DOCSLIB.ORG

How to Work up a Nonunion and Potential Infection How to Work up A

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
How to Work up a Nonunion and Potential Infection How to Work up A 9/24/2015 PRE OPERATIVE PLANNING How to work up a Nonunion and Potential Infection If you could order ONE x-ray study for a the pre-op planning of a tibial nonunion ….it would be??? CT scan to determine if its hypertrophic vs atrophic MRI to elucidate infection status…infected nonunion??? Long alignment film PET / CT to determine infection AND biologic status of nonunion 4 cone down views of tibia, A/P, lateral, and 2 oblique views NON UNION CHARACTERIZATION DETERMINE TRUE PLANE OF DEFORMITY • METHODOLOGY OF CORRECTION OSTEOTOMY POSSIBLE? WITH REASONABLE EXPOSURE • LEVEL OF DEFORMITY LOCATION OF DEFORMITY LEVEL OF OSTEOTOMY • BIOLOGY OF NON‐UNION HYPERTROPHIC vs ATROPHIC 1 9/24/2015 ANALYSIS OF NONUNION BIOLOGY OF NONUNION • HYPERTROPHIC • ATROPHIC • SEPTIC BIOMECHANICAL CHARACTERIZATION EVALUATE “STABILITY” OF CONSTRUCT • MOTION ARTIFACT • BROKEN..LOOSE SCREWS • OSTEOLYSIS • CALLOUS…NO CALLOUS??? • PRIMARY FRACTURE LINE ORIENTATION CT EVALUATION…..helps in this regard 2 9/24/2015 OTA MINI SYMPOSIA 2014 Managing Nonunion: Theory and Practice Moderator: Christopher G. Moran, FRCS Faculty: Pierre Guy, MD; R. Malcolm Smith, MD John J. Wixted, MD STRESS / STRAIN COMMINUTED FRACTURES NEVER FORM A COMMINUTED NONUNION???? AS FRACTURES HEAL…. A DELAYED HEALING SEGMENT SEES MORE STRAIN….THUS CHANGES THE HEALING CURVE FOR THAT SEGMENT REDUCING STRAIN …….ALLOW SEGMENT TO HEAL……. 3 9/24/2015 STRAIN 6‐9 MONTHS NON UNION Fx Healed? TIME 4 9/24/2015 HEALING POTENTIAL 6‐9 MONTHS NON UNION Fx Healed? TIME STRAIN 6‐9 MONTHS HEALING POTENTIAL NON UNION Fx Healed? TIME UNION Strain 6‐9 MONTHS Decrease strain ( add stability) TIME 5 9/24/2015 UNION HEALING POTENTIAL 6‐9 MONTHS Augment healing potential ( add graft) TIME UNION STRAIN HEALING 6‐9 MONTHS POTENTIAL UNION Fx Healing? TIME CRUSH INJURY WITH COMPROMISED TISSUE DISTAL 1/3 TIBIA 6 9/24/2015 14 weeks post op 7 9/24/2015 WHEN IN DOUBT..OR TO BUY TIME…….GET A CT 6 WEEKS post lag screw 8 9/24/2015 9 9/24/2015 PRINCIPLES OF Rx HYPERTROPHIC NON-UNION MECHANICAL STABILIZATION “BIOLOGIC” SURGICAL APPROACH LIMITED NEED FOR BONE GRAFT ADJUVANTS PRINCIPLES OF Rx ATROPHIC NON-UNION MECHANICAL STABILIZATION PLUS PRINCIPLES OF Rx ATROPHIC NON-UNION PROVIDE BIOLOGIC STIMULUS SMALL DEFECTS• BMAC GRAFT + DBM • INDUCTIVE FACTORS (BMP’s, PDGF, PRP, DBM) LARGE DEFECTS• AUTOGRAFT –RIA, ILIAC CREST • VASCULARIZED TRANSPLANT • BONE TRANSPORT 10 9/24/2015 UNION STRAIN HEALING 6‐9 MONTHS POTENTIAL UNION Fx Healing? TIME ANALYSIS OF NON-UNION PREVIOUS TREATMENT • NON‐OPERATIVE • EXTERNAL FIXATION • IM NAILING • ORIF (must R/O infection) DEFORMITY CHARACTERIZATION DETERMINE MAXIMAL DEFORMITY • METHODOLOGY OF CORRECTION • ACUTE vs GRADUAL CORRECTION NERVE INJURY > 15O ACUTE CORRECTION UNLESS SHORTENING AT SAME TIME • CANAL MALALIGNMENT IM NAILING POSSIBLE? REVISION PLATING??? 11 9/24/2015 ANALYSIS OF NON-UNION DEFORMITY • ANGULATION • MALROTATION CT EVALUATION • LEG LENGTH DESCREPANCY • TRANSLATION RELATIVE ALIGNMENT OF MEDULLARY CANALS A/P ANGULATION LATERAL ANGULATION 12 9/24/2015 OBLIQUE PLANE DEFORMITY MAGNITUDE & DIRECTION 48 38 53 30 OBLIQUE PLANE DEFORMITY MAGNITUDE & DIRECTION 48 38 53 30 TRUE PLANE OF DEFORMITY 13 9/24/2015 DEFORMITY ANALYSIS MECHANICAL AXIS DEVIATION • FRONTAL PLANE DEFORMITIES • LEVEL DETERMINED BY INTERSECTION OF MECHANICAL AXIS FEMUR / TIBIA DEFORMITY ANALYSIS CORA • CENTER OF ROTATION AND ANGULATION… INTERSECTION OF ANATOMIC AXIS INTERSECTION OF MECHANICAL AXIS RELATIONSHIP OF ANGULATION TO TRANSLATION 14 9/24/2015 DEFORMITY ANALYSIS IF THE CORA IS NOT AT THE SAME LEVEL AS THE APEX OF THE DEFORMITY…..YOU HAVE A TRANSLATIONAL DEFORMITY AS WELL 15 9/24/2015 PROBLEMS PROBLEMS With any translation……ALWAYS HAS TO BE A COMPENSATORY MAL ROTATION 16 9/24/2015 1” block to level pelvis PROBLEMS • Malrotation 20 degrees Problems • Leg length 1in. • Translation 100% • Angulation 20 degrees • Mechanical axis deviation lateral • Malrotation 20 degrees • Hypertrophic • Infection 17 9/24/2015 Hypertrophic, translation, malrotation, angulation, LLD ANALYSIS OF INFECTION PREVIOUS TREATMENT NON‐OPERATIVE EXTERNAL FIXATION IM NAILING ORIF HOW TO R/O INFECTION??? 18 9/24/2015 INFECTED NONUNION?? HOW TO MAKE DIAGNOSIS PRE –OP • POTENTIAL STAGED RECONSTRUCTION The workup for a “suspected” infected non-union should routinely include Indium labeled WBC scan Intra‐op path (WBC per HPF) Gallium subtraction bone scan MRI with and without contrast PET / CT to determine infection AND biologic status of nonunion WBC, WSR, CRP WBC, WSR,CRP, intra‐op path PRE –OP STUDIES SPECIFIC FOR INFECTION? RADIOGRAPHIC STUDIES • PLAIN FILMS • CT SCANS • MRI • NUCLEAR MEDICINE BONE SCAN WBC / INDIUM LABELED GALLIUM 19 9/24/2015 GALLIUM SCAN ? BONE SCAN INDIUM SCAN MRI…..SENSITIVE……. …BUT NOT SPECIFIC FOR INFECTION PRE – OP - INTRA –OP STUDIES LABORATORY STUDIES • WBC • WSR • CRP PATHOLOGY • SINUS TRACT CULTURE • INTRA‐OP GRAM STAIN • INTRA‐OP BIOPSY 20 9/24/2015 ….WHAT SHOULD I ORDER? WHAT TESTS MAKE THE MOST SENSE………… PERI-OPERATIVE DIAGNOSIS OF INFECTION IN NONUNIONS / ACUTE Fx PRE OP BLOOD WORK • WBC • CRP • ESR COMBINED INDIUM WBC / BONE SCAN INTRA OP gm STAIN INTRA OP DEEP CULTURES TORNETTA et. al….AAOS 2011 WHAT DO THE RESULTS MEAN? PPV…POSITIVE PREDICTIVE VALUE • PROBABILITY THAT THE pt. HAS THE INFECTION COMPARED TO ALL THE PTS THAT ARE INFECTED 21 9/24/2015 WHAT DO THE RESULTS MEAN? NPV…NEGATIVE PREDICTIVE VALUE . PROBABILITY THAT THE pt. DOES NOT HAVE INFECTION ….. COMPARED TO THE ALL PTS THAT ARE NOT INFECTED WBC SCAN RESULTS PPV……50% NPV…..72% CRP RESULTS PPV……54% NPV…..75% 22 9/24/2015 ESR RESULTS PPV……58% NPV…..80% WBC > 11,000 PPV……50% NPV…..70% PATH WBC’S >3 HPF PPV……40% NPV…..81% 23 9/24/2015 RESULTS NO SINGLE TEST WAS INDEPENTLY ACCURATE…….. COMBINATION OF RISK FACTORS USED TO CALCULATE OVERT INFECTION RISK RESULTS RISK FACTORS . ELEVATED WBC, ESR, CRP, AND + SCAN . FOR 0,1,2,3 RISK FACTORS BEING + PPV…O‐22%, 1‐36%, 2‐57%, 3‐83% RESULTS ELIMINATED NUCLEAR SCANS WBC, ESR, AND CRP PPV….O‐25%, 1‐27%. 2‐58%, 3‐100% 24 9/24/2015 RECOMMEND SIMPLE BLOOD TEST ‘s ‐ CRP, ESR, WBC’’s ‐ INTRA‐OPERATIVE WBC/HPF Stucken C, Olszewski DC, Creevy WR, Murakami AM, Tornetta P. Preoperative Diagnosis Of Infection In Patients With Nonunions. J Bone Joint Surg Am. 2013 Aug 7;95(15):1409‐12 FACTORS AFFECTING BONE HEALING PHYSIOLOGIC STEROIDS DIABETES HYPERVITAMINOSIS A & D CASTRATION ANEMIA RADIATION Ca++ METABOLISM BRINKER et.al FACTORS AFFECTING BONE HEALING PHYSIOLOGIC SMOKING!!!!! • NICOTINE….DIRECT TOXIN TO OSTEOBLASTS • INHIBIT COLLAGEN SYNTHESIS • DECREASE OXYGEN CARRYING CAPACITY • PERIPHERAL VASCULAR EFFECT 25 9/24/2015 MAKE PROBLEM LIST CHARACTERIZE NONUNION TYPE • BIOLOGIC • BIO‐MECHANICAL DETERMINE DEFORMITY PARAMETERS EVALUATE POTENTIAL INFECTION STATUS METABOLIC QUALIFIERS Infected distal nonunion with LLD, malrotation, deformity, mechanical axis deviation 26 9/24/2015 PRE-OP PROBLEM LIST BONE LOSS INFECTED DEFORMITY LEG LENGTH DESCREPANCY 27 9/24/2015 WHEN TREATING A NON UNION……..IT’S PROBABLY BETTER NOT TO SCREW UP IF YOU DON’T HAVE TO……. Vert Mooney….Chair U.T. Southwest 1987 Busch Stadium, PMD007379-1.0 Busch Stadium, 28 9/24/2015 CONSTRUCT INSTABILITY 29 9/24/2015 30.
Load more

Recommended publications
  • Pycnodysostosis with a Cathepsin K Mutation: a Case Report
    Ada Medica et Biologica Vol. 49, No.l, 31-37, 2001 Pycnodysostosis with a Cathepsin K Mutation: A Case Report Hiroshi YAMAGIWA1, Mayumi ASAOKA2, Hisayoshi KATO2, Minoru SHIBATA3, and Naoto ENDO1 'Department of Orthopedic Surgery, "Rehabilitation, and 3Plastic Surgery, Niigata University School of Medicine, Niigata, Japan Received October 16 2000 ; accepted January 22 2001 Summary.Pycnodysostosis (PKND) is a type of osteo- the distal phalanges, frequent fractures, and skull sclerosing bone disease. Recent studies have demon- deformities with delayed suture closure4'5'. The cathe- strated that several cathepsin K mutations can be psin K gene, which wa cloned originally from rabbit identified in PKND families. A fifty-three-year-old Japanese womandiagnosed with PKND with typical osteoclasts6', was highly expressed in osteoclasts. features suffered from the nonunion of the right tibial This molecule plays an important role in bone resorp- shaft. We did open reduction and performed a vascular- tion and remodeling. Cathepsin K knockout mice ized fibular graft using an external fixator. A low- show impaired osteoclastic bone resorption, which intensity pulsed ultrasound device was used three leads to osteopetrosis7'8). Recent studies have demon- months after surgery. Union of the tibia was completed strated several mutations in patients with about one year after surgery. Histomorphometric anal- PKND1'9-10'11'. In this paper, we present a clinical, ysis of the iliac bone revealed that the patient had low histomorphometric, and genomic study of a patient turnover bone with increased bone volume. Analysis of with the typical form of pycnodysostosis. Since the cathepsin K coding region from the genomic DNA parental consanguinity has been noted in more than of the patient and her family (consanguineous parents 30% of cases, we also analyzed her consanguineous and three sisters who were all of normal stature) revealed that the patient had a deletion of genomic parents and three sisters.
    [Show full text]
  • Distal Humerus Nonunion After Failed Internal Fixation: Reconstruction with Total Elbow Arthroplasty Dawn M
    (aspects of trauma • an original study) Distal Humerus Nonunion After Failed Internal Fixation: Reconstruction With Total Elbow Arthroplasty Dawn M. LaPorte, MD, Michael S. Murphy, MD, and J. Russell Moore, MD ABSTRACT onunion occurs in 2% ing treatment option. In the 1980s, In nonunion after distal humerus to 5% of distal humerus TEA for nonunion with tightly con- fracture, osteoporosis, devas- fractures.1 The condition strained or custom prostheses had cularized fracture fragments, is difficult to treat, and fair to moderately good results but and periarticular fibrosis limit Nno single treatment modality has a high complication rates (4/7, 57%6; potential reconstructive options. high success rate with few compli- 5/14, 36%10). According to a recent We assessed pain relief, func- 2-6 11 tional gains, and complications cations. Without intervention, the review, however, 31 (86%) of 36 in 12 patients whose long-stand- patient is left with a painful, unstable, patients had a satisfactory result with ing, painful nonunions after previ- and often flail extremity and with a semiconstrained prosthesis, and ous treatment with rigid internal limitations in activities of daily liv- only 7 (19%) of the 36 patients had fixation were reconstructed with ing. Frequently, there is an associ- complications. a semiconstrained total elbow ated ulnar neuropathy. Osteoporosis, In the current study, we assessed arthroplasty, frequently with a devascularized fracture fragments, outcomes (complications, symptoms, triceps-sparing approach and and periarticular fibrosis limit poten- function) after semiconstrained anterior ulnar nerve transposition. tial reconstructive options for long- TEA for long-standing distal humer- At mean follow-up of 63 months, 11 patients had good pain relief and standing distal humerus nonunions.
    [Show full text]
  • Nonunion with Bone Loss
    Nonunion with Bone Loss Tim Weber, MD Jeff Anglen, MD, FACS Original Authors; March 2004; Revised June 2006 and 2010 Etiology • Open fracture – segmental – post debridement – blast injury • Infection • Tumor resection • Osteonecrosis Classification Salai et al. Arch Orthop Trauma Surg 119 Classification Not Widely Used Not Validated Not Predictive Salai et al. Arch Orthop Trauma Surg 119 Evaluation • Soft tissue envelope • Infection • Joint contracture and range of motion • Nerve function: sensation, motor • Vasculature: perfusion, angiogram? • Location and size of defect • Hardware • General health of the host • Psychosocial resources Is it Salvageable? • Vascularity - warm ischemia time • Intact sensation or tibial nerve transection • other injuries • Host health • magnitude of reconstructive effort vs patient’s tolerance • ultimate functional outcome Priorities • Resuscitate • Restore blood supply • Remove dead or infected tissue (Adequate debridement) • Restore soft tissue envelope integrity • Restore skeletal stability • Rehabilitation Bone Loss - Initial Treatment • Irrigation and Debridement Bone Loss - Initial Treatment • Irrigation and Debridement • External fixation Bone Loss - Initial Treatment • Irrigation and Debridement • External fixation • Antibiotic bead spacers Bone Loss - Initial Treatment • ANTIBIOTIC BEAD POUCH – ANTIBIOTIC IMPREGNATED METHYL- METHACRALATE BEADS – SEALED WITH IOBAN Bone Loss - Initial Treatment • Irrigation and Debridement • External fixation • Antibiotic block spacers Beads Block Bone Loss - Initial
    [Show full text]
  • Bone Marrow Injection for Treatment of Aneurysmal Bone Cyst
    MOJ Orthopedics & Rheumatology Bone Marrow Injection for Treatment of Aneurysmal Bone Cyst Research Article Abstract Volume 5 Issue 3 - 2016 Study design: Patients had Aneurysmal bone cyst lesion that underwent to be treated by Injection of Autologous Bone Marrow Aspirates (ABM) and follow up of this case for the final results. Patients and Methods: Sixteen patients had had Aneurysmal bone cyst had been treated by ABM injections. Study have 16 patients 11 females (68.75 %) and 5 Department of Orthopedics, Faculty of Medicine, Egypt Mahmoud I Abdel-Ghany, Assistant male (31.25 %). Age ranged from 3-14 years with average age 7.5 years. Number *Corresponding author: study including 5 cases (31.25 %) with proximal femoral cyst, 9 cases (56.25 %) Professor of Orthopedic and Trauma Surgery Faculty of of injections for every patient ranged from 2-6 times with average 4.4 times. This had tibial cyst (2 distal and 7 proximal tibiea) and 2 cases (12.5 %) had proximal Medicine for Girls, Egypt, Email: humeral cyst. All patients treated by injection of Autologous Bone Marrow Aspirates which obtained from the iliac crest. The bone marrow aspirates was Received: February 26, 2016 | Published: July 29, 2016 obtained percutaneous by bone marrow aspiration needle, According to follow up X-ray during injections we decide continuity of injections. Average size of the defect was 2.3 cm. and average amount bone marrow/inj. Was 10.2 cc. Results: Pain Score according to VAS ranged from 3-9 with average 5.7 which was improved to average 1.5 at final follow up.
    [Show full text]
  • Brown Tumour in the Cervical Spine : Case Report and Review of Literature
    http://crcp.sciedupress.com Case Reports in Clinical Pathology 2019, Vol. 6, No. 1 CASE REPORT Brown tumour in the cervical spine : Case report and review of literature S Carta1, A Chungh1, SR Gowda∗1, E Synodinou2, PS Sauve1, JR Harvey1 1Department of Trauma and Orthopaedics, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, UK 2Wessex Kidney Centre, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, UK Received: September 16, 2019 Accepted: October 18, 2019 Online Published: October 30, 2019 DOI: 10.5430/crcp.v6n1p27 URL: https://doi.org/10.5430/crcp.v6n1p27 ABSTRACT Background: Brown tumour of the cervical spine is very rare and is formed due to focal altered bone remodelling secondary to persistent and uncontrolled primary or secondary hyperparathyroidism. It is considered an extreme form of osteitis fibrosa cystica that occurs in the settings of persistently elevated parathyroid hormone. Case Report: This a unique lesion presented in a 48 year old male with recurrent bone pain and known End Stage Renal Disease (ESRD) on maintenance haemodialysis. The main clinical complaints were weak and painful legs and the initial presentation was after the patient collapsed at home and fractured spinal level C2. The initial assessment included blood tests and radiological imaging. CT scanning of the spine revealed a destructive lytic lesion with loss of height and architectural changes of the C2 vertebral body and cord compression. The differentials included an acute fracture, a metastatic lesion and Brown’s tumour. Further imaging with an MRI of the spine and PET-CT were performed which confirmed the above lesion and excluded metastatic disease and bone marrow infiltration.
    [Show full text]
  • General Principles in the Assessment and Treatment of Nonunions
    General Principles in the Assessment and Treatment of Nonunions Jaimo Ahn, MD, PhD & Matthew Sullivan, MD Revised February 2017 Previous Authors: Peter Cole, MD; March 2004 Matthew J. Weresh, MD; Revised August 2006 Hobie Summers, MD & Daniel S. Chan MD; Revised April 2011 Definitions • Nonunion: (reasonably arbitrary) – A fracture that is not currently healed and is not going to • Delayed union: – A fracture that requires more time than usual to heal – Shows healing progress over time Definitions • Nonunion: A fracture that is a minimum of 9 months post occurrence and is not healed and has not shown radiographic progression for 3 months (FDA 1986) • Not pragmatic – Prolonged morbidity – Narcotic abuse – Professional and/or emotional impairment Definitions (pragmatic) • Nonunion: A fracture that has no potential to heal without further intervention All images unless indicated: Rockwood and Green's Fractures in Adults, 8th Edition 2015 Classification 1. Hypertrophic 2. Oligotrophic 3. Atrophic = Avascular 4. Pseudarthrosis Weber and Cech, 1976 Hypertrophic • Vascularized • Callus formation present on x-ray • “Elephant’s foot” - abundant callus • “Horse’s hoof” - less abundant callus Biology is more than sufficient but can’t consolidate likely need mechanically favorable solution Oligotrophic • Some/minimal callus on x-ray – Not an aggressive healing response, but not completely void of biologic activity • Vascularity is present on bone scan Is there sufficient biology / mechanics for healing? Atrophic • No evidence of callous formation
    [Show full text]
  • Nonunions: Evaluation 10022 and Treatment
    10022 CHAPTER 22 Nonunions: Evaluation 10022 and Treatment ......................................................... Mark R. Brinker, M.D. and Daniel P. O’Connor, Ph.D. a fracture that, in the opinion of the treating physician, s0010 INTRODUCTION shows slower progression to healing than anticipated and p0010 While fracture nonunions may represent a small percent- is at risk of nonunion without further intervention. age of the traumatologist’s case load, they can account for To understand the biological processes and clinical impli- p0070 a high percentage of a surgeon’s stress, anxiety, and frustra- cations of fracture nonunion, an understanding of the normal tion. Arrival of a fracture nonunion may be anticipated fracture healing process is required. The following section following a severe traumatic injury, such as an open fracture reviews the local biology of fracture healing, requirements with segmental bone loss, but may also appear following a for fracture union, and types of normal fracture repair. low-energy fracture that seemed destined to heal. p0020 Fracture nonunion is a chronic medical condition asso- FRACTURE REPAIR ciated with pain and functional and psychosocial disabil- s0030 180 ity. Because of the wide variation in patient responses Fracture repair is an astonishing process that involves p0080 to various stresses177 and the impact that may have on the spontaneous, structured regeneration of bony tissue and patient’s family (relationships, income, etc.), these cases restores mechanical stability. The process begins at the are often difficult to manage. moment of bony injury, initiating a proliferation of tissues p0030 Some 90 to 95 percent of all fractures heal without pro- that ultimately leads to healing.
    [Show full text]
  • Pycnodysostosis with Special Emphasis on Dentofacial Characteristics
    Hindawi Publishing Corporation Case Reports in Dentistry Volume 2015, Article ID 817989, 6 pages http://dx.doi.org/10.1155/2015/817989 Case Report Pycnodysostosis with Special Emphasis on Dentofacial Characteristics Aisha Khoja, Mubassar Fida, and Attiya Shaikh Section of Dentistry, Department of Surgery, The Aga Khan University Hospital, Stadium Road, P.O. Box 3500, Karachi 74800, Pakistan Correspondence should be addressed to Aisha Khoja; [email protected] Received 24 August 2015; Revised 24 October 2015; Accepted 2 November 2015 Academic Editor: Miguel de Araujo´ Nobre Copyright © 2015 Aisha Khoja et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Pycnodysostosis is an autosomal recessive disorder that manifests as osteosclerosis of the skeleton due to the defective osteoclasts mediated bone turnover. The diagnosis of this disorder is established on the basis of its characteristic features and mustbe differentially diagnosed with other bone disorders. Dental surgeons should be aware of the limitations and possible adverse oral complications such as osteomyelitis of bone in these patients. This will guide them in planning realistic treatment goals. This paper reports the clinical and radiographic features of pycnodysostosis with the great emphasis on its dentofacial characteristics. The aim of this case report is to give an insight into the etiology, pathogenesis, and differential diagnosis of this disorder and to prepare the dentists and maxillofacial surgeons to overcome the challenges in treating these patients. 1. Introduction Dental surgeons should be familiar of the classic features of this disorder in order to establish correct and timely Pycnodysostosis is a rare genetic disorder of the bone diagnosis especially when they are the first to encounter these caused by a mutation in the gene that codes the enzyme patients.
    [Show full text]
  • Percutaneous Reaming of Simple Bone Cysts in Children Followed by Injection of Demineralized Bone Matrix and Autologous Bone Marrow Anastasios D
    ORIGINAL ARTICLE Percutaneous Reaming of Simple Bone Cysts in Children Followed by Injection of Demineralized Bone Matrix and Autologous Bone Marrow Anastasios D. Kanellopoulos, MD,* Christos K. Yiannakopoulos, MD,* and Panayiotis N. Soucacos, MD† form in response to venous congestion of the intramedullary Abstract: The authors report the successful treatment of 19 patients space. The latter theory has been supported by others who (mean age 10 years) with active unicameral bone cysts using were able to achieve cyst healing, restoring the venous circu- a combination of percutaneous reaming and injection of a mixture of lation simply by performing multiple perforations.5,9–12 demineralized bone matrix and autologous bone marrow. Follow-up Various treatment modalities have been proposed, ranging ranged from 12 to 42 months (mean 28 months). All patients were from subtotal resection to normal saline injection. The reported asymptomatic at the latest follow-up. Two required a second inter- results are puzzling, since the aggressiveness of the lesions vention to accomplish complete cyst healing. Radiographic outcome treated is rarely defined.9,10,13–20 was improved in all patients according to the Neer classification at the Scaglietti15 described a methylprednisolone injection latest follow-up. There were no significant complications related to technique, reporting a 15% to 88% recurrence rate after an the procedure, nor did any fracture occur after initiation of the above average of three injections. Superior results were reported regimen. using an osteoinductive preparation consisting of demineral- 13,14,21 Key Words: bone marrow, unicameral bone cyst, demineralized bone ized bone matrix (DBM) and autologous bone marrow.
    [Show full text]
  • Management Strategy for Unicameral Bone Cyst
    Management of unicameral bone cyst MANAGEMENT STRATEGY FOR UNICAMERAL BONE CYST Chin-Yi Chuo, Yin-Chih Fu, Song-Hsiung Chien, Gau-Tyan Lin, and Gwo-Jaw Wang Department of Orthopedic Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan. The management of a unicameral bone cyst varies from percutaneous needle biopsy, aspiration, and local injection of steroid, autogenous bone marrow, or demineralized bone matrix to the more invasive surgical procedures of conventional curettage and grafting (with autogenous or allogenous bone) or subtotal resection with bone grafting. The best treatment for a unicameral bone cyst is yet to be identified. Better understanding of the pathology will change the concept of management. The aim of treatment is to prevent pathologic fracture, to promote cyst healing, and to avoid cyst recurrence and re-fracture. We retrospectively reviewed 17 cases of unicameral bone cysts (12 in the humerus, 3 in the femur, 2 in the fibula) managed by conservative observation, curettage and bone grafting with open reduction and internal fixation, or continuous decompression and drainage with a cannulated screw. We suggest percutaneous cannulated screw insertion to promote cyst healing and prevent pathologic fracture. We devised a protocol for the management of unicameral bone cysts. Key Words: unicameral bone cyst, UBC, simple bone cyst, SBC, cannulated screw (Kaohsiung J Med Sci 2003;19:289–95) The unicameral bone cyst (UBC) or simple bone cyst The treatment of UBC includes: conservative (SBC) is encountered in the pediatric age group, with management to allow spontaneous healing during the majority of cases occurring in the first two decades puberty; curettage and grafting with autogenous or of life — with most around the age of 12 years [1,2].
    [Show full text]
  • The Generalized Type, However, Has Received
    THE GENERALIZED TYPE OF OSTEITIS FIBROSA CYSTICA VON RECKLINGHAUSEN'S DISEASE JOHN J. MORTON, M.D. Assistant Professor of Surgery, Yale University School of Medicine NEW HAVEN, CONN. INTRODUCTION The localized form of osteitis fibrosa, especially in its relation to the formation of bone cysts, has been very commonly recognized and com- mented upon during the last twenty years. Bloodgood,1 in numerous publications, and also Barrie,2 Silver,3 and Meyerding,4 have furnished valuable contributions to the American literature; and Elmslie5 has given a good summary of the English cases. The Germans have written at length on the subject. The generalized type, however, has received scant attention, possibly because it is not recognized; and, aside from the article by L\l=o"\tsch,6 no extensive publication has been devoted entirely to this form of the disease, although both Meyerding and Elmslie discuss the generalized cases in their papers. It seemed worth while, therefore, to report the subjoined case: first, because of the rarity of the condition, especially in the United States, and secondly, because of the possibility of correcting some of the deformities arising in this disease. At the same time, it was considered advisable to collect the reports of general types of the disease in order to find what might be learned from them. report of case History.—A man, aged 23, a lathe operator, was referred, Nov. 14, 1919, by Dr. Stanley Cox of Holyoke, Mass., complaining of bowing of the thigh bones. Except for the usual children's diseases, the history was essentially negative.
    [Show full text]
  • Orthognathic Surgery in Pycnodysostosis: a Case Report
    110 Herna´ndez-Alfaro et al. Case Report Congenital Craniofacial Deformities F. Herna´ndez-Alfaro1, J. Arenaz Bu´ a2, M. Serra Serrat3, Orthognathic surgery in J. Mareque Bueno1 1Department Oral and Maxillofacial Surgery Teknon Medical Center, Barcelona, Spain; pycnodysostosis: a case report 2Department of Oral and Maxillofacial Surgery, Complejo Hospitalario Universitario de A Corun˜a, Spain; 3Orthodontist, Barcelona, Spain F. Herna´ndez-Alfaro, J. Arenaz Bu´a, M. Serra Serrat, J. Mareque Bueno: Orthognathic surgery in pycnodysostosis: a case report. Int. J. Oral Maxillofac. Surg. 2011; 40: 106–123. # 2010 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. Pycnodysostosis is an extremely rare genetic osteosclerosis caused by cathepsin K deficiency. It is a human autosomal recessive genetic disorder characterized mainly by osteosclerosis of the skeleton due to decreased bone turnover. It is characterized by short stature, brachycephaly, short and stubby fingers, open cranial sutures and fontanelle, and diffuse osteosclerosis. Multiple fractures of the long bones and osteomyelitis of the jaw are frequent complications. The authors describe an 18-year-old girl with a clinical and radiological diagnosis of pycnodysostosis and the ortho-surgical treatment undertaken. Bimaxillary orthognathic surgery was carried out using rigid fixation and bone grafts. The authors recommend bimaxillary orthognathic surgery as a choice for treating the dentofacial deformities of pycnodysostosis, emphasizing the good and stable results Accepted for publication 19 July 2010 obtained in terms of facial aesthetics and occlusion. Available online 21 August 2010 Pycnodysostosis is a rare osteopetrotic nodysostosis are abnormally dense and narrowing of the airway1–3,5–7,10.
    [Show full text]