Supramalleolar lateral closing wedge osteotomy for the treatment of varus ankle arthrosis

BACKGROUND: Medial ankle joint pain with localized cartilage degeneration due to medial joint overload in varus malalignment of the hindfoot lends itself to treatment by lateral closing wedge supramalleolar osteotomy. METHODS: From 1998 to 2003, nine patients between the ages of 21 to 59 years were operated. The etiology of the malalignment and degeneration was posttraumatic in eight and childhood osteomyelitis in one. Preoperative and postoperative standing radiographs were analyzed to determine the correction of the deformity and the grade of degeneration. Function and pain were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale. The average followup was 56 (range 15 to 88) months. RESULTS: The average time to osseous union was 10 +/- 3.31 weeks. There were no operative or postoperative complications. The average AOFAS score improved from 48 +/- 16.0 preoperatively to 74 +/- 11.7 postoperatively (p<0.004). The average pain subscore improved from 16 +/- 8.8 to 30 +/- 7.1 (p<0.008). The average tibial-ankle surface angle improved from 6.9 +/- 3.8 degrees of varus preoperatively to 0.6 +/- 1.9 degrees of valgus postoperatively (p<0.004). In the sagittal plane, the tibial-lateral-surface angle remained unchanged. At the final followup, two patients showed progression of radiographic ankle arthrosis grades. In one patient, it rose from grade 0 to I. In the other patient it advanced from grade II to III, with subsequent ankle arthrodesis required 16 months after the index procedure. Seven patients returned to their previous work. CONCLUSIONS: Lateral supramalleolar closing wedge osteotomy was an easy and safe procedure, effectively correcting hindfoot malalignment, relieving pain, restoring function, and halting progression of the degeneration in the short-term to mid-term in seven of nine patients.

Outcome and patients' satisfaction after functional treatment of acute lateral ankle injuries at emergency departments versus family doctor offices

BACKGROUND: In some Western countries, more and more patients seek initial treatment even for minor injuries at emergency units of hospitals. The initial evaluation and treatment as well as aftercare of these patients require large amounts of personnel and logistical resources, which are limited and costly, especially if compared to treatment by a general practitioner. In this study, we investigated whether outsourcing from our level 1 trauma center to a general practitioner has an influence on patient satisfaction and compliance. METHODS: This prospective, randomized study, included n = 100 patients who suffered from a lateral ankle ligament injury grade I-II (16, 17). After radiological exclusion of osseous lesions, the patients received early functional treatment and were shown physical therapy exercises to be done at home, without immobilization or the use of stabilizing ortheses. The patients were randomly assigned into two groups of 50 patients each: Group A (ER): Follow-up and final examination in the hospital's emergency unit. Group B (GP): Follow-up by general practitioner, final examination at hospital's emergency unit. The patients were surveyed regarding their satisfaction with the treatment and outcome of the treatment. RESULTS: Female and male patients were equally represented in both groups. The age of the patients ranged from 16 - 64 years, with a mean age of 34 years (ER) and 35 years (GP). 98% (n = 98) of all patients were satisfied with their treatment, and 93% (n = 93) were satisfied with the outcome. For these parameters no significant difference between the two groups could be noted (p = 0.7406 and 0.7631 respectively). 39% of all patients acquired stabilizing ortheses like ankle braces (Aircast, Malleoloc etc.) on their own initiative. There was a not significant tendency for more self-acquired ortheses in the group treated by general practicioners (p = 0,2669). CONCLUSION: Patients who first present at the ER with a lateral ankle ligament injury grade I-II can be referred to a general practitioner for follow-up treatment without affecting patient satisfaction regarding treatment and treatment outcome.

Lateral external fixation: a new surgical technique for displaced unreducible supracondylar humeral fractures in children

BACKGROUND: Percutaneous Kirschner wire fixation represents the classic treatment for displaced supracondylar humeral fractures in childhood. This type of treatment first requires satisfactory reduction of the fracture. Failure to achieve a satisfactory reduction or inadequate stabilization can result in instability of the fracture fragments, which can result in either an unsatisfactory cosmetic or functional outcome. In our experience, these problems can be overcome with the use of a small lateral external fixator. METHODS: Between 1999 and 2005, thirty-one of 170 Gartland type-III supracondylar humeral fractures were treated with a lateral external fixator. The outcome of treatment was analyzed with regard to limb alignment, elbow movement, cosmetic appearance, and patient satisfaction. RESULTS: In twenty-eight of the thirty-one patients, a satisfactory reduction was achieved with closed methods. All children except one had a normal or good range of movement. The cosmetic result was excellent in all cases. All of the children and their parents stated that they would choose this treatment again. CONCLUSIONS: The use of a small lateral external fixator seems to be a safe alternative for the treatment of displaced supracondylar fractures of the humerus when a closed reduction appears to be unattainable by means of manipulation alone or when sufficient stability is not achieved with standard methods of Kirschner wire fixation.

PHYLOGENETIC ANALYSES, GENE DOSAGE EFFECT AND SELECTION IN MEMBERS OF THE LATERAL BOUNDARY DOMAIN (LBD) GENES TRANSCRIPTION FACTOR FAMILY

Wood formation is an economically and environmentally important process and has played a significant role in the evolution of terrestrial plants. Despite its significance, the molecular underpinnings of the process are still poorly understood. We have previously shown that four Lateral Boundary Domain (LBD) transcription factors have important roles in the regulation of wood formation with two (LBD1 and LBD4) involved in secondary phloem and ray cell development and two (LBD15 and LBD18) in secondary xylem formation. Here, we used comparative phylogenetic analyses to test potential roles of the four LBD genes in the evolution of woodiness. We studied the copy number and variation in DNA and amino acid sequences of the four LBDs in a wide range of woody and herbaceous plant taxa with fully sequenced and annotated genomes. LBD1 showed the highest gene copy number across the studied species, and LBD1 gene copy number was strongly and significantly correlated with the level of ray seriation. The lianas, cucumber and grape, with multiseriate ray cells showed the highest gene copy number (12 and 11, respectively). Because lianas’ growth habit requires significant twisting and bending, the less lignified ray parenchyma cells likely facilitate stem flexibility and maintenance of xylem conductivity. We further demonstrate conservation of amino acids in the LBD18 protein sequences that are specific to woody taxa. Neutrality tests showed evidence for strong purifying selection on these gene regions across various orders, indicating adaptive convergent evolution of LBD18. Structural modeling demonstrates that the conserved amino acids have a significant impact on the tertiary protein structure and thus are likely of significant functional importance.

Lateral meniscal cyst causing common peroneal palsy

Lateral meniscal cysts are relatively common, but only in rare instances do they cause common peroneal nerve irritation. There are, we believe, no cases reported in which both the sensory and motor functions of the nerve have been compromised. We present a case of a lateral meniscal cyst that became palpable and led to symptoms of numbness and weakness in the distribution of the common peroneal nerve. The MRI findings were of an oblique tear of the lateral meniscus with an associated multiloculated meniscal cyst that coursed behind the biceps tendon before encroaching on the common peroneal nerve. Surgical resection confirmed the tract as located on the MRI and histology confirmed the mass to be a synovial cyst. Resection of the cyst and arthroscopic excision of the meniscal tear led to resolution of the symptoms in 3 months.

Mini-arthrotomy for lateral discoid menisci in children

BACKGROUND: Long-term results after partial, extended, or complete resection of lateral discoid meniscus in children revealed knee arthritis. The purpose of this study was to evaluate whether the operative approach, arthrotomy or arthroscopy, has an impact on the outcome and the development of arthritis. METHODS: A retrospective comparison of 2 well matching groups totaling 40 children with symptomatic lateral discoid meniscus (48 knees, mean age 8.9 years, 13 male and 27 female patients). Meniscus resection was performed via mini-arthrotomy in group 1 (n=17 patients, 20 knees) and arthroscopically in group 2 (n=23 patients, 28 knees). RESULTS: In the follow-up (mean 57 months in group 1, 62 months in group 2), functional results indicated a trend to better results in the International Knee Documentation Committee score (P=0.12) and in the Lysholm score for group 1 (P=0.13) but not in the Ikeuchi score (P=0.48). The comparison of the radiographic arthritis grading in the follow-up showed no significant arthritis in either group (P=0.22). The overall complication rate was similar in both groups (2/20, 10% in group 1; 3/28, 12% in group 2). CONCLUSIONS: Most likely because of the appropriate visualization of the children's joint and the easier instrumentation, the mini-arthrotomy led to slightly superior results compared with those after arthroscopic resection regarding functional outcome and 5 years after surgery. We can recommend the mini-arthrotomy for the resection of lateral discoid meniscus particularly in young children with narrow joint spaces and for surgeons that are not familiar with arthroscopies of small joints. LEVEL OF EVIDENCE: III (therapeutic study, case series with control group).

Biomechanical analysis of torsion and shear forces in lumbar and lumbosacral spine segments of nonchondrodystrophic dogs

OBJECTIVE: To determine stiffness and load-displacement curves as a biomechanical response to applied torsion and shear forces in cadaveric canine lumbar and lumbosacral specimens. STUDY DESIGN: Biomechanical study. ANIMALS: Caudal lumbar and lumbosacral functional spine units (FSU) of nonchondrodystrophic large-breed dogs (n=31) with radiographically normal spines. METHODS: FSU from dogs without musculoskeletal disease were tested in torsion in a custom-built spine loading simulator with 6 degrees of freedom, which uses orthogonally mounted electric motors to apply pure axial rotation. For shear tests, specimens were mounted to a custom-made shear-testing device, driven by a servo hydraulic testing machine. Load-displacement curves were recorded for torsion and shear. RESULTS: Left and right torsion stiffness was not different within each FSU level; however, torsional stiffness of L7-S1 was significantly smaller compared with lumbar FSU (L4-5-L6-7). Ventral/dorsal stiffness was significantly different from lateral stiffness within an individual FSU level for L5-6, L6-7, and L7-S1 but not for L4-5. When the data from 4 tested shear directions from the same specimen were pooled, level L5-6 was significantly stiffer than L7-S1. CONCLUSIONS: Increased range of motion of the lumbosacral joint is reflected by an overall decreased shear and rotational stiffness at the lumbosacral FSU. CLINICAL RELEVANCE: Data from dogs with disc degeneration have to be collected, analyzed, and compared with results from our chondrodystrophic large-breed dogs with radiographically normal spines.

[Navigation and robotics of the lateral skull base]

Computer-aided microscopic surgery of the lateral skull base is a rare intervention in daily practice. It is often a delicate and difficult minimally invasive intervention, since orientation between the petrous bone and the petrous bone apex is often challenging. In the case of aural atresia or tumors the normal anatomical landmarks are often absent, making orientation more difficult. Navigation support, together with imaging techniques such as CT, MR and angiography, enable the surgeon in such cases to perform the operation more accurately and, in some cases, also in a shorter time. However, there are no internationally standardised indications for navigated surgery on the lateral skull base. Miniaturised robotic systems are still in the initial validation phase.

Right ventricular rupture after lateral thoracotomy for removal of rib-associated telangiectatic osteosarcoma in a dog

OBJECTIVE: To describe a case of a focal right ventricular rupture following removal of a rib-associated telangiectatic osteosarcoma (TOS) in a dog. CASE SUMMARY: A 2-year-old spayed female mixed-breed dog, weighing 20 kg, was presented in compensated hypovolemic shock due to active bleeding into the thoracic cavity. The dog was stabilized with appropriate fluid administration. Subsequent computed tomographic examination revealed a large mineralized mass originating from the body of a rib and displacing the heart. Two days after surgical removal of this mass, focal right ventricular rupture occurred and the dog died. The mass was later identified as a TOS. NEW OR UNIQUE INFORMATION PROVIDED: Although hemothorax secondary to TOS has been described previously, this report describes for the first time, spontaneous focal right ventricular rupture as a rare complication of thoracotomy and rib resection for the removal of a rib-associated, intrathoracic TOS.

Chronic intervertebral disk herniation associated with fused vertebrae treated by vertebral lateral corpectomy in a cat

A 10-year-old Domestic Shorthair cat was admitted for chronic ambulatory paraparesis and a spinal malformation. The clinical examination revealed paraparesis accentuated on the left side. Thoracolumbar radiographs revealed a spinal malformation with a narrowed intervertebral space between L1 and L2, and a dorsal fusion at the level of L2-L3 with a common dorsal process. Magnetic resonance imaging (MRI) revealed an intervertebral disk herniation with a ventral compression of the spinal cord at the level of L1/2. A standard vertebral lateral corpectomy with a foraminotomy was performed with a good outcome.

State of the science on controversial topics: missing maxillary lateral incisors - a report of the Angle Society of Europe 2012 meeting

BACKGROUND The optimal long-term management of the congenitally missing maxillary lateral incisor continues to cause controversy within the specialty. The Angle Society of Europe meeting 2012 dedicated a day to address some of the current controversies relating to the management of these missing lateral incisors. FINDINGS The format of the day consisted of morning presentations and afternoon breakout sessions to discuss a variety of questions related to the management of missing lateral incisors. CONCLUSIONS The consensus viewpoint from this day was that the care of patients with congenitally missing lateral incisors is best achieved through a multi-disciplinary approach. The current evidence base is weak, and further well-designed, prospective trials are needed.

Illusions of fusions: assessing cervical vertebral fusion on lateral cephalograms, multidetector computed tomographs, and cone-beam computed tomographs

INTRODUCTION The aims of this study were to compare lateral cephalograms with other radiologic methods for diagnosing suspected fusions of the cervical spine and to validate the assessment of congenital fusions and osteoarthritic changes against the anatomic truth. METHODS Four cadaver heads were selected with fusion of vertebrae C2 and C3 seen on a lateral cephalogram. Multidetector computed tomography (MDCT) and cone-beam computed tomography (CBCT) were performed and assessed by 5 general radiologists and 5 oral radiologists, respectively. Vertebrae C2 and C3 were examined for osseous fusions, and the left and right facet joints were diagnosed for osteoarthritis. Subsequently, the C2 and C3 were macerated and appraised by a pathologist. Descriptive analysis was performed, and interrater agreements between and within the groups were computed. RESULTS All macerated specimens showed osteoarthritic findings of varying degrees, but no congenital bony fusion. All observers agreed that no fusion was found on MDCT or CBCT. They disagreed on the prevalence of osteoarthritic deformities (general radiologists/MDCT, 100%; oral radiologists/CBCT, 93.3%) and joint space assessment in the facet joints (kappa = 0.452). The agreement within the rater groups differed considerably (general radiologists/MDCT, kappa = 0.612; oral radiologists/CBCT, kappa = 0.240). CONCLUSIONS Lateral cephalograms do not provide dependable data to assess the cervical spine for fusions and cause false-positive detections. Both MDCT interpreted by general radiologists and CBCT interpreted by oral radiologists are reliable methods to exclude potential fusions. Degenerative osteoarthritic changes are diagnosed more accurately and consistently by general radiologists evaluating MDCT.

Far lateral lumbar disc extrusion: MRI findings and surgical treatment

This case report describes the magnetic resonance imaging (MRI) findings and the treatment of a far lateral extrusion of disc material at the sixth and seventh lumbar vertebrae (L6-L7) in a five-year-old male Alpine Dachsbracke dog referred to our hospital for investigation of the complaint of a one week progressive lameness in the left pelvic limb and poorly localized back pain. An extra-foraminal left lateral disc herniation impinging on the sixth lumbar nerve root was diagnosed by MRI examinations. Due to the far lateral position of the extruded disc material on MRI, surgical opening of the spinal canal was not necessary. Removal of the herniated soft disc material impinging on the L6 nerve root, and fenestration of the L6-L7 disc was performed laterally. To the author's knowledge 'far-lateral' disc herniation beyond the neuroforamen without any spinal canal contact has not been described in dogs until now. A complete recovery with no evidence of pain was achieved only after a couple of weeks after surgery. We acknowledge that it is possible that other pathological mechanisms may have contributed to clinical signs and to a delayed recovery.