Treatment of Aneurysmal Bone Cysts by Minimally Invasive Curettage and Allogenic Bone Impaction Grafting: Mid-to Long-term Results

OBJECTIVE

Recurrence is the main hinderance in treatment of aneurysmal bone cysts (ABCs). Therefore, several treatment modalities and adjuvant therapies have been proposed. In this study, we aim to evaluate the long-term effectiveness of percutaneous curettage and allogenic bone grafting as a new, minimally invasive modality in treating ABCs.

METHODS

We performed a retrospective review of the medical records of patients diagnosed with primary ABCs at a university hospital over a 10-year period (2000-2010). We selected all patients who were diagnosed with primary ABC in the extremities and pelvis, treated with the same surgical procedure, and were followed for at least 2 years postoperatively. All patients underwent the same procedure of percutaneous curettage and impaction of allogenic pulverized fine bone fragments (harvested from locally stored femoral heads) mixed with autologous bone marrow aspirate from the iliac bone. We reported patient's characteristics (age and gender), site and size of the lesion, presenting symptoms, Capanna classification, follow-up duration, and post-operative complications. Assessment of cyst healing was based on the appearance on radiographs according to the modified Neer classification.

RESULTS

Nineteen patients were included in this study; 10 patients were males and nine were females. The mean age was 9.6 years (range 3-15). The location of the lesions was as follows: femur (eight), tibia (four), pelvis (four), proximal humerus (one), distal radius (one), and calcaneus (one). The most common presenting symptom was pain in the involved area. Pathological fracture was the presenting feature in two patients. The mean follow-up duration was 6.4 years (range 2-18). The earliest radiological sign of incorporation of the allograft was seen at 3 months after surgery. All patients showed bone remodeling and radiographic resolution (classified as either A or B on the modified Neer classification) of their cystic lesions within 6 months. No local recurrence, infection, or pathological fractures occurred during the follow-up period.

CONCLUSION

Percutaneous curettage and impaction of allogenic bone graft mixed with autogenic bone marrow aspirate is an efficient, minimally invasive, reproducible, and affordable procedure for the treatment of primary ABCs.

Management of a rare case of isolated U-shaped displaced sacral fracture in a young female high school student

Sacral fractures in young healthy patients are usually linked to high-energy trauma. They are often associated with multiple other injuries. Isolated sacral fractures are rare and can be easily missed in the absence of other surrounding pelvic or spinal injuries. In this article, we present a rare case of isolated U-shaped displaced sacral fracture despite the high-energy mechanism of injury being missed on initial presentation. This is a 17-year-old healthy female who presented to the emergency department after falling from five-meter height. She complained of lower back pain and inability to ambulate. Physical examination revealed significant sacral tenderness, bilateral lower limb weakness and hypoesthesia, anesthesia of the saddle area, weak anal tone and absent anal reflex. Initial radiographs showed no apparent fractures. Further imaging by pelvic computed tomography, however, revealed an isolated U-shaped displaced sacral fracture. The patient was treated by decompression and lumbopelvic fixation by triangular osteosynthesis and iliosacral screw. This fixation method restored stability of the spinopelvic junction and allowed for early mobilization. At her 18-month follow-up visit, she showed minimal disability score (10%) on the Oswestry Disability Index. In conclusion, sacral fractures are considered exceedingly rare to occur in isolation and in young healthy patients.

Thermographic Assessment of Reperfusion Profile Following Using a Tourniquet in Total Knee Arthroplasty: A Prospective Observational Study

Background

Infrared thermal imaging is a non-invasive technique capable of detecting changes in temperature that could ultimately signify changes in blood supply. Flir One is a smartphone-based thermal camera, working by a downloadable application, capable of detecting the limb temperature through a non-contact method using infrared thermography technology. Using the Flir One camera, we will assess the lower limb reperfusion profile following the tourniquet release post total knee arthroplasty (TKA).

Methods

A prospective study included 46 patients who underwent primary TKA. We used the (Flir One Gen 3) thermographic camera to capture images at ankle joint preoperatively, and at 1, 10, and 20 minutes post tourniquet release on operation side. The contralateral ankle stands as control.

Results

The mean preoperative temperature (in Celsius) of ankle control side and operated side were 33.03 (SD=1.65) and 33.26 (SD=1.42), respectively. The mean ankle temperature on operation side was 19.73 (SD=2.85), 30.49 (SD=2), and 32.43 (SD=1.31) at 1, 10, and 20 minutes post tourniquet release, respectively, while the control side showed a mean temperature of 32.85 (SD=1.42), 32.84 (SD=0.91), and 33.15 (SD=0.95) at the same time intervals. There was a significant statistical difference between both ankle temperatures at 1 and 10 minutes (P=0.00 for each time). At 20 minutes, 37 ankles (80.4%) at operation side reached a temperature level similar but below the level of control side; however, the difference was not significant (P=0.692).

Conclusion

Infrared thermography using the smartphone-connected camera is a simple, non-invasive, feasible, and reliable technology. It provides an objective measure to assess the perfusion status of the limbs. In TKA, the distal limb will reach full reperfusion status after approximately 20 minutes of tourniquet release.

Unusual Osteoblastoma of the First Metatarsal Bone Treated by Total Resection and Fibular Autograft: A Case Report

CASE

A 25-year-old man presented with progressive pain and swelling of the left foot for 4 years. The images showed a contrast-enhanced mixed lesion (osteolytic and blastic) of the first metatarsal bone with surrounding soft-tissue edema. The differential diagnoses favored chronic osteomyelitis or neoplasia, most likely benign. Histopathology confirmed the diagnosis of osteoblastoma as immature bone trabeculae rimmed by osteoblasts appeared. Then, the patient was successfully treated with wide surgical excision of the first metatarsal bone and reconstruction using a nonvascularized fibular autograft. After 3 years of follow-up, the graft was well incorporated and no recurrence was encountered.

CONCLUSION

Osteoblastoma is rare in metatarsals; only 12 cases have been reported. It may have similar clinical and radiological picture to osteomyelitis. Wide surgical excision followed by fibular autograft reconstruction is an effective treatment option.

The Yield of Lumbosacral Spine MRI in Patients with Isolated Chronic Low Back Pain: A Cross-Sectional Study

Background

The role of routine lumbosacral MRI in patients presented with isolated chronic low back pain (CLBP) is still unclear. Most patients with CLBP will show diverting degenerative changes on MRI. As it is uncertain whether surgical treatment of degenerative MRI changes results in alleviation of back pain or not, the necessity of doing a diagnostic lumbosacral MRI remains questionable. This study aimed to evaluate the yield of lumbosacral MRI among Jordanian patients presented with isolated CLBP.

Methods

We reviewed medical records of all patients who presented to neurosurgery outpatient clinic at Jordan University Hospital from December 2016 to December 2019. Only patients with a chief complaint of isolated CLBP were included. We obtained the relevant data from the computerized medical files and detailed radiological findings from their MRI reports.

Results

One hundred and sixty-seven patients (167) matched the inclusion criteria. We reported positive findings in MRI in 112 patients (67%), but 55 patients (32.93%) had normal MRI findings. Dehydration of intervertebral disc was the most common finding. Positive MRI findings were most evident in the middle-age group (41–60 years old). Disc protrusion finding in middle-aged females was significantly less prevalent than males (P = 0.012).

Conclusion

Jordanian patients presented with CLBP have similar worldwide patterns of lumbar degenerative changes. Providing that near one-third of patients with CLBP have normal MRI findings, we suggest following a streamlined protocol for imaging of patients presented with CLBP to reduce healthcare costs.