.34 years at presentation. The W PRED was significantly lower than BSA PRED (P < 0.05), with a median W PRED:BSA PRED ratio of 0.85 [interquartile range (IQR) 0.8 to 0.9]. The difference between W PRED and BSA PRED decreased proportionally to patients’ weights up to 30 kg. No differences were noted between the various BSA formulas using both weight and height for the calculation of BSA. The Bland–Altman analysis showed a proportional error between W PRED and BSA PRED up to the average daily dose of 60 mg, with a mean bias of 0.86 (95% limits of agreement = 0.68 to 1.05). Ten out of the 33 patients (30%) were given a lower than recommended BSA PRED dose by more than 5 mg/day. In conclusion, the dosage of prednisone at 2 mg/kg per day versus 60 mg/m² per day is not equivalent for patients with weights <30 kg and/or dose <60 mg/day.     

Interleukin-1 cluster gene polymorphisms in childhood IgA nephropathy

We have carried out a study with the aim of investigating the association between single nucleotide polymorphisms (SNPs) of the IL-1 gene cluster and childhood IgA nephropathy (IgAN). SNPs of the IL-1α, IL-1β, and IL-1 receptor antagonist (RN) genes (IL1A, IL1B, and IL1RN, respectively) were analyzed in 182 patients with childhood IgAN and in 500 healthy controls. The IgAN patients were also dichotomized and compared with respect to proteinuria (<4 mg and ≥4 mg/m² per hour, respectively), the presence or absence of podocyte foot process effacement, and the presence of pathologically early and advanced disease markers, such as interstitial fibrosis, tubular atrophy, or global sclerosis. Significant differences in SNP frequencies were observed for the IL1B and IL1RN genes (rs1143627, rs3917356, and rs1143633 in the IL1B gene, and rs928940, rs439154, and rs315951 in the IL1RN gene). Moreover, rs1143627, rs3917356, and rs1143633 of IL1B were found to be significantly associated with the presence of podocyte foot process effacement. Our results suggest that the IL1B and IL1RN genes are associated with increased susceptibility to IgAN in children. They also suggest that the development of proteinuria in IgAN is related to IL1A and that podocyte foot process effacement is associated with IL1B.     

Surgical Site Infection Following Surgery for Inflammatory Bowel Disease in Patients with Clean-Contaminated Wounds

Background  It is generally believed that the accompanying conditions in patients with inflammatory bowel disease (IBD) are associated with a high incidence of surgical site infection (SSI), and sometimes these patients are classified as compromised hosts without definitive clinical evidence. The aim of this study was to clarify the impact of IBD on the occurrence and features of SSI in patients with clean-contaminated wounds. Methods  We conducted prospective SSI surveillance of 580 patients with clean-contaminated wounds who underwent surgery between March 2006 and December 2007 using the National Nosocomial Infection Surveillance system. Multivariate analyses using stepwise logistic regression were performed to determine risk factors for SSI. Results  A total of 562 patients with clean-contaminated wounds who underwent surgery for IBD [ulcerative colitis (UC), n = 173; Crohn’s disease (CD), n = 122] or colorectal cancer [(CA), n = 267] were identified for evaluation. SSI was observed in 12.6% of all patients and there was no significant difference in infection rate by type of disease (UC, 14.5%; CD, 13.9%; CA, 10.9%). Multivariate logistic regression analysis yielded an ASA score ≥3 [odds ratio (OR) = 2.04; 95% confidence interval (CI) = 1.06–3.93] and rectal surgery (OR = 2.35; 95% CI = 1.28–4.31) as independent risk factors for SSI. IBD surgery was not an independent risk factor for overall SSI (OR = 1.62; 95% CI = 0.94–2.80). However, there was a significant difference in the incidence of incisional SSI [IBD, 11.9% (UC, 12.7%; CD, 10.7%); CA, 4.9%, p = 0.003]. In the analysis of rectal surgery, the incidence of incisional SSI was 5.3% in CA patients, 12.0% in UC patients, and 26.3% in CD patients. In contrast to overall SSI data, IBD surgery was found to be an independent risk factor for incisional SSI (OR = 2.59; 95% CI = 1.34–5.03). Conclusions  In patients of surgery restricted to clean-contaminated wounds, IBD was shown to be an independent risk factor for incisional SSI. With the use of proper operative procedures and techniques, the incidence of organ/space SSI should not be high in patients who undergo an uncomplicated IBD surgical procedure.     

Behaviour of nonresorbable bioactive glass–ceramic implanted into long bone defects: comparison with cancellous allografts

Introduction  The goal of this retrospective study was to compare the long-term results after implantation of the nonresorbable glass–ceramic material and transplantation of the cancellous allografts into the defects of long bones. Method  The bone cysts were excochleated and filled using granules of glass–ceramic material or cancellous allografts. Clinical, radiographic and scintigraphic examinations of 30 patients were carried out 2–14 years after their surgery. Results  Though signs of complete incorporation allowing full weight-bearing capacity were observed on plain radiographs, we detected pain in six out of nine patients after diaphyseal implantation of nonresorbable glass–ceramic. We found an increase in ^99 mTc-methylene diphosphonate uptake on the delayed images in the area of glass–ceramic implantation, mainly in its diaphyseal location. In patients after bone transplantation, the cancellous allografts were completely integrated and the scintigraphic findings were physiological. Conclusion  The implantation of the nonresorbable glass–ceramic material into the diaphyseal defects of long bones is not suitable based on our study.     

Experience with tacrolimus in children with steroid-resistant nephrotic syndrome

Children with steroid-resistant nephrotic syndrome (SRNS) are at risk of developing renal failure. We report here the results of a single-center retrospective observational study of the remission rate in pediatric patients with SNRS receiving tacrolimus. Serial renal biopsies from children on tacrolimus therapy were evaluated for tubulointerstitial fibrosis and transforming growth factor-β immunostaining. Of the 16 children with SRNS, 15 went into complete remission after a median of 120 days of therapy. Nine children were able to stop steroids, while the others were on tapering doses. Forty-seven percent had relapses, most of which were steroid-responsive. Serial renal biopsies were obtained from seven children after a median treatment duration of 24 months; two of these children had increased tubulointerstitial fibrosis and four showed increased transforming growth factor-β tissue staining. Children with worsening histological findings were younger. There was no significant association between tacrolimus exposure and biopsy changes, although the average trough level was higher in those children with worsening histological findings. In conclusion, tacrolimus may be a safe and effective alternative agent for inducing remission in children with SRNS. However, caution needs to be taken when prescribing this agent due to its narrow therapeutic index. Serial renal biopsies are necessary to check for subclinical nephrotoxicity, especially in younger children and those with higher trough levels.