g-Fong Chen

Acute noncontiguous multiple-level thoracic disc herniations with myelopathy: a case report.

Study Design. The case report of a 38-year-old man with a unique acute, triple-level, noncontiguous thoracic disc herniation (T6, T9–T10, and T11–T12), delayed onset of lower limb weakness, paresthesias below the T10 dermatome, and urinary dysfunction following minor trauma resulting from a motorcycle accident. Objectives. To present an unusual case of herniation that could involve ambiguous test results (imaging findings not necessarily correlated with severity of clinical manifestations). Summary of Background Data. Multiple-level symptomatic disc herniations of the thoracic spine are rare, and the reported cases are mostly of contiguous, two-level lesions with chronic clinical presentation. No case of acute three-level noncontiguous ruptured thoracic disc herniations with myelopathy has been reported. Methods. Through the left transthoracic approach, partial corpectomy, complete discectomy, and interbody fusion of the T9–T10 vertebrae were performed. The less prominent lesions of the T6 and T12–L1 vertebrae were left untreated. Results. Remarkable improvement of neurologic symptoms, including motor weakness and bladder dysfunction, was observed 1 week after operation. At 1-year follow-up, he could walk without aid and with a somewhat spastic gait. However, paresthesias below dermatome T12 persisted. The patient refused to accept the recommendation of further surgical decompression of the nerves at the T6 and T12–L1 vertebral lesions. Conclusion. Since the presentation of thoracic disc herniation is variable and difficult to correlate with imaging findings, decompression at all lesion levels in a patient with symptomatic multiple-level ruptured thoracic disc herniations may be necessary to achieve complete symptom relief and satisfactory results.

High-grade osteosarcoma treated with hemicortical resection and biological reconstruction.

Wide excision with a 2–3 cm safe margin is widely‐accepted in treating high‐grade osteosarcoma. However, a wider margin sacrifices more healthy bone and may jeopardize joint function. We hypothesize that our innovative hemicortical resection for such tumors leads to better joint function without higher recurrence rate.

Primary Hyperparathyroidism With Brown Tumor Mimicking Metastatic Bone Malignancy

Bone and joint pain are commonly encountered conditions in daily practice. In the elderly, when osteolytic lesions are identified in imaging studies, metastatic bone tumor is the first impression that comes to the clinicians mind. Although the worst-case scenario should be ruled in, other differential diagnoses such as metabolic bone disease should be considered as well. We report a case of brown tumor caused by parathyroid adenoma. The patient had initial presentation of diffuse bone pain and multiple osteolytic lesions on imaging studies similar to metastatic bone tumor. With a systematic approach and awareness of metabolic bone disease, an accurate diagnosis was finally reached. Appropriate treatments, including preventive internal fixation of the impending femoral fracture and surgical excision of the parathyroid adenoma were performed accordingly. The key treatment for the condition was surgical excision of the parathyroid adenoma. After normalization of serum intact-parathyroid hormone level, the bony lesions resolved and required no further orthopedic surgery. The patient is now symptom-free. In addition to suspecting malignancy, the clinician should be highly alert to other possible causes of bony lesions. Brown tumor should be kept in mind during daily practice.

Effectiveness of plate augmentation for femoral shaft nonunion after nailing.

Background: Treatment options for nonunion of the femoral shaft fracture after intramedullary nail fixation are controversial. The methods of exchanging an existing nail with a larger‐sized nail, dynamization, removal of the nail followed by plating, and bone grafting have all been reported. From those options, exchange nailing seems to be the most popular choice. In our study, we used plate augmentation and bone grafting with retention of the nail. The purpose of our study was to evaluate the effectiveness of this method in treating femoral shaft nonunion after open reduction and internal fixation with intramedullary nail fixation. Methods: Between January 2003 and December 2009, 22 patients who had nonunion after open reduction and internal fixation with intramedullary nail for femoral shaft fracture were included in our study. There were 13 men and nine women participants, with a mean age of 34.3 years (range, 17–77 years). The mean period of nonunion after surgery was 20.0 months (range, 7–63 months). The patients were classified into three groups, atrophic, oligotrophic, and hypertrophic. We retained the nail and performed plate augmentation for all patients, with simultaneous autologous bone grafting as indicated. We followed up on all patients with plain film examination, and to assess functional recovery status to determine osseous union condition. Results: All 22 of the patients achieved postoperative bony union uneventfully at a mean time of 22.1 weeks (range, 12–40 weeks). The mean operative time was 105 minutes (range, 60–150 minutes), and the mean blood loss was 340 ml (range, 150–700 ml). All of the patients could walk bearing full weight without pain within 3 months. There were no significant complications such as broken hardware, implant back‐out, axial or rotational malalignment, or deep infections. Conclusion: Plate augmentation with retention of the nail with autologous bone grafting may be an effective and reliable alternative in treating nonunion of the femoral shaft fracture after open reduction and internal fixation with intramedullary nail.

Cementation of Cross-linked Polyethylene Liner Into Well-Fixed Acetabular Shells Mean 6-Year Follow-Up Study

The purpose of this study was to evaluate retrospectively the outcomes of cementation of cross-linked polyethylene (PE) liner in a well-fixed metal shell in 23 hips with an average follow-up period of 6 years. The mean Harris hip score was 69.6 +/- 12 (range, 46-83) points preoperatively. The average postoperative follow-up was 72.3 months (range, 56-100 months). At the final follow-up, the mean Harris hip score was 95.5 +/- 3 (84-100) points. There was no change in the bone-shell interface. No new osteolytic lesions were identified. The lesions impacted with bone graft had united completely. The remaining osteolytic lesions had decreased in size. There was no recurrent osteolysis, hip dislocation, component migration, and failure at the cement-metal interface. The results of the current study revealed that cementation of cross-linked PE liner into a well-fixed shell provided good midterm durability.

Extracorporeally irradiated autograft-prosthetic composite arthroplasty using AML extensively porous-coated stem for proximal femur reconstruction: a clinical analysis of 14 patients.

Allograft‐prosthetic composite for reconstruction of the proximal femur after tumor excision is widely used as an alternative to megaprosthesis. To achieve greater biological fixation, we employed a long‐stem prosthesis that is cemented proximally into the extracorporeally irradiated autograft and press‐fit distally into the host femur without any supplementary plate fixation of the junction instead of the standard all‐cemented technique.

Joint replacement in human immunodeficiency virus-infected patients.

Background: Human immunodeficiency virus (HIV)‐infected patients are at risk for bacterial and opportunistic infections with worsening immunosuppression. Methods: From June 2000 to January 2009, six patients who were diagnosed with HIV infection underwent 10 joint replacement procedures, including six total hip arthroplasties, two total knee arthroplasties, and one shoulder hemiarthroplasty. An ordinary dose of postsurgical‐empirical antibiotics was prescribed, with an average follow‐up period of 38.6 months. All prostheses of total knee arthroplasty and shoulder hemiarthroplasty were fixed with vancomycin‐impregnated bone cement. Results: The rate of postoperative infection for HIV infected patients is supposed to be higher than for HIV negative patients. However, in our institution, there have been no HIV‐ positive patients who have suffered postoperative infection. Conclusion: HIV‐positive patients can have excellent outcomes after undergoing various arthroplastic surgeries. This revelation, coupled with the advances in antiviral therapy that have helped to lengthen HIV patient lifespans, strongly suggests that these patients should receive arthroplastic surgery.

Comparison of a minimally invasive technique with open tension band wiring for displaced transverse patellar fractures

Background: Open reduction and internal fixation with tension band wire is the standard treatment for displaced transverse patellar fractures. Recently, some minimally invasive techniques have been proposed as possible alternative methods. This retrospective study compared a newly reported percutaneous osteosynthesis with conventional open method for the treatment of displaced transverse patellar fractures. Methods: The minimally invasive technique was performed by percutaneous osteosynthesis with modified Carpenter’s (POMC) technique, using figure‐eight wiring through two‐paired cannulated screws under the control of arthroscopy and fluoroscopy. The conventional open surgery was performed with open modified anterior tension band (OMATB) technique. Totally 60 displaced transverse fractures were included in our study. Twenty were treated with percutaneous technique and 40 with open method. Outcome assessment included analysis of radiographic images, range of motion, Lysholm scores, complications, and reoperations. Results: Mean follow‐up was 37.3 months. Comparison of POMC and OMATB groups showed statistically significant results as follows: shorter surgical time, 70.4 ± 12.5 minutes for POMC group; greater degrees of flexion, 140.4 ± 6.1 for POMC group; better total range of motion, 139.6 ± 8.2 for POMC group; higher Lysholm scores, 93.6 ± 3.1 for POMC group. Frequencies of total complications and reoperations were significantly lower in POMC group. Conclusion: POMC method was a reproducibly reliable method, offering better functional outcome, lower incidence of complications, and reoperations, as compared with standard OMATB group for transverse patellar fractures. Nevertheless, it is not recommended for severely comminuted fractures.

Osteomyelitis of the femur mimicking bone tumors: a review of 10 cases

BackgroundThe clinical symptoms and radiographic appearance of osteomyelitis can mimic those of bone tumors.MethodsWe reviewed 10 patients with osteomyelitis of the femur who were initially diagnosed as having bone tumors and were subsequently transferred to our institution.ResultsNocturnal pain of moderate intensity occurred in seven patients, and all 10 patients had elevated C-reactive protein levels. The radiographic findings included the following: a permeative, moth-eaten osteolytic lesion in six patients, an osteolytic lesion with sclerotic borders in three patients, and cortical destruction with pathological fracture in one patient. Magnetic resonance imaging was performed for eight patients, and only one had a positive penumbra sign. All patients underwent a surgical biopsy to confirm the final diagnosis for histological analysis and cultures. Klebsiella pneumoniae was detected in six patients and Staphylococcus aureus, the most common organism in osteomyelitis, was detected in three. Recurrence of infection occurred in five patients following debridement surgery; of these three had a Klebsiella pneumoniae infection. All patients received antibiotic treatment for an average of 20.4 weeks (range, 4 to 44) and surgical treatment an average of 1.8 times (range, 1 to 4). At the final follow-up, all patients were fully recovered with no signs of infection.ConclusionsWhen used in combination, clinical examinations, laboratory data, and radiographic findings can reliably distinguishing osteomyelitis from bone tumors.

Improvement in High-Grade Osteosarcoma Survival: Results from 202 Patients Treated at a Single Institution in Taiwan.

AbstractThe aim of this study was to compare survival before and after 2004 and define the prognostic factors for high-grade osteosarcomas beyond those of typical young patients with localized extremity disease.Few studies have reported the long-term treatment outcomes of high-grade osteosarcoma in Taiwan.A total of 202 patients with primary high-grade osteosarcoma who received primary chemotherapy at Taipei Veterans General Hospital between January 1995 and December 2011 were retrospectively evaluated and compared by period (1995–2003 vs 2004–2011). Patients of all ages and tumor sites and those following or not following controlled protocols were included in analysis of demographic, tumor-related, and treatment-related variables and survival.Overall survival and progression-free survival at 5 years were, respectively, 67.7% and 48% for all patients (n = 202), 77.3% and 57.1% for patients without metastasis (n = 157), and 33.9% and 14.8% for patients with metastasis (n = 45). The survival rates of patients treated after 2004 were significantly higher (by 13%–16%) compared with those of patients treated before 2004, with an accompanying 30% increase in histological good response rate (P = .002). Factors significantly contributing to inferior survival in univariate and multivariate analyses were diagnosis before 2004, metastasis at diagnosis, and being a noncandidate for a controlled treatment protocol.By comparison with the regimens used at our institution before 2004, the current results support the effectiveness of the post-2004 regimens, which consisted of substantially reduced cycles of high-dose methotrexate and a higher dosage of ifosfamide per cycle, cisplatin, and doxorubicin, for treating high-grade osteosarcoma in Asian patients.