Osteoblastoma of the patella: case report

A 34-year-old man came to our clinic because of left knee pain and mild swelling. Local tenderness over the peripatellar area was observed during physical examination. The range of motion of the knee was full. The radiographic presentation of the patella revealed an osteolytic lesion with a thin sclerotic rim without evidence of extra-articular involvement. The computed tomography revealed an upper pole intraosseous lesion. Intralesional curettage and allogeneic bone grafting were carried out. The pathologic examination demonstrated primitive osteoblasts, with osteoid features and many giant cells. A diagnosis of the osteoblastoma was made. Following surgery, the patient regained full range of motion and was pain-free. Complete healing of the lesion without evidence of recurrence was noted in follow-up radiographs 2 years postoperatively.

Treatment of giant cell tumor of the distal radius

The results of surgical treatment of giant cell tumors of the distal radius were reviewed in 12 patients between 1982 and 1995. All 12 patients had Grade III lesions. Six of the 12 patients were treated using intralesional curettage with local excision, and the other six patients underwent en bloc resection with total condyle (four of the six by osteoarticular allograft, and the other two by fibular autograft) reconstruction with the aim of preserving the functional joint. There were no early or late complications such as infection, graft fracture, implant failure, or nonunion. No local tumor recurrence was seen in either group during the average followup of 6 years (range, 3-16 years). The best functional result was seen in the patients treated with intralesional curettage. The functional result of the resection group was good, achieving an average of 69% (range, 56%-83%) of their range of motion and 70% (range, 63%-77%) of their grip strength on the contralateral side. Intralesional excision should not be excluded as a possible treatment of Grade III lesions, although en bloc resection was used more commonly for these lesions because of tumor surgery reasons. Grade III lesions were treated with curettage when the tumor did not invade the wrist, destroy more than 50% of the cortex, or break through the cortex with an extraosseous mass in more than one plane. Reconstruction with osteoarticular allograft after en bloc resection is recommended in this non-weightbearing joint when there is contraindication for curettage of the lesion.

Pulmonary lymphangitic sarcomatosis from cutaneous angiosarcoma: an unusual presentation of diffuse interstitial lung disease

Pulmonary lymphangitic sarcomatosis (PLS) is not much recognized clinically although it shows similar pathological patterns and diagnostic features to pulmonary lymphangitic carcinomatosis (PLC). We report a case with hand angiosarcoma whose chest X-ray findings revealed a diffuse interstitial pattern consistent with lymphangitic spreading. The final diagnosis was made by open lung biopsy. The clinical, diagnostic and pathological features of this disease process are reviewed.

Management of aggressive benign and malignant bone tumors of the shoulder region

BACKGROUND

The shoulder girdle is one of the most common sites of aggressive malignant and benign bone tumors. Curative resections and sparing of the limb are possible. However, reconstruction methods remain a challenge and the functional results vary.

METHODS

Fourteen patients with aggressive benign or malignant bone tumors about the shoulder girdle who were treated with surgical resection with possible need for reconstructions were retrospectively analyzed. There were 8 men and 6 women. Their ages ranged from 15 to 70 years; the mean age at operation was 36 years. Ten patients had malignant bone tumors and four had extensive giant-cell tumors. A variety of reconstructive procedures were performed after resection of the tumors. The choice of procedure depended on the type of resection and the needs of the patients. Supplementary chemotherapy or radiotherapy was undertaken after surgical procedures in 9 patients.

RESULTS

The length of follow up ranged from 16 months to 10 years. The functional results were described and graded quantitatively according to the functional rating system of the Musculoskeletal Tumor Society. Overall, 6 patients achieved excellent and good shoulder functions at follow-up examination, while 8 acquired fair or poor functional results. Four patients died from lung metastasis, while 10 survived and are disease free. Resection of the glenoid cavity and the proximal part of the humerus with loss of the abductor mechanism resulted in poor function of the shoulder.

CONCLUSION

The choice of treatment options depended upon the staging of tumors, the extent of resection, the needs of individual patients, the preservation and reconstruction of rotator cuff, the experience of surgeons, and the facilities at the hospital. The functional results were related to the area of involvement and the type of resection. The preservation of the abductor mechanism provided good functional results.

Video-assisted thoracoscopic surgery to the upper thoracic spine

BACKGROUND

The standard open technique for exposure of the upper thoracic spine, T1-T4, usually requires a difficult thoracotomy. From November 1, 1995 to June 30, 1997, eight patients underwent video-assisted thoracoscopic spinal surgery in our institute to treat their upper thoracic spinal lesions endoscopically.

METHODS

A new approach, the so-called "extended manipulating channel method," was used in this series that allows the combined use of video-assisted thoracoscopy and conventional spinal instruments to enter the chest cavity freely for the procedures. Patients' ages ranged from 44 to 89 years (average, 60 years). Definitive diagnoses included two pyogenic spondylitis and six spinal metastases. Five patients presented initially with myelopathy.

RESULTS

There were no deaths or neurologic injuries associated with this technique. The mean surgical time was 3.1 h. The mean duration of chest tube retention was 3.3 days. The mean total blood loss was 1,038 ml, and two patients had a blood loss of more than 2,000 ml owing to bleeding from epidural veins or raw osseous surfaces. Complications included one superficial wound infection and one subcutaneous emphysema that resolved spontaneously. In this series, there was no need of conversion to open thoracotomy for the patients.

CONCLUSIONS

The thoracoscopy-assisted spinal technique using the extended manipulating channels, usually 2.5-3.5 cm, allows variable instrument angulations for manipulation. The mean surgical time (3.1 h) was considered no longer than for an open technique for the equivalent anterior procedure. Such an approach can achieve less procedure-related trauma and has proved to be a good alternative to other treatment modalities.

Treatment of fibrous dysplasia involving the proximal femur

Twenty-two patients with fibrous dysplasia in the femoral neck or trochanteric area were treated with curettage and bone grafting with a sliding hip compression screw and plate. Follow-up ranged from 2 to 6 years (average: 4 years). Fourteen patients had monostotic and 8 had polyostotic disease. Four patients had pathologic fractures. Bone grafting included a deep-frozen allogeneic cortical strut and cancellous bone. After implanting the lag screw and cortical strut, the remaining defect space was filled with iliac bone. Postoperatively, all patients had good bone healing and complete incorporation of the implanted graft. There were no recurrences or complications, and functional results were rated as good and excellent.

Papillary and follicular thyroid carcinomas with bone metastases: a series of 39 cases during a period of 18 years

BACKGROUND

Bone metastases can cause death in patients with papillary or follicular thyroid carcinoma. There is, however, limited information about the clinical presentations and prognoses of patients with papillary and follicular thyroid carcinomas with bone metastases in Taiwan.

MATERIALS AND METHODS

A series of 39 patients with papillary or follicular thyroid carcinomas with bone metastases treated at our center from 1977 through 1995 was retrospectively reviewed to elucidate the clinical presentations and results of treatment of this disease.

RESULTS

The occurrence rate of bone metastasis in papillary and follicular thyroid carcinomas was 4.3%. Of the 39 patients, whose mean age was 57.5 years, 28 (71.8%) had follicular and 11 (28.2%) had papillary carcinomas. Thirty-two patients (82.1%) were female and 7 (17.9%) were male. Twenty-nine patients (74.4%) presented with bone metastases before the thyroid cancers were diagnosed. Bone metastases were detected using radiography in 33 patients and using 131I scans in 28 patients. Thirty-one patients (79.5%) had multiple bone metastases. The spine was the most frequently involved site (53.8%). Three patients were disease-free and 14 patients died during the course of treatment. Using the Kaplan-Meier method, the 5-year survival rate was estimated to be 64.9%.

CONCLUSION

Bone metastasis, although rare in patients with papillary carcinoma, was not very uncommon in patients with follicular carcinoma. Bone metastases occurred more often in older patients. Multiple bone metastases were noted more often than single bone metastasis. Most patients had symptoms and signs resulting from metastatic bone lesions. Although multimodality therapy was tried, the prognoses for most patients with bone metastases were poor.

Giant-cell tumor of the patella: report of two cases

Two patients with giant-cell tumors of the patella are presented in this report. Both patients were young females who were noted to have had nonspecific anterior knee pain and mild swelling of 1 to 12 months' duration prior to admission to our hospital. Local tenderness over the peripatellar area and slight limitation of full flexion were noted during physical examination. The radiographic presentation of each patella appeared as an expansile and lytic lesion with a thin cortex, without evidence of intra-articular involvement. Chest radiography and routine laboratory examination results were normal. After biopsy, intralesional curettage with phenol cauterization and allograft reconstruction was the preferred treatment in these two patients, with both tumors considered to be stage 2 according to Enneking's staging system. Following surgery, range of motion exercise was started after 6 weeks of immobilization with a long leg splint. Both patients regained full range of motion and were pain free. Radiographically, bone remodeling without evidence of recurrence was noted in both patients 2 years postoperatively.

Semistructural allografting in bone defects after curettage

BACKGROUND AND OBJECTIVES

A variety of aggressive benign bone tumors often require wide bone and soft tissue excision for adequate local control, but this creates a large defect and a seriously weakened extremity. Restoration of limb function presents a difficult problem.

METHODS

The treatment of 104 patients with space occupying lesions of the long bone were analyzed. Deep-frozen (-70 degrees C) cortical strut allografts with or without allogeneic cancellous bone graft were implanted into the defects after extensive intralesional curettage. Thirty-six patients had fibrous dysplasias, 29 unicameral bone cysts, 22 giant cell tumors, 12 aneurysmal bone cysts, 3 benign fibrous histiocytomas, and 2 ossifying fibromas. Fifty-six patients had pathologic fracture. The average volume after curettage was 210 ml (range 60-460 ml). The average follow-up period was 50 months.

RESULTS

At follow-up evaluation, the radiographs demonstrated complete incorporation of the allogeneic implant and new bone formation in the cavity in 83% of the patients (86/104). All fractures healed. There was no local recurrence or fracture of the cortical graft; neither were there other serious complications except one avascular necrosis of the femoral head. Good or excellent functional results were found in 97% (101/104) of the patients.

CONCLUSIONS

For large osseous defects, the reconstructive technique using cortical stent allograft provides increased strength, easy fixation, remodeling of the cystic defect, and healing of the fracture and prevents deformity. However, remodeling occurs slowly and may never be complete.

Excision curettage and allografting of giant cell tumor

Between 1987 and 1994 we followed 22 patients with giant cell tumors involving the long bones. Their average age was 31 years (range 17-50 years). Five patients had grade II tumors and the other 17 grade III lesions. The average volume of lesions after curettage was 231 ml (range 56-450 ml). All of the patients underwent a modified excisional curettage, and the cavity was filled with deep-frozen allogenic corticocancellous bone graft with supplementary fixation. Two patients developed postoperative complications including a superficial wound infection in one case and a traumatic tibial plateau fracture in one case. The overall outcome was good or excellent in 91% of the patients (i.e., 20/22 cases). There was no degenerative joint arthritis and, surprisingly, no instance of tumor recurrence. Allograft infection and fracture were not present. An allogeneic cortical strut with cancellous bone graft can be used safely and is effective for grafting cavitary lesions created after complete removal of the tumor.

Analysis of techniques for video-assisted thoracoscopic internal fixation of the spine

Between November 1, 1995, and January 31, 1996, four separate thoracoscopic spinal fixation surgeries were performed via extended manipulating channels using the so-called three-portal technique. The diagnoses included three spinal metastases and one T11 burst fracture. All patients had myelopathy at presentation. Using the three-portal technique, the conventional spinal instruments and fixation devices could be passed freely through the extended manipulating channels (usually 3-4 cm) into the chest cavity and manipulated by techniques similar to those used in standard open procedures. A reduction-fixation spinal plate with variable screw and plate anchoring angles was successfully inserted in the procedures. The total length of the operation ranged from 3.5 to 5 h (average 4.3 h), and the total blood loss was 1000-2500 ml (average 1500 ml). There were no intraoperative deaths, and no patient showed neurological deterioration following the procedures. On the basis of these results, we believe that the combination of video-assisted thoracoscopy and conventional spinal instruments presented in this report would be an ideal method for performing these procedures. Throughout the operation, only one trocar was employed for introducing the thoracoscope. The thoracoports were used temporarily during tumor tissue retrievals. This technique makes thoracoscopy-assisted spinal fixation simple and easy. It allows greater control of intraoperative vessel bleeding and reduces the number of portals required during the procedure (on average to 3). In addition, the technique reduced the amount of endoscopic materials required for the procedure, thus reducing the cost of treatment.

Video-assisted thoracoscopic treatment of spinal lesions in the thoracolumbar junction

BACKGROUND

The endoscopic treatment of spinal lesions in the thoracolumbar junction (T11-L2) poses a great challenge to the surgeon. From November 1, 1995 to December 31, 1996, we successfully used a combination of video-assisted thoracoscopy and conventional spinal instruments to treat 38 patients with anterior spinal lesions. Twelve of them had lesions in the thoracolumbar junction.

METHODS

The so-called extended manipulating channel method was used to perform vertebral biopsy, discectomy, decompressive corpectomy, interbody fusions, and/or internal fixations in these patients. The size of the thoracoscopic portals was greater than usual in order to allow conventional spinal instruments and a thoracoscope to enter the chest cavity freely and be manipulated by techniques similar to those used in standard open surgical procedures. In this series, the procedures were performed by using either a three-portal approach (2. 5-3.5 cm) or a modified two-portal technique involving a 5-6 cm larger incision and a small one for introducing the scope.

RESULTS

None of the operations resulted in injury to the great vessels, internal organs, or spinal cord. The total time for the operation ranged from 1.5 to 4.5 h (average, 3); and the total blood loss ranged from 50 to 3000 cc (average, 1050). One patient was converted to an open procedure due to severe pleural adhesion. Complications included two instances of transient intercostal neuralgia, one superfical wound infection, and one residual pneumothorax.

CONCLUSIONS

The video-assisted technique with the extended manipulating channel method presented in this report simplifies thoracoscopic spinal surgery in the thoracolumbar junction and makes it easier. It avoids division of the diaphragm, removal of the rib, and wide spread of the intercostal space, and it allows greater control of intraoperative vessel bleeding. Using this technique, the number of portals required during the procedure can be reduced. In addition, the technique reduces the endoscopic materials required, thus lowering overall cost. It is an effective and promising approach.

Allogeneic cortical strut for benign lesions of the humerus in adolescents

Allogeneic cortical strut associated with or without cancellous bone grafting for benign adolescent humeral shaft lesions is an alternative management option offering a good chance of stabilization and healing. This study monitored 16 patients who had been treated with this surgical method from 1988 to 1993. There were nine boys and seven girls between the ages of 11 and 16 years (average, 14). Eleven patients had unicameral bone cysts; two had aneurysmal bone cysts; and three had fibrous dysplasia. All 16 patients received fresh-frozen (-70 degrees C) cortical strut inlay grafts in the humeral shaft defect after subtotal excision of the large lesions. No intramedullary rod or plate was used. The follow-up period ranged from 26 to 58 months (average, 41). There were no local recurrences or fractures of the shaft or allograft implants. The radiographs of all humeri revealed the cortical grafts to be well incorporated with new bone formation in the cavity. The overall functional results were good and excellent. This reconstruction with biologically safe and active material provided increased strength and prevented refracture.

Total knee arthroplasty in a rheumatoid arthritic knee with large geode: a case report

Geodes (subchondral cysts) are a well-known manifestation of rheumatoid arthritis. Solitary cysts or cysts larger than 2 cm are not generally found in the knee joint of patients with rheumatoid arthritis (RA). We report a case of RA involving both knees with a giant geode over the right proximal tibia. Surgical treatment was performed including synovectomy, cyst enucleation and packing of autogenous bone chips followed by primary total knee arthroplasty. The postsurgical result was excellent with the knee restored to good function and complete healing of the cystic lesion.

A rare neurological presentation due to ossification of the posterior longitudinal ligament of the thoracic spine and ankylosing spondylitis: case report

Ossification of the posterior longitudinal ligament (OPLL) may be associated with certain rheumatic conditions including ankylosing spondylitis (AS), diffuse idiopathic skeletal hyperostosis (DISH) or spondylosis. More than 95% of all OPLL are localized at the cervical spine. Herein, we report a case of OPLL at the thoracic spine in an HLA-B27-positive female patient with ankylosing spondylitis. The patient was presented to use with spastic paraparesis. The imaging studies included plain roentgenograms, tomograms, myelo-CT and magnetic resonance imaging (MRI). A continuous rod-like ossification along the posterior aspects of the fourth to sixth thoracic vertebrae with spinal cord compression was noted. The patient underwent a laminectomy from T4 to T6. At the second year follow-up examination, residual upper back soreness and mild left thigh pain were noted. However, the patient had resumed a full daily schedule and could walk freely without any support.

Technique of video-assisted thoracoscopic surgery for the spine: new approach

Although video-assisted thoracoscopy has only recently been applied to treat a variety of thoracic spine lesions, many problems and difficulties are encountered with this technique owing to limited trocar space and lack of suitable endoscopic instruments. Between November 1995 and March 1996, we practiced a new approach for video-assisted thoracoscopic surgery, the "extended manipulating channel method," for treating 18 patients with thoracic spinal lesions endoscopically. The thoracoscopic portals were made larger (usually 3-4 cm) and placed slightly more posterior than usual, which allows use of a combination of conventional spinal instruments and video-assisted thoracoscopy to enter the chest cavity and be manipulated similar to that with techniques used for standard open surgical procedures. In our series the endoscopic spinal procedures included biopsy only (n = 1), thoracic discectomy (n = 1), multilevel anterior discectomy and fusion (n = 1), corpectomy for decompression (n = 4), decompressions and interbody fusions (n = 10), and internal instrumentations (n = 4). Throughout the operation only one trocar was used for introducing the thoracoscope. There were no intraoperative deaths, and no patients showed neurologic deterioration due to the procedures. We conclude that such a technique makes thoracoscopy-assisted spinal surgery simpler and easier and has proved to be an effective, promising procedure. It does not appear to compromise the therapeutic goals set for the patients. The intraoperative vessel bleeding can be easily controlled, and the number of portals for the procedures can be reduced (on average, three portals are enough). Few endoscopic materials were used with our patients, and thus the total economic cost to the patients was reduced.

Tuberculosis of the long bone in children

From 1985 to 1994, there were 24 cases of long bone solitary tuberculosis. They were 18 boys and 6 girls with an average age of 18 months. All of the patients were treated by open biopsy and curettage and antituberculosis therapy (isoniazid and rifampin) for 6 months. Two patients had incomplete administration of the drug therapy. The lesions were in the metaphysis. Epiphyseal involvement was not significant. The tuberculin skin test was negative in 3 children and the culture was negative in 17 cases. After 2 years and 8 months' followup, there was radiographic evidence of good bone remodeling. Although there uncommonly is not a delay in diagnosis of skeletal tuberculosis despite prolonged symptoms, diagnostic biopsy with curettage of the lesion is indicated for isolated lesions, especially when the diagnosis is in doubt. It is significant that surgical debridement can shorten the duration of antituberculosis therapy and lead to improved results.

Distal chevron osteotomy with intra-articular lateral soft-tissue release for treatment of moderate to severe hallux valgus deformity

We retrospectively reviewed the results of 32 patients (38 feet), with hallux valgus angles between 35 degrees and 60 degrees, who were treated by standard distal chevron osteotomy and intra-articular lateral soft tissue release. The average follow-up period was 5.2 years (4-7 years). The preoperative intermetatarsal angle averaged 14.4 degrees, and the postoperative angle averaged 7.7 degrees. The preoperative hallux valgus angle averaged 42.7 degrees, and the postoperative angle averaged 18.8 degrees. Subjectively, the satisfaction rate in terms of symptom improvement, cosmetic appearance and function was over 90%. Avascular necrosis of the first metatarsal head was not found in our series, which indicated that additional lateral soft tissue release is not contraindicated in combination with chevron osteotomy. Based on the level of satisfaction in our series, we conclude that the combination of distal chevron osteotomy and intraarticular lateral soft tissue release has broader application than the chevron osteotomy alone for patients with hallux valgus deformity.

Ankle arthrodesis with cross screw fixation. Good results in 36/40 cases followed 3-7 years

Tibiotalar arthrodesis by an anterior approach, using internal compression with cancellous crews, offers wide exposure, good possibilities of correcting deformities, and good bony apposition. From 1987 to 1991, we used this technique in 42 ankle joints (40 patients). The indications were posttraumatic arthrosis, sequelae of septic arthritis, necrosis of the talus and failed ankle arthrodesis. In 13 ankles with severe deformity, a bone graft was also used. 38 patients (40 ankle joints) were available for follow-up after 4 (3-7) years. Solid union was achieved in 38 ankles after an average of 13 weeks. The clinical result was good-to-excellent in 36 ankles. We conclude tha this is a simple and effective method for ankle arthrodesis in both low-risk and, coupled with bone grafting, in properly selected high-risk patients.

Treatment of the femoral neck amd trochanteric benign lesions

Thirty-five patients with a benign lesion of the femoral neck or trochanter were treated and seen in followup at the authors' institution from 1988 to 1991. Sixteen men and 19 women between the ages of 18 and 54 years (average, 27 years) were seen at an average followup of 3 years 6 months (range, 2-5 years). Eight patients had aneurysmal bone cyst; 14 had monostotic fibrous dysplasias; 2 had giant cell tumors; and 11 had simple bone cysts. Eleven patients had pathologic fractures. All patients were treated with curettage and bone grafting in conjunction with a sliding hip compression screw and plate. The bone grafting included a combination of a deep frozen allogenic cortical strut with autogenous iliac cancellous bone to fill the remaining defect space after lag screw and cortical strut had been implanted. At followup, all patients had good bony healing and incorporation of the implanted graft. There were no complications and no local recurrences. All of the functional results were excellent.

Fracture of the entire posterior process of talus associated with subtalar dislocation: a case report

This is a case report of a 52-year-old woman who sustained a medial subtalar dislocation with fracture of the posterior process of the talus in a traffic accident. After closed reduction of the subtalar dislocation, tomography demonstrated that the talus fracture involved the entire posterior process and the posterior portion of the talar body. The fracture of the talus was treated with an open reduction and miniscrew fixation. At follow-up examination 32 months later, the functional and radiographic results were graded as good. The proposed mechanism of this case was a forced plantarflexion and inversion acting simultaneously on the subtalar joint. This was different from an isolated medial subtalar dislocation, which was caused by an inversion.

Treatment of giant cell tumor of long bone

From 1981 to 1991, sixty-eight patients with giant cell tumors of their long bones were treated and followed-up at Chang Gung Memorial Hospital. Thirty-three males and thirty-five females between the ages of 14 and 76 (average, 32 years) were followed for an average duration of 3.5 years (range, 2.5 years to 7.3 years). Forty-five primary lesions and 23 cases of recurrent lesions were diagnosed. Seventeen patients were classified as grade II while 51, as grade III. Surgical procedures included intralesional curettage and wide resection. The local recurrent rate following surgery was 13% (9/68). The overall outcome was 85% (58/68) good or excellent results. Complications included one superficial infection, 9 local recurrences and 3 fractures of fixation devices. In addition, one patient with a lung metastasis was noted. In the primary lesion group, there were 9 grade II and 10 grade III lesions treated by curettage and grafting. Of these 4 grade II and 5 grade III patients had local recurrences. The recurrent rate was 47% (9/19) following intralesional curettage with cancellous bone graft (8/16) or bone cement (1/3). The average period before local recurrence was 10.4 months. Seven of the 9 recurrent patients received radical resections and allograft reconstruction with good results at short-term follow-up. The other two patients were lost in follow-up. The cases in the curettage group had shown low recurrent rate (1/10) after 1989 and high recurrent rate (8/9) before 1989 (p < 0.001). The most important factor for local recurrence appeared to be inadequate curettage with similar recurrence rates regardless of the type of bone graft used. A careful approach to the surgical margin including use of a dental burr and local adjuvant treatment with phenol, the rate of local recurrence may be decreased. There were no recurrences in the wide resection group. Although radical resection yield a best chance for cure, the sacrifice of the joint with subsequent arthroplasty resulted a compromise of the joint function.

Surgical indications in low lumbar burst fractures: experiences with Anterior Locking Plate System and the reduction-fixation system

A study of 14 surgically treated patients with low lumbar burst fractures (L3 to L5) is reported. Initially, 13 patients presented with incomplete neurologic deficits below the level of injury. The follow-up period ranged from 24 to 40 months, with an average of 30 months. In group 1, seven patients underwent one-stage anterior decompression, fusion, and Anterior Locking Plate System (ALPS) fixation. In Group 2, seven patients had posterior surgery with decompression, portero-lateral fusion, and a short segment fixation, one above and one below the injuried level, with the reduction-fixation transpediculate system. Indications for one-stage anterior surgery consisted of patients with incomplete neurologic deficits, segmental kyphotic deformity caused by loss of anterior vertebral height (< 50%), or canal encroachment < 50%. When there is significant radiologic evidence of lamina fractures, displaced or greenstick type, or injuries that occurred at the L5 level, the posterior approach was undertaken initially. This may be followed by anterior surgery if satisfactory vertebral height restoration or canal clearance was not achieved. Five dura tears (36%) were noted during surgery: two tears in group 1 and three tears in group 2. There were two patients in group 2 (29%) who had screws broken; however, none in group 1 demonstrated implant failure. In the low lumbar region, the step-off ALPS plate is preferable to the straight plate because of the increasing size of the vertebral body toward the caudal area. A low profile and easy application were its advantages. However, the ALPS could not be distracted or compressed anteriorly.

Posterior tibial tendon tear combined with a fracture of the accessory navicular: a new subclassification?

A 58-year-old woman with a diagnosis of a tear of the posterior tibial tendon associated with the os accessory navicular fracture was treated surgically. We believe that the dysfunction of the posterior tibial tendon was associated with an os accessory navicular fracture. This case is proposed as a new subclassification that was separate from the traditional classification of the tear of the posterior tibial tendon.

Salmonella psoas abscess--a case report

The clinical presentation of psoas abscess is often non-specific and insidious that may mislead the diagnosis and treatment. The abscess often extends beyond the retroperitoneum and pelvis before its diagnosis, and leads to serious complications. Many diseases have the similar signs and symptoms and must be ruled out. Computed tomogram is the most useful and reliable diagnostic tool. Only a few cases of salmonella psoas abscess were reported in the literature, and were usually associated with spinal osteomyelitis or septic hip. We present a case of salmonella psoas abscess in a patient with diabetes mellitus. The patient had the history of cholecystitis with sepsis due to salmonella infection 4 years before and cholecystectomy had been done. No associated lesion was found to be associated with the abscess, and we believed the abscess being the result of recurrent bacteremic attack. High index of suspicion, early diagnosis, adequate drainage and effective antibiotic treatment are the key points in managing the disease.

Treatment of an adult with neglected congenital pseudoarthrosis of the tibia with acute fracture: a case report

Treatment of congenital pseudoarthrosis of the tibia is very difficult. Numerous surgical procedures have been used including bone grafting, fixation, pulsed electromagnetic field, vascularized fibular bone grafting and lengthening devices. Previous studies, often reporting unsatisfactory results, are limited to children and adolescents. In adults, the following factors need to be considered: leg length discrepancy, leg deformity, soft tissue problems, lack of potential for growth and difficulties in healing. We reported a case of untreated congenital pseudoarthrosis of the tibia with fracture in a 32-year-old man. Conventional treatments used included excision of the pseudoarthrosis, correction of the deformity, intramedullary fixation, bone grafting and soft tissue transplantation for lengthening and coverage. These procedures led to good bony union and a satisfactory outcome.

Intercondylar fractures of the distal humerus: routine anterior subcutaneous transposition of the ulnar nerve in a posterior operative approach

Intercondylar fractures of the distal humerus in adults are rare and notoriously difficult to treat. The goals of open reduction are to preserve the articular surface and restore elbow function. We treated 20 patients by open reduction with dual-plate internal fixation and routine anterior subcutaneous transposition of the ulnar nerve. The follow-up period ranged from 15 to 35 months. The fractures were classified according to Muller's system. The results were evaluated using the Cassebaum rating system and subjective functional status. Excellent or good results were achieved in 15 elbows (75%), two had a fair result, and three, poor. A clearer understanding of fracture patterns, rigid dual-plate internal fixation, and early rehabilitation are needed to improve the results from this vexing injury. We recommended routine ulnar nerve anterior subcutaneous transposition using a posterior approach. Compared with published reports, our preliminary results demonstrated no postoperative ulnar nerve compression syndrome at follow-up. Routine anterior subcutaneous transposition of the ulnar nerve to avoid the postoperative ulnar nerve compression syndrome is required.

Squamous cell carcinoma arising in chronic osteomyelitis--clinical analysis of 7 cases

Retrospectively, we analyzed 7 cases of chronic osteomyelitis complicated with squamous cell carcinoma (SCC), who had been treated consecutively in Chang Gung Memorial Hospital from April 1983 to Jan. 1991. There were 6 males and one female, with the age between 43 and 80 years (average 57 years). The distribution of these lesions was 5 in the lower legs and 2 in the thighs; one had another hip lesion. The duration of discharging sinus presented before malignant change was from 4.5 years to 50 years (average 30 years). The pathological findings were all well-differentiated squamous cell carcinoma. Amputation was performed in 5 of them. Limb salvage procedure was selectively done in one case. Chemotherapy and regional irradiation without surgery was given in the remaining case. Follow up examination showed that the short term results were satisfactory in all cases. Six cases had at least one year of follow-up; the longest follow-up was 8 years.

Dedifferentiated chondrosarcoma arising from osteochondromatosis. A case report

Multiple hereditary osteochondromata has a higher incidence (5%-25%) of malignant change into chondrosarcoma than solitary osteochondroma (1%-2%); but only less than 10% of all chondrosarcomas may undergo dedifferentiated change into fibrosarcoma or malignant fibrous histiocytoma. We have a case presented here with osteochondromatosis who was found to have dedifferentiated chondrosarcoma arising from pelvic osteochondroma. Radical extra-compartmental resection was done and followed by chemotherapy and radiotherapy. Recurrence was found 3 months later. Early recognition of malignant change and adequate surgical resection with adjuvant therapy may prevent local recurrence and increase the survival rate.

Lower extremity compartmental syndrome following snake-bite envenomation--one case report

Acute compartmental syndrome develops when the intracompartmental pressure rises rapidly, even if only for a short duration. Loss of function and/or viability of the intracompartmental muscles may occur within a short period. Consequently early recognition and management are essential. We report a case where a young child with severe snake bite envenomation who and acute compartmental syndrome who had complete functional recovery following emergent fasciotomy and delayed primary closure.

Treatment of femoral shaft fractures with the Hoffmann external fixator in prepuberty

Twenty-two children with femoral shaft fractures, between the age of 10 and 14 years, were treated with the Hoffmann external fixation apparatus from 1980 to 1985. This method of treatment is very simple. It requires less surgical exposure and allows earlier ambulation and easy nursing care. In addition, it makes patients comfortable in multiple trauma conditions. The average time to union and removal of fixators was 72 days (range, 44 to 80 days). There were no deep wound infections, nonunions, or rotationary deformities. On followup, all patients regained the range of motion of knee joints in 3 months without significant leg length discrepancy or radiographic evidence of growth disturbance. The device may serve as an alternative method for femoral shaft fractures in prepuberty, especially in areas of tropical climate.

Acute femoral neck fracture in children--preliminary report

Nineteen children, aged 3-15 years, with acute femoral neck fracture were treated. The follow-up period ranged from 2 years to 6 years, 9 months (avg. 54.8 +/- 14.5 months). The clinical and radiological assessments were carried out according to the assessment system of Ratliff. Undisplaced fractures and all intertrochanteric fractures were treated conservatively and displaced ones by reduction and multiple pinning. The outcomes reveal 14 (79%) with good results, 2 (10.5%), fair and 3 (15.8%), poor. Four hips (21%) developed avascular necrosis with 2 requiring secondary surgical procedures. Both of them also had leg length discrepancy. Another 3 hips (15.8%) developed coxa vara, one of them had mild leg length discrepancy.

Femoral shaft fracture treated with Hoffmann external skeletal fixator in young teens

External skeletal fixation has been proved to be an effective method in treating complex femoral shaft fracture in adult patients with multiple trauma, extensive soft tissue injury or vascular injury which need reconstructive procedures. This method has the advantages of less extensive surgical exposure, easy wound access, and early ambulation. Twenty-two cases of femoral shaft fracture, between the ages of 10 and 15, were treated with the Hoffmann external skeletal fixator in Chang Gung Memorial Hospital from 1981 to 1985. The average time for union and removal of fixator was 72 +/- 8 days (from 44 to 150 days). The average leg length discrepancy was 0.6 +/- 0.3 cm. There was no deep wound infection, nonunion, rotationary deformity in closed fracture. All patients regained their range of motion of knee within 3 months after removal of the Hoffmann apparatus. The advantages of simple technique, less extensive surgical exposure, early ambulation, easy nursing care, patient comfort and no significant complications make it a good alternative method for treatment of femoral shaft fracture in young teens.

One-stage combined operation of congenital dislocation of the hips in older children

From 1977 to 1983, 17 patients with 20 long-standing congenitally dislocated hips were treated with a one-stage combined operation and then followed for more than 3 years by our institution. The growth of the proximal femur after femoral osteotomy was studied. The average neck-shaft angle was 111 degrees immediately after operation, and 128 degrees at follow-up. The outcome was largely independent of either age at operation or bilateral involvement. Our findings revealed 30% good and 50% excellent results in our patients.