All that clots is not blood: Bone cement implantation syndrome presenting as an intracardiac mass and pulmonary embolism

Bone cement implantation syndrome (BCIS) is a rare and potentially fatal perioperative complication of cemented orthopaedics surgery. A CT-pulmonary angiogram and echocardiogram images were acquired from an 88-year-old patient who had a perioperative collapse while undergoing a revision operation for a peri-implant fracture of the right femoral neck. Findings were suggestive of an intracardiac clot connected to a saddle pulmonary artery embolus. Patient also developed disseminated intravascular coagulation. Overall findings were suggestive of bone cement implantation syndrome.

The role of shuntography in diagnosis of mechanic complications after implantation of ventriculoperitoneal shunts in patients with idiopathic normal pressure hydrocephalus: a retrospective clinical evaluation

Background Mechanical obstruction of ventriculoperitoneal shunt (VPS) during the first year after shunt implantation is a common complication and is widely described in the literature. In this paper, we evaluated the suitability of the shuntography for the diagnosis of mechanical complications of the VPS in patients with idiopathic normal pressure hydrocephalus (iNPH). Methods We retrospectively identified 49 patients with pathologic shuntography over of a period of 20 years in our hospital. The percentage of procedure-associated complications was determined. Results Ninety-eight percent (n = 48) of the patients who underwent shuntography showed clinical and radiographic signs of underdrainage prior to examination. Shuntography revealed mechanical complications of the VP shunt in 37% (n = 18) as a cause of clinical deterioration and following revision operation. During shuntography, mechanical obstruction was discovered in 78% (n = 14) and disconnection of shunt components in 22% (n = 4). In the obstruction group, in 50% (n = 7) the closure was detected in the ventricular catheter, in 29% (n = 4) in the distal catheter of the VPS, and in 21% (n = 3) in both sides of the VPS. In the case of an inconspicuous shuntography (63%, n = 31), the patients received symptomatic therapy (32%, n = 10) or re-adjustment of the valve setting (68%, n = 21). Fifty-seven percent of the patients who underwent surgical treatment improved clinically by at least one point according to the Kiefer score. Conclusion Shuntography can produce valuable clinical information uncovering mechanic complications after implantation VPS in patients with idiopathic normal-pressure hydrocephalus. Patients with mechanical complications of their VPS needed revision surgery and showed clinical benefit after treatment.

Activin A and Follistatin Serum Concentrations in Breast Augmentation Patients

Background: Capsular contracture is caused by an excessive fibrotic reaction similar as observed in other progressive fibrotic disorders. For their pathogenesis, several studies confirmed the importance of activins and follistatin. The aim of this study was to determine and analyze serum levels of Activin A and follistatin in patients with capsular contracture after aesthetic breast augmentation. Methods: The study included 361 female patients who underwent primary aesthetic breast augmentation, came for control examination after breast augmentation or for revision operation because of capsular contracture. Blood samples were taken and using a specific ELISA to determine the serum concentration levels of Activin A and Follistatin. Results: Ninety-six patients (n = 96), who developed a capsular contracture Baker ≥°III and underwent revision surgery were collected (capsular fibrosis group). One-hundred and fourteen patients (n = 114) were asymptomatic for capsular fibrosis Baker ≥°III after primary breast augmentation and 33 (n = 33) of them had developed no capsular fibrosis after more than 10 years (long-term group). For control group, blood samples were taken from 167 patients (n = 167) before primary aesthetic breast augmentation. Serum Activin A levels were significantly higher in the long-term Group compared with those in the capsular fibrosis- and the control groups. Follistatin levels were significantly lower in the capsular fibrosis group compared to the control- and the long-term groups. A small amount of control group patients (n = 16) developed a capsular fibrosis within 2 years after primary breast augmentation with significant lower follistatin levels. Retrospectively, they showed significantly lower serum follistatin levels than the control group even before the onset of capsular contracture. Conclusions: Capsular fibrosis has no effect on Activin A serum levels. In contrast, follistatin serum levels are lower in patients with capsular fibrosis. These results show that besides many other factors, a dysregulation of the Activin–follistatin axis may have importance on the pathogenesis of capsular contracture.

Early Clinical Outcome of Comparative Study between Revision Operation and Radiofrequency Treatment for Management of Failed Back Surgery Syndrome

Objective: Intractable back pain and radicular pain after lumbosacral spine surgery are challenges for surgeons because the pathophysiology of failed back surgery syndrome (FBSS) remains unknown. Various medications, exercise, reoperation, spinal cord stimulation, and various interventional treatments, such as epidural injection, and radiofrequency treatment, have been suggested as treatment options. However, the clinical outcomes for each treatment are unclear. Methods: We retrospectively evaluated clinical outcomes of consecutive FBSS patients who underwent revision operation or radiofrequency treatment from 2014 to 2017, who previously showed response to nerve block. Pain was analyzed preoperatively and 1 month, 6 months, and 12 months postoperatively using a visual analogue scale (VAS). Short Form 36 (SF-36) health survey and Oswestry Disability Index (ODI) scores were assessed preoperatively and 12 months postoperatively. Results: A total of 70 patients was included in the present study (33 males, 37 females). When comparing preoperative and postoperative 12-month results, back pain VAS score decreased from 5.5 to 4.2 for revision operation and from 5.1 to 4.7 for radiofrequency treatment. Leg pain VAS score decreased from 6.5 to 4.02 for revision operation and 6.2 to 4.3 for radiofrequency treatment. ODI score decreased from 70.9 to 36.1 for revision operation and 70.2 to 36.1 for radiofrequency treatment. SF-36 score increased from 28.9 to 64.1 for revision operation and from 29.6 to 59.6 for radiofrequency treatment. Differences between treatments were not statistically significant after 12 months (p>0.05) but were at 1 month (p=0.01). Conclusion: Compared with revision operation, radiofrequency treatment is not inferior on early clinical outcome (up to 1 year following the treatment) in terms of pain relief, functional capacity, patient satisfaction, and quality of life in patients with FBSS. Radiofrequency treatment can be considered in patients who are not good candidates for surgical treatment based on imaging results or underlying diseases and who are responsive to diagnostic/therapeutic nerve blocks.

326 Resorbable Composite Materials for Fracture Fixation

Introduction Titanium-based fracture fixation devices often necessitate removal in the maxillofacial region. Resorbable composite implants negate the need for a revision operation; however, concurrent devices either possess a prolonged degradation profile or bioactivity, resulting in undesirable bone deposition. To that end, a novel, fast-resorbing, non-bioactive composite material is proposed, which still possesses an osteoinductive potential, thereby aiding fracture healing. Method Three bioglasses were available (NCL1-3) as filler material. NCL2 was selected and different concentrations (5%; 20%) were added to reinforce medical grade poly(lactic-co- glycolide) (PLGA). The final compression moulded samples underwent material characterisation and an 8-week degradation assay. Results No significant difference was found between the cytotoxicity of the glasses and both the positive (apatite wollastonite) and negative (absence of glass) controls in relation to mesenchymal stem cells or osteoblasts. pH and weight change analyses showed an increased rate of degradation with an increase in glass concentration. Although reinforcement with NCL2 did not increase the mechanical properties of the polymer, no significant difference was present between the mechanical properties of the composites, and, as made, both 5% and 20% composites had flexural strengths of 13MPa±5, which did not decrease significantly during degradation. Conclusions NCL1-3 are non-toxic in the context of fracture healing. The PLGA/NCL2 composite is not suitable for fracture fixation as produced currently, due to increased polymer degradation and lower mechanical properties. However, 20% compositions are recommended for future research, as they would hypothetically provide a superior osteoinductive response without significantly lowering the mechanical properties of the composite.

Surgical Site Infection Following Intramedullary Nailing of Subtrochanteric Femoral Fractures

Aim: To investigate the incidence, risk factors and pathogenic micro-organisms causing superficial and deep infection in subtrochanteric femoral fractures managed with an intramedullary nail. Materials and Methods: Following institutional board approval, all consecutive patients presenting with a subtrochanteric fracture were retrospectively identified, over an 8-year period. Basic demographics, fracture characteristics, fracture union, revision operation, mortality and other complications were reported and analysed. Variables deemed statistically significant (p-value < 0.05) were then included into a revised adjusted model of logistic regression analysis, where we reported on the odds ratio (OR). Results: The overall incidence of infection was 6.4% (n = 36/561; superficial: 3.7%; deep: 2.7%). Associations with deep infection included: non-union (OR 9.29 (2.56–3.38)), the presence of an open fracture (OR 4.23 (3.18–5.61)), the need for massive transfusion (OR 1.42 (2.39–8.39)), post-operative transfusion (OR 1.40 (1.10–1.79)) and prolonged length of stay (OR 1.04 (1.02–1.06)). The Commonest causes of superficial infection were Staphylococcus aureus (28.5%), enteric flora (23.8%) and mixed flora (23.8%); whereas coliforms (60%) and Staphylococcus aureus (26.7%) were the commonest micro-organisms isolated in deep infection. Polymicrobial infection was identified in 38.5% and 80% of superficial and deep infections, respectively. Conclusion: Causative micro-organisms identified in both superficial and deep infection were similar to those reported in post-traumatic osteomyelitis. In an attempt to minimise infection, the treating clinician should focus on modifiable risk factors with adequate patient optimisation, prompt surgical treatment, adequate antibiotic coverage and wound care when treating patients with subtrochanteric femur fracture.

Outcome after Two Sequential Revision Hip Arthroplasties for CoC Bearing Fracture with 10 Years Follow-up: A Case Report

Introduction: Revisions due to the fracture of ceramic-on-ceramic (CoC) bearing are rare, however when they occur, they represent a major challenge to an orthopedic surgeon for ensuring safe and long-term survival of the replaced bearing. Case Report: We present a case of fractured ceramic liner of total hip prosthesis that underwent revision to a metal-on-polyethylene (MoP) bearing couple, with consequent huge periprosthetic metallosis. Shortly after, the second revision operation followed using the third bearing couple of ceramic-on-polyethylene (CoP). At 10 years follow-up after the operation due to ceramic fracture, the patient is now pain free with full range of motion of the revised hip. Conclusion: Establishment of diagnostic routes and recommended protocols for CoC bearing fracture would allow easier recognition of potential fracture and diminish its consequences for the patients. Keywords: Tribology, Revision Hip Arthroplasty, Ceramic Bearing Fracture.

Surgical Outcomes of Revision Operation for Non-Cholesteatomatous Chronic Otitis Media

Background and Objectives The aim of this study was to investigate the surgical outcomes of revision operation due to recurrence of non-cholesteatomatous chronic otitis media (COM) surgery cases.Subjects and Method From 1989 to 2018, 5197 cases of COM surgery were performed at Kangdong and Hallym University Sacred Heart Hospital. Among them, clinical data of 297 subjects who had undergone revision tympanoplasty and/or mastoidectomy for recurrent noncholesteatomatous COM were retrospectively collected from computerized database of middle ear surgery (Korean Otological Society program 2005). Each case was categorized by surgical approaches into canal wall down mastoidectomy (CWDM), canal wall up mastoidectomy (CWUM), or tympanoplasty only groups.Results Tympanoplasty only was performed in 170 cases, CWDM in 74 cases, and CMUM in 53 cases. Postoperative perforation occurred in 9.4% of total cases, and less frequently in CMDM compared with tympanoplasty only (<i>p</i>=0.023), and CMUM (<i>p</i>=0.049), respectively, whereas no differences between tympanoplasty only and CMUM (<i>p</i>=0.930) were found. Postoperative infection rate was 1.0% and did not show any differences among the groups. Postoperative successful hearing was obtained in 66.7% of total cases, and the success rate of tympanoplasty only was better than that of CMDM (<i>p</i>=0.001), and CMUM (<i>p</i>=0.011). And, that of CMUM was better than that of CMDM (<i>p</i>=0.011).Conclusion The results showed that postoperative perforation occurred less frequently in CMDM than in tympanoplasty only and in CWUM; successful hearing was achieved more frequently in tympanoplasty alone than in the other surgical approaches in recurrent non-cholesteatomatous COM.

Cerebrospinal fluid biomarkers of neuroinflammation in children with hydrocephalus and shunt malfunction

Background Approximately 30% of cerebrospinal fluid (CSF) shunt systems for hydrocephalus fail within the first year and 98% of all patients will have shunt failure in their lifetime. Obstruction remains the most common reason for shunt failure. Previous evidence suggests elevated pro-inflammatory cytokines in CSF are associated with worsening clinical outcomes in neuroinflammatory diseases. The aim of this study was to determine whether cytokines and matrix metalloproteinases (MMPs) contribute towards shunt failure in hydrocephalus. Methods Using multiplex ELISA, this study examined shunt failure through the CSF protein concentration profiles of select pro-inflammatory and anti-inflammatory cytokines, as well as select MMPs. Interdependencies such as the past number of previous revisions, length of time implanted, patient age, and obstruction or non-obstruction revision were examined. The pro-inflammatory cytokines were IL-1β, IL-2, IL-5, IL-6, IL-8, IL-12, IL-17, TNF-α, GM-CSF, IFN-γ. The anti-inflammatory cytokines were IL-4 and IL-10, and the MMPs were MMP-2, MMP-3, MMP-7, MMP-9. Protein concentration is reported as pg/mL for each analyte. Results Patient CSF was obtained at the time of shunt revision operation; all pediatric (< 18), totaling n = 38. IL-10, IL-6, IL-8 and MMP-7 demonstrated significantly increased concentrations in patient CSF for the non-obstructed subgroup. Etiological examination revealed IL-6 was increased in both obstructed and non-obstructed cases for PHH and congenital hydrocephalic patients, while IL-8 was higher only in PHH patients. In terms of number of past revisions, IL-10, IL-6, IL-8, MMP-7 and MMP-9 progressively increased from zero to two past revisions and then remained low for subsequent revisions. This presentation was notably absent in the obstruction subgroup. Shunts implanted for three months or less showed significantly increased concentrations of IL-6, IL-8, and MMP-7 in the obstruction subgroup. Lastly, only patients aged six months or less presented with significantly increased concentration of IL-8 and MMP-7. Conclusion Non-obstructive cases are reported here to accompany significantly higher CSF cytokine and MMP protein levels compared to obstructive cases for IL-10, IL-6, IL-8, MMP-7 and MMP-9. A closer examination of the definition of obstruction and the role neuroinflammation plays in creating shunt obstruction in hydrocephalic patients is suggested.

Risk Factors and Options of Management for an Incidental Dural Tear in Biportal Endoscopic Spine Surgery

Study Design: Here we perform a retrospective analysis regarding an incidental dural tear (IDT) during biportal endoscopic spinal surgery (BESS).Purpose: This study investigates the causes of IDT specifically related to technical procedures of BESS with the aim of lowering its risk during training.Overview of Literature: The incidence of dural tear is reported 0.5%–18% in open spinal surgery and 1.7%–4.3% during endoscopic spinal surgery. Because conversion to open surgery for direct repair could become necessary during endoscopic spinal surgery, prevention of this complication is essential.Methods: We have retrospectively studied IDTs by four surgeons during 1 or 2 years after starting BESS for lumbar degenerative diseases and analyzed the locations, sizes, and specific endoscopic conditions specific to each.Results: Twenty-five cases (1.6%) of IDTs among 1,551 cases of BESS occurred; 13 cases (52%) of these were within the first 6 months. The locations were dorsal midline in 12 cases, ipsilateral side in 11 cases, and contralateral side in two cases. The tear sizes were <10 mm in 20 cases and ≥10 mm in five cases. IDT commonly occurred due to injury of central dural folding during flavectomy under turbid surgical fields due to small bleeds under water. Twenty cases with IDTs of <10 mm were treated well with the patch technique. Among five cases of ≥10 mm, three underwent open repair within a few days, and two of these which failed to conservative management required a delayed revision operation due to pseudomeningocele. No cases progressed to surgical site infection or infectious spondylitis.Conclusions: IDTs of <10 mm can be successfully treated with the patch technique. To prevent IDT during the early learning period, maintaining clear visibility by securing fluent saline outflow and meticulous hemostasis of small bleeding from exposed cancellous bone and epidural vessels is essential with caution not to injure the central dural folding during midline flavectomy.