Solitary Radiolucent Erdheim-chester Disease: A Case Report and Literature Review

Background: Erdheim-chester disease (ECD) is a rare non-Langerhans histiocytosis of unknown etiology, which typically presents with bilateral symmetric osteosclerosis and multi-organ involvement. Lesions may be intraosseous or extraosseous and involve the heart, pulmonary system, CNS, and skin in order of decreasing likelihood. Objective: The objective of this study is to discuss a case of erdheim-chester disease and conduct a review of the literature. Case: We describe a rare case of erdheim-chester in an asymptomatic 37-year-old male who was diagnosed after suffering a right ulnar injury. Subsequent evaluation revealed a solitary radiolucent ulnar lesion without multi-system involvement. Results & Conclusion: The case is unique in its solitary distribution, lytic radiographic appearance, and asymptomatic presentation preceding pathologic fracture. This presentation may simulate multiple other bone lesions.

Primary Hyperparathyroidism in the Common Orthopaedic Practice

An extensive review of the publications on primary hyperparathyroidism (pHPT) is presented in this report. It has strongly been emphasized in the literature that patients with pHPT may present either with the classical symptomatology or with asymptomatic disease, emerged due to biochemical screening. The clinical and epidemiological presentation of pHPT in western countries has changed profoundly during the past few decades, and bone disease is nowadays a distinct rarity. The introduction of serum calcium screening for osteoporosis and the technological advances in the laboratory assessment of parathyroid hormone have played important roles in early diagnosis. Subsequently, the disease is increasingly being detected as asymptomatic hypercalcaemia without guiding signs or symptoms. A third type of disease, the normocalcaemic variant, has been recently described in the literature. However, the potential diagnosis of pHPT should always be on the orthopaedics’ list of differential diagnoses in female or elderly patients with vertebral fractures and nephrolithiasis, either symptomatic or asymptomatic, as well as when solitary or multiple osteolytic lesions are encountered on the radiographs. Additionally, a middle aged woman with parathyroid adenoma and subsequent brown tumors detected on the pelvic radiographs is reported. Her initial laboratory findings indicated a minimal increase of the serum calcium, a mild increase of the erythrocyte sedimentation rate, and a significant increase in total serum alkaline phosphatase. Finally, the detection of elevated parathyroid hormone levels indicated the diagnosis of pHPT and necessitated imaging studies of the parathyroid glands, which indicated a parathyroid adenoma. Following successful excision of the parathyroid adenoma, the patient suffered from the hungry bone syndrome. After a follow-up of 20 years, the patient had normal calcium, vitamin D, and parathyroid hormone serum levels, while a pelvic radiograph indicated no significant changes in the appearance of the brown tumors.

Total Knee Arthroplasty Conversion after Open-wedge High Tibial Osteotomy

Background: Open-wedge High Tibial Osteotomy (HTO) is an effective treatment for Osteoarthritis (OA) of the knee; however, postoperative changes due to HTO can make subsequent Total Knee Arthroplasty (TKA) technically difficult and can affect long-term survival. Case Report: Medio-lateral stability along with balanced flexion and extension gaps provides a good functional outcome. A 71-year-old man underwent TKA conversion after open-wedge HTO 12 years earlier; the conversion was performed due to arthritic deterioration in the knee. Medial instability was noted because of poor ligament balancing. The residual medial instability was managed with a knee brace due to the unavailability of the constrained prosthesis. Management of persistent mediolateral instability persisting after soft tissue release and balancing ideally requires varus-valgus constraint. Conclusion: TKA conversion after open-wedge HTO requires a special technique and careful preparation before surgery.

Complications after Spinal Surgery in Patients with Parkinson’s Disease

Background: Several studies have shown that spinal surgeries in patients who suffer from Parkinson’s Disease have a high rate of complications. These patients often need revision surgery. Objective: This is a retrospective study involving 21 patients with Parkinson’s Disease. This study aimed to examine the complications after spinal surgery. Methods: We studied 21 patients with Parkinson’s Disease retrospectively, who had undergone a previous operation by the same surgeon between 2004 to 2019. There were 11 females and 10 males. The mean age was 71.9 years (range, 52 to 85). However, the initial diagnosis and types of surgery were different. The mean time of follow-up for each patient was 3.6 years (ranging from 2 to 8 years). Results: Most of the patients had a post-operative complication within a period of three years. Τhe most common complication was kyphotic deformity and camptocormia. Twelve patients (57.1%) underwent revision surgery, and three patients (14.2%) denied treatment. In four patients (19.04%), kyphotic deformity or stooped posture remained. Only one patient (4.7%) presented with no complication in a follow-up of 8 years. Conclusion: Patients with Parkinson’s disease have a high rate of complications after spinal surgery and often need revision surgery. For this literature review, the overall number of patients was 502, and the mean revision rate was 43.6%. The surgeon must inform patients of possible complications, and a thorough post-operative observation must be implemented.

Traumatic Heel Pad Avulsion in a Pediatric Patient

Introduction: Heel pad injuries can have devastating and debilitating consequences. All efforts to primarily reapproximate the heel pad should be undertaken. Reconstruction of the heel pad can often require multiple complex surgeries including microvascular flaps and tissue transfers. There is a paucity of successful techniques for primary repair in the literature. Case Presentation: In this case report, we describe the successful use of polydioxanone suture with sterile buttons for the repair of the heel pad in a pediatric patient. An 8-year-old male was struck by a vehicle, sustaining a full-thickness heel pad avulsion injury measuring approximately 16-cm in length. The soft tissue was sharply debrided and repaired primarily to the calcaneal periosteum using #1 polydioxanone suture with external suture buttons, and an incisional wound VAC was applied. He was placed into a long-leg bent knee cast and kept non-weight bearing for a total of 6 weeks, at which time the suture and buttons were removed and he was progressed to weight bearing as tolerated in a walking boot. At the 6-month follow-up examination, the heel pad was viable and well-fixed; the patient reported no pain and was not limited in any chosen activities. Conclusion: This construct was shown to provide effective fixation while mitigating reported concerns of tissue necrosis caused by suture repair. At 1 year from injury, the patient’s mother noted a slight limp with running but not with walking. He reported no pain at any time, and his Oxford Ankle-Foot Questionnaire for Children score was 58, indicating excellent patient-reported outcome following his procedures.

Preliminary Results of Expandable Transforaminal Lumbar Interbody Fusion Cages

Background: Compared with static cages, expandable cages for Transforaminal Lumbar Interbody Fusion (TLIF), are thought to require less posterior bony removal and nerve root retraction. They may allow the creation of a greater lordotic angle and lordosis restoration. Objective: This study investigated whether TLIF using an expandable lordotic interbody cage facilitates an improvement in both segmental lordosis and the restoration of intradiscal height. Methods: A total of 32 patients with 40 operated segments underwent TLIF surgery for lumbar degenerative disc disease and were consecutively included in this prospective observational study. Of those patients, 25 received monosegmental treatment, six were treated bisegmentally, and one was treated trisegmentally. All patients were assessed clinically and radiographically preoperatively, as well as one week, six months, and two years postoperatively. Results: Two patients required revision for screw loosening and pseudarthrosis. In four patients, the endplate was violated intraoperatively due to cage placement. Postoperatively, cage subsidence was observed in four patients. Significant improvement in the mean degree of spondylolisthesis was noted at the two-year mark. Mean segmental lordosis improved postoperatively. A significant increase in mean disc height of the treated segment was also found. Overall, with the exception of pain, no significant clinical or radiographic changes were reported between the first postoperative week and the two-year year follow-up mark. The mean pain, functional, and quality of life outcomes improved significantly from the preoperative to postoperative period, with no deterioration between six months and two years. Conclusion: This study demonstrates that favorable outcomes can be achieved by using an expandable titanium cage in TLIF procedures.

Kinematic Alignment Technique for TKA on Degenerative Knees with Severe Bone Loss: A Report of 3 Cases

A severely degenerative knee joint with substantial bone attrition poses a significant challenge when performing Total Knee Arthroplasty (TKA) using the Kinematic Alignment (KA) technique. In order to restore the pre-arthritic knee anatomy, the surgeon has the task of estimating quantity and location of bone loss. We present three such cases and describe the key steps to safely perform KATKA in these complex situations.

Proposal of a New Reference Point to Determine the Tibial Resection Depth during Total Knee Arthroplasty for Valgus Knees

The tibial resection depth during total knee arthroplasty for valgus knees has been variously described and not been standardized yet. Accordingly, it has been proposed in this article, that the sulcus between the medial and lateral intercondylar tibial tubercles can be used as a reference point for the tibial resection depth. The resection can be performed 8 to 9 mm distal to the sulcus.