Konstantinos Soultanis

Late infection in patients with scoliosis treated with spinal instrumentation.

Sixty patients were treated using a multilevel spinal instrumentation system. Spine arthrodesis was done posteriorly in all patients using a combination of two rods, hooks, screws, and cross-link plates. The Galveston technique was used in three patients. Five patients presented with late deep wound infections 1 to 5 years postoperatively. Two patients presented with a local subcutaneous abscess, whereas the remaining patients had a local drainage. Exploration revealed pus lining the instrumentation surface, at least one loose cross-link nut, and local hardware corrosion and metal infiltration of the surrounding tissues. All patients had a satisfactory bony arthrodesis, so instrumentation was removed. Intraoperative cultures revealed three coagulase-negative Staphylococci, one Acinetobacter baumani, and one Peptostreptococcus. A continuous irrigation system with antibiotics was placed for 5 days in all patients in combination with intravenous antibiotics and oral antibiotics. All patients responded to the treatment, with no recurrence of the infection after removal of the instrumentation. Although the exact nature of these infections requires additional investigation, the findings suggest a correlation between instrumentation failure and loosening and late infection. Bone involvement was not observed and removal of instrumentation was a reliable means of treatment.

Risk Factors for Idiopathic Scoliosis: Review of a 6-Year Prospective Study

This study identified factors associated with the prevalence of idiopathic scoliosis and curve evolution in schoolchildren from northwestern and central Greece. A total of 85,627 children aged 9-15 years were screened for scoliosis. A subset of children with curves of at least 10 degrees underwent clinical and radiographic follow-up. The total population screened and the cohort followed for curve progression were evaluated according to factors associated with curve evolution. The prevalence of scoliosis was 1.7%, with most cases appearing at ages 13 and 14 years and small scoliotic curves (10 degrees-19 degrees) being most prevalent (prevalence 1.5%). Prevalence was associated with gender; age; and magnitude, apex, and direction of the curve. Progression of the curve occurred in 14.7% of 839 children, while 27.4% demonstrated spontaneous improvement of at least 5 degrees. A high risk of curve progression was associated with the following: sex--girls, curve pattern--right thoracic and double curves in girls and right lumbar in boys, maturity--girls before the onset of menses, age--time of pubertal growth spurt, and curve magnitude--curves > or = 30 degrees. Although only a small percentage of scoliotic curves undergo progression, the pattern of the curve according to curve direction and the sex of the child plays a significant role in the ability to identify which curves will progress.

Outcome of a Dynamic Neutralization System for the Spine

One hundred fourteen patients (66 men and 48 women; mean age, 49 years) underwent spine stabilization using a dynamic neutralization system between January 1999 and August 2010 for degenerative disk disease, spinal instability, or spinal stenosis. Mean follow-up was 6.8 years (range, 1-11 years). Seven patients were lost to follow-up. Radiological examination and clinical evaluation, including the Oswestry Disability Index, the Roland-Morris Disability Questionnaire, and patient satisfaction, were performed.Mean Oswestry Disability Index score improved from 57% (severe disability) preoperatively to 22% (moderate disability) postoperatively. Mean Roland-Morris Disability Questionnaire score improved from 52% preoperatively to 35% postoperatively; 79 (74%) patients declared themselves very satisfied with the end result of the operation. Postoperatively, 27 (25%) patients experienced complications, including screw loosening (n=22), infection (n=2), back (n=5) and leg (n=2) pain, and endplate vertebral fracture (n=1). Three patients with screw loosening, 2 with deep infection, and 1 with severe persistent back and leg pain underwent rigid spine arthrodesis.Dynamic neutralization systems can be considered for degenerative disk disease, spinal instability, and stenosis. Patient satisfaction with the procedure is excellent. However, in the long term, the complication rate, most commonly screw loosening, is high and reoperations are common. In this setting, long-term follow-up is recommended, and the use of this system should be reconsidered.

Lumbopelvic fracture–dislocation combined with unstable pelvic ring injury: One stage stabilisation with spinal instrumentation

Fractures of pelvic ring are the result of high-energy trauma and they can be treated surgically with external or internal fixation. Traumatic fracture dislocation of S1 vertebra can be stabilised effectively with spinal instrumentation. Combined pelvic ring disruption with fracture-olisthesis of S1 is reported to be very uncommon and challenging to treat. We present a patient with such an unstable injury pattern and the surgical treatment in one stage procedure he underwent.

Peripheral Arterial Embolization of Cement during Revision Spine Surgery

Cement embolism of the pulmonary arteries is a well-known complication of percutaneous vertebroplasty as well as orthopedic procedures involving instrumentation of the medullary canal. A few cases of paradoxical cement embolism have also been described. Herein, we report a case of cortical bone void filler embolism to the infragenicular arteries during revision spine surgery. The cement had entered the aorta via the left L3 lumbar artery. To the best of our knowledge, this is the first report of embolism due to direct arterial migration of cement during an orthopedic procedure.

A Nonphosphaturic Mesenchymal Tumor Mixed Connective Tissue Variant of the Sacrum

Tumor-induced or oncogenic osteomalacia is a rare paraneoplastic syndrome characterized by overproduction of fibroblast growth factor-23 as a phosphaturic agent and renal phosphate wasting. A range of predominantly mesenchymal neoplasms have been associated with tumor-induced osteomalacia and classified as phosphaturic mesenchymal tumor mixed connective tissues. However, phosphaturic mesenchymal tumor mixed connective tissues could be nonphosphaturic in the first stage of the disease, either because the tumors are resected early in the clinical course or because the patients osteomalacia was attributed to another cause. This article presents a case of a 42-year-old woman with a 2-year history of low back and right leg pain. Laboratory examinations including serum and urine calcium and phosphorous were within normal values. Imaging of the lumbar spine and pelvis showed an osteolytic lesion occupying the right sacral wing. Histology was unclear. Reverse-transcription polymerase chain reaction analysis for fibroblast growth factor-23 was positive and confirmed the diagnosis of phosphaturic mesenchymal tumor mixed connective tissues. Preoperative selective arterial embolization and complete intralesional excision, bone grafting, and instrumented fusion from L4 to L5 to the iliac wings bilaterally was performed. Postoperative recovery was uneventful. Neurological deficits were not observed. A lumbopelvic corset was applied for 3 months. At 12 months, the patient was asymptomatic. Serum and urine values of calcium and phosphorous were normal throughout the follow-up evaluation.

Anterior thigh flap extended hemipelvectomy and spinoiliac arthrodesis

We present the technique of anterior thigh flap extended external hemipelvectomy with spinoiliac arthrodesis in treatment of the patient with recurrent low-grade pelvic chondrosarcoma extending to the lower lumbar spine. Extended hemipelvectomy involves skeletal resection beyond the standard hemipelvectomy that is the SI joint by removal of contiguous musculoskeletal structures, such as elements of the sacral and lumbar spine or contralateral pelvic bone, in addition to the affected innominate bone. Spinoiliac arthrodesis reestablishes spinopelvic stability; the anterior thigh musculocutaneous flap provides reliable well-vascularized soft tissue coverage. This technique may serve an important role in the surgical management of patients with low-grade pelvic malignancies.

Cellular Response of the Tendon Sheath in Tendon Injury: ExperimentalResearch in New Zealand Rabbits

Purpose: We aimed to investigate the synovial sheath cell migration in response to flexor tendon injury under direct visualization. Methods: We used New Zealand rabbits based on an animal model described in previous studies, which we modified in order to create conditions similar to real tendon injury and healing. We used a special paint marker (1,1’-dioctadecyl1-3,3,3’,3’-tetramethylindocarbocyanine-percolate-Dil) of the sheath cells. The Flexor Digitorum Profondus first was sectioned through a distal skin incision and pulled outside the sheath through a proximal skin incision. Then the sheath was labeled. A second intrasynovial full thickness cross-section of the flexor was done and repaired by Kessler and running type suture. We harvested the tendons day 1, 3, 5, 7, 14 and 28 after tendon injury. Tendon sections were prepared with cryotomy and tested by infrared microscope. To evaluate our results, we divided the migration of synovial sheath cells in four phases: 1st phase) no or sporadic migration to the surface of the tendon, 2nd phase) massive migration to the surface of the tendon, 3rd phase) migration just below the surface of the tendon, and 4th phase) migration in the endotenon. For each day’s group the percentage of tendon sections in each phase of migration was determined. Results: According to our findings the second phase of migration of cells was 85% reached on the 3rd day, the third phase 66.6% reached on the seventh day and the fourth phase 50% reached on the fourteenth day after flexor tendon injury. Conclusions: This study confirms that the synovial sheath cells migrate first into the surface and later into the core of the healing tendon.

Reliability study for rib index.

Objectives The Rib Index, (RI), extracted from the double rib couture sign (DRCS) on lateral spinal radiographs to evaluate rib hump deformity in IS patients has been earlier introduced (Grivas at al 2000). Although various papers using the RI have been published, no study of its reproducibility was reported. To estimate the variations of the RI in a number of a pair set of lateral chest radiographs of healthy volunteers. The hypothesis was that the RI should have minimal variability for each patient having successive lateral radiographs.

Tuberculous Spondylitis of the Craniovertebral Junction

Craniovertebral junction tuberculosis is rare, accounting for 0.3 to 1% of all tuberculous spondylitis cases. MR imaging is the modality of choice to detect bone involvement, abscess formation and subligamentous spreading of the pus, to differentiate from other lesions affecting the craniovertebral junction, and to determine the efficacy of treatment. Given the fact that surgical treatment of patients with craniovertebral junction tuberculosis has been associated with a high mortality rate ranging up to 10% and recurrence rate ranging up to 20%, conservative is the standard of treatment for most patients. This article presents a patient with craniovertebral junction Mycobacterium tuberculosis infection diagnosed with CT-guided biopsy. A halo vest was applied and antituberculous treatment with rifampicin, isoniazid and ethambutol was initiated. At 6-month follow-up, the patient was asymptomatic; CT of the cervical spine showed healing of the bony lesions. The halo vest was removed and physical therapy was recommended. Antituberculous treatment was continued for a total of 18 months, without any evidence of infection recurrence