Christina Arnaoutoglou

Accuracy of pedicle screw placement: a systematic review of prospective in vivo studies comparing free hand, fluoroscopy guidance and navigation techniques.

IntroductionWith the advances and improvement of computer-assisted surgery devices, computer-guided pedicle screws insertion has been applied to the lumbar, thoracic and cervical spine. The purpose of the present study was to perform a systematic review of all available prospective evidence regarding pedicle screw insertion techniques in the thoracic and lumbar human spine. Materials and methodsWe considered all prospective in vivo clinical studies in the English literature that assessed the results of different pedicle screw placement techniques (free-hand technique, fluoroscopy guided, computed tomography (CT)-based navigation, fluoro-based navigation). MEDLINE, OVID, and Springer databases were used for the literature search covering the period from January 1950 until May 2010.Results26 prospective clinical studies were eventually included in the analysis. These studies included in total 1,105 patients in which 6,617 screws were inserted. In the studies using free-hand technique, the percentage of the screws fully contained in the pedicle ranged from 69 to 94%, with the aid of fluoroscopy from 28 to 85%, using CT navigation from 89 to 100% and using fluoroscopy-based navigation from 81 to 92%. The screws positioned with free-hand technique tended to perforate the cortex medially, whereas the screws placed with CT navigation guidance seemed to perforate more often laterally.ConclusionsIn conclusion, navigation does indeed exhibit higher accuracy and increased safety in pedicle screw placement than free-hand technique and use of fluoroscopy.

Diagnostic and treatment modalities in nonunions of the femoral shaft. A review

Nonunions of the femoral shaft represent a treatment challenge for the orthopaedic surgeon and a serious socioeconomic problem for the patient. Inadequate fracture stability, insufficient blood supply, bone loss or presence of infection are the main reasons for the development of a nonunion. Careful classification and exclusion of infection are crucial for the choice of the proper treatment alternative. Nail dynamization, primary intramedullary nailing or nail exchange, plate osteosynthesis and external fixation along with bone grafting, usage of bone substitutes and electrical stimulation can stimulate osseous union. A review of the aetiology, classification and treatment should prove helpful managing this serious complication.

Low grade fibromyxoid sarcoma: a case report and review of the literature

Low grade fibromyxoid sarcoma (LGFMS) is a distinctive variant of fibrosarcoma with a high metastasizing potential and sometimes long interval between tumour presentation and metastasis. We present the case of a 50-year-old male who developed a large mass in the posterior aspect of his lower left thigh. The tumor was excised with preservation of the neurovascular structures surrounded by the mass. The tumour measured 11 × 10 × 9 cm and on pathology evaluation was diagnosed as LGFMS. Due to the relative rarity of LGFMS, there is no dedicated protocol regarding follow-up recommendations. In order to early diagnose possible metastasis it is important to inform the patients about the longstanding metastatic potential of the disease.

Prospective analysis of surgical outcomes in patients undergoing decompressive laminectomy and posterior instrumentation for degenerative lumbar spinal stenosis

OBJECTIVES The aim of this study was to evaluate the outcome of wide surgical decompression and concomitant posterior instrumentation in patients with degenerative lumbar spinal stenosis. METHODS Thirty-seven consecutive patients (14 men, 23 women; mean age 64 years; range 36 to 82 years) with degenerative lumbar spinal stenosis were prospectively evaluated following surgical treatment with spinal decompression and concomitant instrumented posterior fusion. The mean duration of symptoms before surgery was 24 months (range 12 to 60 months). Preoperatively, six patients had degenerative spondylolisthesis (grade 1) and two patients had degenerative lumbar scoliosis. Decompression was performed at one level in four patients, at two levels in 16 patients, at three levels in 11 patients, and at four levels in six patients. Discectomy was also performed in seven patients. Preoperatively and postoperatively, the patients were assessed by the Oswestry Disability Index and a visual analog scale for overall pain (leg and low back pain). The satisfaction level of the patients for surgical outcome was also questioned. The mean follow-up period was 4.6 years (range 1 to 7 years). RESULTS Preoperatively, the mean Oswestry Disability Index score was 60.5% and the mean overall pain score was 7.5. Postoperatively, the Oswestry Disability Index score significantly decreased to 36.8% and the overall pain score significantly decreased to 3.5 (p<0.001). Preoperative and postoperative walking distances of the patients were as follows, respectively: more than 1,000 meters (6 and 14 patients), 500 to 1,000 meters (5 and 7 patients), less than 500 meters (26 and 16 patients). Twenty patients did not use any analgesics and eight patients used analgesics on a weekly basis. Twenty-six patients were satisfied with the surgical outcome, nine patients were somewhat satisfied, and two patients were dissatisfied. Overall, the outcomes were excellent to good in 22 patients (59.5%). None of the patients required revision surgery. CONCLUSION Most patients with degenerative lumbar spinal stenosis benefit from decompressive surgery. Patients with long-standing preoperative symptoms and concomitant diseases often have poor results and are less satisfied with the postoperative outcome.

Traumatic periprosthetic acetabular fracture treated by acute one-stage revision arthroplasty. A case report and review of the literature

Periprosthetic acetabular fractures are uncommon. Their management is difficult and postoperative complications such as nonunion and prosthetic loosening are common. Few reports concerning traumatic periprosthetic acetabular fractures and their management are available. We present a case of a traumatic, high-energy periprosthetic T-Type acetabular fracture without dislocation of the components of the arthroplasty, treated by an acute one-stage revision arthroplasty. To our knowledge, there have been no published cases with this type of injury pattern and this management algorithm.

Multiple recurrences and late metastasis of adamantinoma in the tibia: a case report

Adamantinoma is a rare, low-grade, malignant bone tumour. We report on a 46-year-old woman who had early multiple recurrences of adamantinoma of the right tibia and late metastasis to the lung and ribs 13 years after the first surgical treatment. She underwent multiple complete tumour excisions and eventually below-knee amputation and removal of the left lung and sixth to eighth ribs.

Misdiagnosed bilateral C5-C6 dislocation causing cervical spine instability: a case report

IntroductionThe diagnosis of cervical spine injuries remains a significant problem in many blunt trauma patients. Correct and early diagnosis of these injuries is imperative as delayed or missed diagnoses result in increased morbidity and mortality.Case presentationA 57-year-old Caucasian woman presented with a misdiagnosed bilateral C5-C6 dislocation one month after a fall and head injury, without clearance of the cervical spine in her previous visits to two physicians and having already started physiotherapy sessions, despite the presence of pain in the clinical examination. Dislocation was treated with open reduction and spinal fusion with posterior instrumentation 4 weeks post-trauma.ConclusionsEvery physician should be highly suspicious of cervical spine injury in blunt trauma patients with positive clinical examination and include radiologic studies in his screening modality. Physiotherapy sessions should under no circumstances be started in the presence of underlying spine injury.

Low-grade central osteosarcoma of distal femur, resembling fibrous dysplasia

We report a case of a 32 year-old male, admitted for a lytic lesion of the distal femur. One month after the first X-ray, clinical and imaging deterioration was evident. Open biopsy revealed fibrous dysplasia. Three months later, the lytic lesion had spread to the whole distal third of the femur reaching the articular cartilage. The malignant clinical and imaging features necessitated excision of the lesion and reconstruction with a custom-made total knee arthroplasty. Intra-operatively, no obvious soft tissue infiltration was evident. Nevertheless, an excision of the distal 15.5 cm of the femur including 3.0 cm of the surrounding muscles was finally performed. The histological examination of the excised specimen revealed central low-grade osteosarcoma. Based on the morphological features of the excised tumor, allied to the clinical findings, the diagnosis of low-grade central osteosarcoma was finally made although characters of a fibrous dysplasia were apparent. Central low-grade osteosarcoma is a rare, well-differentiated sub-type of osteosarcoma, with clinical, imaging, and histological features similar to benign tumours. Thus, initial misdiagnosis is usual with the condition commonly mistaken for fibrous dysplasia. Central low-grade osteosarcoma is usually treated with surgery alone, with rare cases of distal metastases. However, regional recurrence is quite frequent after close margin excision.