Fares E. Sayegh

Efficacy of Steroid and Nonsteroid Caudal Epidural Injections for Low Back Pain and Sciatica: A Prospective, Randomized, Double-blind Clinical Trial

Study Design. Prospective, double-blind, randomized, case-control study. Objective. To evaluate the efficacy of caudal epidural injections (CEI) containing steroid versus nonsteroid preparations when treating patients suffering from low back pain (LBP) and sciatica. Summary of Background Data. Literature seems to be deprived of well-designed randomized, controlled studies that evaluate the effectiveness of CEI in the treatment of chronic LBP; hence the value of CEI remains still the subject of controversy. Methods. Patients suffering from severe chronic LBP and sciatica were randomly allocated into 2 groups. Steroid-group’s patients (n = 93) underwent CEI containing 12 mL of xylocaine 2% and 1 mL of betamethasone dipropionate and betamethasone phosphate (2 + 5) mg/dL. Water for Injection (WFI)-group’s patients (n = 90) underwent CEI containing 12 mL of xylocaine 2% and 8 mL of WFI. Both groups were statistically comparable as far as their demographic data and the cause and duration of symptoms were concerned. Patients answered the Oswestry Disability Index questionnaire and underwent physical examination, before and at 1 week, 1 month, 6 months, and 1 year following the CEI. Results. Symptoms improved in 132 patients (72.1%) following CEI. The mean Oswestry Disability Index questionnaire score of steroid-group’s patients was statistically significant lower than that of the WFI-group at all postinjection re-evaluations. Patients receiving steroid CEI experienced faster relief during the first postinjection week. The Straight Leg Rising test improved in both groups following CEI; this improvement was faster among steroid-group’s patients. Fifty-one patients (27.8%), noticed no improvement 1 week post-CEI and underwent a second CEI (with the same preparation) 7 to 14 days later. Nineteen of them reported improvement; 32 (steroid-group:13, WFI-group:19) did not respond well and underwent operative decompression (n = 15) or spinal fusion (n = 17). Conclusion. CEI containing local anesthetic and steroids or WFI seems to be effective when treating patients with LBP and sciatica. CEI containing steroid preparations demonstrated better and faster efficacy.

Radial head replacement with the MoPyC pyrocarbon prosthesis

BACKGROUND Radial head fractures often pose therapeutic dilemmas. We present the early results of patients who underwent radial head replacement with the MoPyC prosthesis (Bioprofile, Tornier, Saint-Ismier, France). MATERIALS AND METHODS We re-evaluated patients who underwent post-traumatic radial head resection and implantation of the MoPyC prosthesis due to pain and motion restriction. All patients underwent radiographic evaluation. Clinical evaluation was performed using the Broberg-Morrey and the Mayo Elbow Performance Score (MEPS) scales. RESULTS Thirty-two patients (20 men, 12 women; mean age, 54 years; 22 dominant upper limbs) were evaluated. Twenty had a comminuted radial head fracture (Mason IV, 15; Mason III, 5), 2 from radial head fracture malunion, and 10 had complex elbow injuries (comminuted radial head fractures with ligamentous ruptures with or without coronoid process fractures). Mean follow-up was 27 months (range, 21-46 months). The mean results at the latest follow-up were flexion-extension, 130° (range, 105°-150°); pronation, 74° (range, 60°-80°); and supination, 72° (range, 60°-80°). No laxity was evident during valgus and varus stress tests. Mean grip strength was 96% of the contralateral side. Broberg-Morrey scores were excellent in 33%, good in 44%, and fair in 23%. MEPS results were excellent in 80%, good in 17%, and fair in 3%. There were 6 cases of periprosthetic lucencies or osteolysis of the radius without any clinical signs of loosening. CONCLUSIONS Radial head replacement with the MoPyC pyrocarbon prosthesis (when performed in carefully selected patients) yields satisfactory results regarding range of motion and function of the elbow joint.

Adolescent idiopathic scoliosis and exercising: is there truly a liaison?

Study Design. Cross-sectional observational study. Objective. Evaluation and comparison of the prevalence of adolescent idiopathic scoliosis (AIS) among 2 groups of patients (athletes and nonathletes) to determine whether athletic activities are related to the development of AIS. Summary of Background Data. The potential association between AIS and exercising remains uncertain. The latter has often been considered as a therapeutic means and a causative factor of the former. Methods. A group of 2387 adolescents (boys: 1177, girls: 1210, mean age: 13.4 years) was evaluated. All completed a questionnaire concerning personal, somatometric, and secondary sex characteristics, type, duration and character of daily-performed physical activities, and existing cases of AIS among relatives. Patients were classified into 2 groups according to their answers; “athletes” and “nonathletes.” The groups were comparable as far as age, height, weight, onset of menstruation, family history of scoliosis, and side of handedness were concerned. Children underwent physical examination by 3 orthopedic surgeons who were unaware of their level of athletic activities. Children considered, by all, to be suspicious of suffering from scoliosis, underwent further radiographic evaluation. Results. In 99 cases (athletes: 48, nonathletes: 51), AIS was radiographically confirmed (Cobb angle >10°). No statistically significant difference was found between athlete and nonathlete adolescents (P = 0.842), athlete and nonathlete boys (P = 0.757), and athlete and nonathlete girls (P = 0.705), as far as the prevalence of AIS was concerned. The mean value of the Cobb angle of the main scoliotic curve was not statistically different between male athletes and nonathletes (P = 0.45) and female athletes and nonathletes (P = 0.707). With the Cobb threshold reset at 20°, no statistically significant differences were detected either. Conclusion. Our results demonstrate that systematic exercising is probably not associated with the development of AIS. Actively participating in sports activities doesn’t seem to affect the degree of the main scoliotic curve either.

FUNCTIONAL OUTCOME AFTER EXPERIMENTAL CAUDA EQUINA COMPRESSION

Spinal nerve roots often sustain compression injuries. We used a Wistar rat model of the cauda equina syndrome to investigate such injuries. Rapid transient compression of the cauda equina was produced using a balloon catheter. The results were assessed by daily neurological examination and somatosensory evoked potential (SEP) recording before surgery and ten weeks after decompression. Compression of the spinal nerves induced changes in the SEP which persisted for up to ten weeks after decompression, but it had no effect on the final neurological outcome. Our study shows the importance of early surgical decompression for cauda equina syndrome.

Management of traumatic sacral fractures: A retrospective case-series study and review of the literature

BACKGROUND Being the result of high-energy trauma in most cases, traumatic sacral fractures are rare, difficult to recognise and frequently misdiagnosed. Furthermore they may lead to vascular injuries, mechanical instability, neurological impairment and increased morbidity. As a result, patients with traumatic sacral fractures may suffer major socio-economic consequences. OBJECTIVE This retrospective case-series study evaluated the functional, neurological, mental and emotional status of patients who had suffered traumatic sacral fractures and either followed conservative or underwent operative treatment at our department. PATIENTS AND METHODS We evaluated the clinical and radiographic results of all patients who had suffered traumatic sacral fractures between December 2003 and June 2007. The case-notes of all patients were reviewed, all co-existing injuries were registered and an ISS was calculated for each patient. At the latest follow-up visit, all patients completed the Short Form-36 questionnaire as well. RESULTS Sixteen patients (eleven male, five female) were included in this study. At the time of initial admission, the mean age of the patients was 30 years (range: 14-53) and the mean ISS was 33.2 points (range: 21-59). The mean follow-up period was 24.1 months (range: 13-40). Six patients were treated operatively (four patients diagnosed with some type of neurological impairment at their initial physical examination and two patients due to pelvic instability). The mean ISS of the patients who were treated operatively was 41.1 points (range: 21-59), whereas of those who were treated conservatively was 28.5 points (range: 21-45). No patient had any neurological deficit at his/her latest re-evaluation. Patients who were treated conservatively achieved the best scores in every domain of the SF-36 questionnaire, when compared with those who were treated operatively. CONCLUSION The diagnosis and management of sacral fractures may pose several dilemmas in everydays clinical praxis. Patients suffering from traumatic sacral fractures who were treated conservatively seem to have better functional and mental/emotional outcomes, probably because their injuries were less severe than those of the patients who were treated conservatively.

Circulating periostin levels in patients with AS: association with clinical and radiographic variables, inflammatory markers and molecules involved in bone formation

OBJECTIVE The aim of this study was to evaluate serum periostin levels in patients with AS in comparison with healthy controls as well as their association with clinical, inflammatory and radiographic parameters and molecules involved in bone formation. METHODS Serum samples for periostin, total Dickkopf-1 (Dkk-1), sclerostin, VEGF and inflammatory markers were obtained from 65 TNF inhibitor-naive patients with AS. The BASDAI, BASFI, modified Stoke AS Spine Score and BASRI for the spine (BASRI-s) were assessed for each patient. Serum periostin levels were also measured in 36 sex-, age- and BMI-matched controls. RESULTS Serum periostin levels were significantly lower in AS patients compared with controls [234.4 pg/ml (s.e.m. 7.5) vs 291.4 (s.e.m. 8.3), respectively; P < 0.001]. Periostin levels were higher in AS patients with elevated CRP (P = 0.005), high BASDAI (P = 0.014) and low BASRI-s (P = 0.033) and were correlated with BMI (r = -0.304, P = 0.014), ESR (r = 0.395, P = 0.001), CRP (r = 0.413, P = 0.001), BASRI-s (r = -0.242, P = 0.047) and sclerostin (r = -0.280, P = 0.024). In multiple regression analysis, periostin levels were an independent variable of CRP (β = 0.160, P = 0.009) and sclerostin levels (β = -0.311, P = 0.012). CONCLUSION Our data suggest that periostin levels are low in patients with AS. Among AS patients, periostin levels are higher in those with higher disease activity, higher systemic inflammation and less extensive radiographic damage. Periostin is independently associated with CRP and sclerostin levels.

The role of CT in diagnosis and treatment of distal tibial fractures with intra-articular involvement in children

AIM Distal tibial fractures with intra-articular involvement during childhood are injuries with potentially severe complications if not treated promptly. Daily clinical practice indicates that sole use of plain radiographs may lead to misdiagnosis and subsequent erroneous selection of suitable treatment. The role of computed tomography (CT) in the classification and treatment decision of these injuries is unclear. This study aims to determine whether CT evaluation is required in the management of these fractures. PATIENTS AND METHODS We assessed 64 distal tibial fractures with intra-articular involvement on two separate occasions in a blinded study, in order to classify the fracture and decide the appropriate treatment approach. In the first part of the study, plain radiographs were evaluated in order to diagnose the type of the fracture and select the appropriate treatment. In the second part, CT scans were performed in the same patients in order to re-evaluate diagnosis and treatment. The study included fractures prior to physeal closure (Salter-Harris III and IV fractures, n=32) as well as transitional fractures (J. Tillaux and triplane fractures, n=32). RESULTS According to plain radiographs, 31 patients were diagnosed with SH III fracture, 8 with SH IV, 9 with J. Tillaux and 16 with triplane fracture. Surgical treatment was decided in 18 patients and non-surgical in 46. After CT scan evaluation, 20 patients were diagnosed with SH III, 12 with SH IV, 9 with J. Tillaux, and 23 with triplane fracture. In this occasion the number of patients referred for surgical treatment raised to 42 leaving only 22 patients to be treated conservatively. CONCLUSIONS Computed tomography lead to changes in fracture classification and treatment decision. Treatment decision changed for 24 patients after CT evaluation. Treatment decision in patients with SH III and IV did not change significantly opposed to patients with transitional fractures, where CT scan had major impact on treatment decision. Despite the irradiation of immature skeleton and higher cost containment, this study indicates that patients with transitional distal tibial fractures as well as patients with displaced SH III and IV fractures must undergo CT examination in order to make accurate diagnosis and select the appropriate treatment.

Serum levels of Dkk-1, sclerostin and VEGF in patients with ankylosing spondylitis and their association with smoking, and clinical, inflammatory and radiographic parameters

OBJECTIVE To evaluate serum Dickkopf-1 (Dkk-1), sclerostin and vascular endothelial growth factor (VEGF) levels in patients with ankylosing spondylitis (AS) compared to healthy controls as well as their association with smoking, and clinical, inflammatory and radiographic parameters. METHODS Serum samples for total Dkk-1, sclerostin and VEGF were obtained from 57 tumour necrosis factor (TNF) inhibitor naïve patients with AS and 34 sex-, age- and body mass index (BMI)-matched controls. The erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), Bath AS Disease Activity Index (BASDAI), Bath AS Functional Index (BASFI), modified Stroke AS Spine Score (mSASSS) and smoking status were assessed for each patient. RESULTS There was no significant difference in serum bone metabolism markers between AS patients and controls. Dkk-1 levels were significantly (P<0.05) higher in AS patients with elevated ESR and CRP and no syndesmophytes, and were significantly (P<0.001) correlated with sclerostin levels (r=0.592). VEGF levels were significantly (P<0.05) higher in AS patients with current and ever smoking, elevated ESR and CRP, and high BASDAI and BASFI, and were significantly (P<0.05) correlated with ESR (r=0.284), CRP (r=0.285), BASDAI (r=0.349) and BASFI (r=0.275). In multivariate regression analyses, high Dkk-1 levels were significantly (P≤0.001) associated with elevated ESR and CRP, no syndesmophytes and high sclerostin levels, and high VEGF levels significantly (P<0.05) with ever smoking, and elevated ESR and CRP. CONCLUSION In AS, serum Dkk-1 concentrations appear to be related not only to syndesmophyte formation but also to systemic inflammation. Furthermore, high VEGF levels may be associated with smoking exposure.

Measured Resection versus Gap Balancing Technique for Femoral Rotational Alignment: A Prospective Study

Purpose. To compare the measured resection technique and the gap balancing technique for correction of the femoral rotational alignment. Methods. 57 women and 6 men (mean age, 70 years) with end-stage osteoarthritis and ±15° malalignment and ±10° flexion contracture of the knee underwent primary total knee arthroplasty through the medial approach using the measured resection technique (n=34) or the gap balancing technique (n=29). Femoral rotational alignment was evaluated before and 7 days after surgery using computed tomography by referencing the 2 posterior condyles to the transepicondylar axis. Results. The 2 groups did not differ significantly in terms of correction of the femoral rotational alignment (3.4°±1.4° vs. 3.5°±3.1°, p=0.817). Conclusion. The measured resection and the gap balancing techniques achieved comparable correction of femoral rotational alignment.

Simultaneous bilateral fracture-dislocation of the talus: a case report.

A bilateral talar body fracture-dislocation in a 29-year-old multitrauma patient is presented. There was a comminuted fracture associated with an ankle, subtalar and talonavicular subluxation on the right lower limb and an open fracture with complete dislocation of the body of talus on the left side. We performed a minimal invasive reduction and stabilization of the fractures with the use of K-wires, due to severe contamination of the wounds and the patients poor general condition. After a 28-month follow-up there were signs of posttraumatic arthritis but no signs of avascular necrosis of the talus bilaterally. The range of motion in both ankle joints was limited but the patient had a satisfactory level of activity.