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Background Hip pain during pregnancy is very common, but hip avascular necrosis represents a very rare entity. Case report We report a rare case of a healthy30-year-old female patient pregnant with twins, that suffered right hip avascular necrosis in the peripartum period, her symptoms were initially neglected as a benign cause of hip pain, this led to aggressive treatment at a young age. Discussion With less than 100 cases reported in the literature, pregnancy is not a well-known risk factor for femoral head avascular necrosis and it should be differentiated from one of the more common hip pathologies in pregnancy which is the so-called “Pelvic pain syndrome” and transient osteoporosis of the hip. Conclusion Having a high index of suspicion and low threshold for MRI imaging in a pregnant woman with hip pain is a must to prevent such complications., Highlights • Corticosteroids and alcohol intake are the most common atraumatic cause of hip osteonecrosis • Hip and pelvic pain during pregnancy are very frequent and may hide a serious event such as hip avascular necrosis • Hip avascular necrosis can have disastrous complications if not diagnosed in young pregnant women. • Having a high index of suspicion in a pregnant woman with hip pain is a must to prevent such complications

Schwannomas are benign tumors affecting the nerve sheath. Their presence in the subperiosteal region is extremely rare. We report a case of a 66-year-old male patient with a 10-year history of unexplained pain of the anterior leg that turned out to be caused by a subperiosteal schwannoma of the mid-tibia. We believe this case report will increase surgeons' index of suspicion about this condition when dealing with cases of unexplained bony pain, consequently allowing for early diagnosis and better outcomes.

We present a case of a 38-year-old female patient, presenting with debilitating simultaneous bilateral avascular necrosis of the femoral head (AVNFH) 10 years after cocaine detoxification, making her wheelchair-bound for six months. This case is reported for the rarity of association of cocaine with AVNFH, and for the unique fact of the simultaneous bilateral condition occurring a long time after cocaine ingestion in the absence of other important risk factors. This report postulates cocaine as a possible cause of bilateral AVNFH, which can increase the index of suspicion of this pathology, allowing early diagnosis and better outcomes.

Study design Retrospective matched cohort study. Objective To determine if low-pressure lumbar provocation discography (PD) results in long-term accelerated disc degeneration, internal disc disruption, or disc herniation in patients with symptomatic low back pain (LBP). Summary of background data Study of subjects without clinically-significant LBP suggests that high-pressure PD may accelerate disc degeneration. Methods Consecutive patients with symptomatic LBP who underwent magnetic resonance imaging (MRI), PD, and repeat MRI more than 7 years later, but did not undergo subsequent spinal fusion surgery, were included. Punctured discs were matched (1:2 to 1:4) to corresponding discs in a control cohort by age, BMI, Pfirrmann score (±2), and presence of disc herniation; control cohort inclusion required MRIs for symptomatic LBP, separated by more than 7 years. The primary outcome of the study was a progression in Pfirrmann score category (I-II, III-IV, V). MRI disc-to-CSF T2 signal-intensity ratio, disc height, disc herniations, high intensity zones (HIZs), and Modic changes were assessed. Results Baseline and follow-up MRIs were available for 77 discs exposed to PD, and for 260 discs in the matched control cohort. There was no difference in the proportion of punctured discs that advanced in Pfirrmann score category in the PD group (17%, 95% CI 9-27%) compared with corresponding discs in the Control group (21%, 95% CI 17-27%), P = 0.3578, or in non-punctured discs in the PD group (35%, 95% CI 21-51%) compared with corresponding discs in the Control group (34%, 95% CI 27-42%), P = 0.1169. There were no differences in disc-to-CSF T2 signal-intensity ratio, presence of disc herniations, HIZs, or Modic changes following puncture in the PD versus matched cohort discs or in the non-punctured PD cohort discs versus corresponding control cohort discs (P > 0.05). Conclusion Patients with symptomatic LBP who underwent low-pressure PD, but who did not undergo a subsequent spinal fusion surgery, developed disc degeneration and new disc herniations at a similar rate to corresponding discs in matched control patients. Level of evidence 3.

The level of termination of the conus medullaris (CM) and thecal sac (TS) is subject to variations. We try to correlate in this study these variations with the lumbar lordosis angle (LLA) using MRI scans. A retrospective study was conducted using available MRI scans of the lumbar spine. The CM level of termination (CMLT) and the TS level of termination (TSLT) were identified according to a vertebral level after dividing it into 3 parts. The LLA was also identified for each individual. Linear regression models were fitted to the data available on 141 individuals. Of these 70 were males and 71 were females. The most common site of CMLT was at the upper third of L1 (32.6%) and that of the TSLT was at the middle third of S2 (29.8%). The mean LLA was 46° (20°–81°). The most proximal CMLT was at the upper third of T12, whereas the most distal one was at the upper third of L2. The most proximal TSLT was at the upper third of S1, whereas the most distal one was at S3-S4 disc space. The CMLT showed a positive correlation with the LLA. In conclusion the CMLT and TSLT may be related to variations of the LLA.

Minimally invasive posterior spinous process–splitting laminoplasty preserving the paraspinal musculature has been introduced to treat patients with lumbar spinal stenosis. Despite its theoretical advantage of limiting muscular trauma, additional efforts are required to evaluate patients' clinical and functional results following this procedure. Between 2010 and 2012, 37 patients underwent spinous process–splitting laminoplasty for lumbar stenosis at a mean age of 68 years (range, 36–87 years) and were followed for minimum of 1 year (mean, 1.3 years). There were 22 (59%) men and 15 (41%) women. Mean number of levels treated with a spinous process–splitting laminoplasty was 2.2 (range, 1–6 levels). Patients had statistically significant improvements in their scores for all self-reported outcomes, including visual analog scale (VAS) for back and leg pain, Oswestry Disability Index (ODI), and Short Form 36 (SF-36) components. Mean VAS significantly decreased by 4.4±3.2 points for back pain and 3.9±3.7 points for leg pain ( P P P =.0017) for the physical component and 21.8±25.6 points ( P =.0062) for the mental health component. Four (10.8%) patients had a dural tear requiring repair (3 were intraoperative), 3 (8%) had an epidural hematoma requiring evacuation, 1 (2.7%) had an infection requiring irrigation and debridement, and 2 (5%) had additional decompression for symptom recurrence secondary to instability. Lumbar spinous process–splitting laminoplasty is a novel minimally invasive technique that provides adequate decompression for the neuronal elements and may avoid extensive paraspinal muscular damage associated with conventional laminectomy. Patients demonstrated significant improvements in pain and overall heath and function scores at a minimum 1-year follow-up. [ Orthopedics. 2016; 39(5):e950–e956.]

We compared open stabilization of vertebral fractures to percutaneous spinal fixation techniques in patients with a diagnosis of either ankylosing spondylitis (AS) or diffuse idiopathic skeletal hyperostosis (DISH). A retrospective review of patients known to have AS or DISH treated for spinal column fracture at a single institution between 1995 and 2011 was performed. Patients were analyzed by the type of fixation, divided into either a percutaneous group (PG) or an open group (OG). There were 41 patients identified with a spinal column fracture and history of AS or DISH who received surgical intervention. There were 17 (42%) patients with AS and 24 (58%) with DISH. Patients in the PG and OG cohorts presented with similar mechanisms of injury, Injury Severity Scale, number of vertebral fractures, number of additional injuries, and Arbeitsgemeinschaft fur Osteosynthesefragen (AO) classification scores. Mean operative time (254.76minutes versus 334.67minutes, p=0.040), estimated blood loss (166.8 versus 1240.36mL, p

The surgical management of metastatic disease of the spine continues to evolve. For most of the recent three decades, radiation therapy provided the mainstay of treatment for patients with symptomatic metastatic disease of the spine. Surgical treatment during this era often involved dorsal spinal cord decompression with no or limited spinal instrumentation1,2. These procedures generally provided only an indirect decompression of the spinal cord and often increased spinal instability. However, with advances in the understanding of metastatic processes in the spine and evolution of surgical techniques and instrumentation, surgical treatment plays a prominent role in the care of patients with metastatic epidural spinal cord compression. Studies have now yielded Level-I evidence on the efficacy of surgery for metastatic disease of the spine for improving quality of life and outcomes in patients with spinal metastasis. Concurrently, advances in radiation oncology now allow high-precision targeting of tumors and increased efficacy when treating radioresistant lesions3. These advances together have led to important advances in the treatment of metastatic disease of the spine. Research findings continue to identify appropriate candidates for surgical intervention for metastatic spinal disease as well as to define optimal surgical and radiation therapy techniques. In considering treatment methods, it is essential to account for factors such as tumor type and/or biology, extent of disease, neurologic status, an individual patient’s expectations, quality of life, and life expectancy. For example, hematopoietic tumors reliably respond to radiation therapy and rarely require surgery for a compressive neurologic deficit alone. Aggressive surgical intervention may be futile in the face of established neurologic deficit and/or rapidly advancing tumor refractory to treatments. However, many patients continue to present with symptomatic solid organ metastases and reasonable life expectancies and will benefit from a comprehensive evaluation by surgeons in concert with medical and …

Extensor tendon rupture is a common condition following penetrating injuries, whereas closed rupture is rare unless in a mallet finger. We describe an unusual case of closed rupture of both extensor tendons to the index finger. The extensor indicis proprius and extensor digitorum longus were avulsed proximal to the extensor retinaculum in a 23-year-old male patient due to forced hyperflexion of his index finger.

The treatment of metastatic disease to the spine involves a comprehensive evaluation of the patient and an individualized treatment plan based on the tumor type and location, the extent of the disease, and the general medical condition of the patient. Careful consideration of these factors dictates the treatment options, which include surgery, radiation, chemotherapy, and/or palliative options. Patients with a good overall prognosis may be considered candidates for more aggressive surgical resections, such as en bloc resections, whereas those with a poor prognosis may benefit from less invasive piecemeal resections to decompress the spine and restore neurologic function while minimizing the morbidity associated with more invasive procedures. The goals of surgery are tailored to the overall prognosis and should be aimed at optimizing the quality of the patient's life.

Many studies have attempted to define a safety zone for the axillary nerve in lateral approaches to the deltoid, but with varying results. The main objective of our study was to analyze the variations in the position of this nerve, especially in relation to the length of the humerus. Overall, 16 cadaveric shoulders were dissected. The distances between both the anterolateral edge of the acromin (anterior distance) and the lateral edge of the acromion (posterior distance) to the axillary nerve were measured; the length of the humerus was also measured. Correlation analysis was performed between each distance and the length of the humerus. The average anterior and posterior distance were 7.2 cm ± 0.84 cm and 7.9 cm ± 0.92 cm, respectively; the average length of the humerus was 30.7 cm ± 3.2 cm. A significantly high positive correlation was found between the length of the humerus and both anterior distance (P = .94), and posterior distance (P = .92). In shoulder surgery, prior measurement of the length of the humerus could predict the distance between the acromion and the axillary nerve, and determine its position.

Dislocation is a feared complication following total hip replacement (THR). While repairing the piriformis tendon after THR reduces dislocation, we analyze in this study the effect of piriformis tendon preservation on reducing the dislocation rate.226 THRs were done following the usual posterior approach and by the same surgeon. All patients received the same prosthetic design. All cases were primary THR. After reaching the external rotators, the piriformis muscle was identified and dissected on its inferior border from the gemellus superior and elevated by a retractor. Further stages were performed in the usual manner. Patients were followed up for a mean of 3 years.226 THRs were done for 217 patients, 118 of whom were females and 99 were males with a mean age of 62. Nine patients received bilateral THRs. 112 procedures were performed on the right side and 114 on the left side. THR was performed in 70 cases following femoral neck fractures and in 156 cases due to osteoarthritis. No intraoperative or long-term complications were found while preserving the piriformis. Postoperative hip X-rays showed good positioning of both the femoral and acetabular components. No cases of dislocation were identified after a mean follow-up of 3 years.Preservation of the piriformis tendon during the postero-lateral approach in THR is a possible surgical technique that is easy to use and reproducible in both arthritic and traumatic conditions. It follows an anatomical intermuscular plan and permits full exposure of both the proximal femur and the acetabulum. Compared to the literature, preserving the piriformis tendon seems to be superior to repairing it in terms of dislocation of THR.

The objective of this study is to determine the relationship of the variations of the lumbar lordosis angle (LLA) to the aortic bifurcation level and inferior vena cava (IVC) confluence level using CT angiography. A retrospective study was conducted using the data available on abdominopelvic CT angiography scans. The LLA, the level and angle of bifurcation of the aorta, the level and angle of confluence of the IVC were identified using multiplanar and 3D reconstruction. Linear regression models were fitted to the data. We interpreted 181 scans for 181 individuals having a mean age of 55 years (18-89). The most common site of aortic bifurcation was at L4-L5 disc space (34.8%) and that of vena confluence was at the upper of L5 (29.3%). The mean LLA was 34.65° (13°-77°). The mean aortic bifurcation angle was 47.43° (17°-100°) and the mean IVC confluence angle was 71.86° (30°-120°). The positions of the aortic bifurcation and venous confluence levels showed a proximal shift with an increasing LLA P < 0.001. This study showed that the level of bifurcation of the aorta and the level of confluence of the IVC may vary with the variations of the LLA.

Secondary chondrosarcoma is a distinctive type of tumor that originates from a preexisting cartilaginous lesion. Most commonly, it is associated with solitary or multiple osteochondromas. A fraction of cases arises from other conditions, such as Maffucci syndrome and Ollier disease. A sudden increase in the size of the cartilaginous cap of an osteochondroma is a sign of malignant transformation to secondary chondrosarcoma. However, there is no strict cutoff in terms of thickness of the cartilaginous cap that can be regarded as being pathognomonic of malignancy. Most cases of secondary chondrosarcoma are low to intermediate grade. Distant metastasis is uncommon, and the prognosis is good for most patients. Overall survival at 5 years is approximately 90%. Surgical resection with wide margins is the best treatment option, but local recurrence remains a significant problem in approximately 10% to 20% of patients. Patients with secondary chondrosarcoma of the pelvis are especially at risk for local recurrence.

Aneurysmal bone cysts rarely affect the carpus. We present a case of aneurysmal bone cyst affecting the lunate. Curettage and bone grafting of the lesion was successful, with no recurrence after 2 years of follow-up.

Stress fractures may be easily misdiagnosed as another entity, especially tumors, which may prompt very severe surgical treatment and sometimes amputation. The appropriate use of modern radiography may make the difference in proper diagnosis of stress fractures.

Malignant eccrine porocarcinoma is a rare tumor of sweat glands with a high local recurrence rate and a tendency to metastatic spread. We present a case of a 77-year-old male patient that presented with a recurrent, periungual porocarcinoma mimicking onychomycosis and ingrown toe nail that was successfully treated by surgical excision. To our knowledge no such case has been described in this location in the English literature.

We present a case of delayed presentation of a subdural haematoma causing cauda equina syndrome which occurred 96 hours after a spinal anaesthetic had been administered for an elective total hip replacement in an 86-year-old man. The patient had received low-molecular-weight heparin anticoagulation which had been delayed until 12 hours postoperatively. No other cause of the haemorrhage could be identified.