Small Tears Research Articles

Cystiysticercosis as a differential diagnosis of knee pain: A rare case report

Cysticercosis is caused by larval stage of pork tapeworm(Taenia solium). There is difficulty in diagnosing cysticercosis by ultrasound alone in its early stage especially if the lesion is small.we need to adopt MRI for early diagnosis and for starting optimum treatment for the patient. We discuss about a case of cysticercosis of vastus medialis muscle who presented with knee pain in orthopedic OPD and medical treatment was given with complete resolution of infection. Case Report: A 31 years old male who presented with complaints of pain in the (L) knee for 2 weeks duration, difficulty in sitting cross legged and squatting for 1 week. He was also complaining of mild swelling on the medial aspect of the knee. On local examination, a diffuse swelling of distal thigh (medial aspect) with knee effusion was present with induration of vastus medialis muscle. On ultrasonography it was diagnosed as a small tear in the vastus medialis muscle.But MRI scan showed evidence of 1x0.8x0.5cm well defined oval cystic lesion in the deep muscular plane of vastus medialis in its distal one third with surrounding muscle edema and knee effusion. Patient was completely asymptomatic with full range of knee ROM after treatment with albendazole alone for 4 weeks..Conclusion: We should keep Intra muscular cysticercosis as a differential diagnosis for knee pain especially in endemic areas. Muscular cysticercosis with no other systemic involvement can be treated with albendazole alone. Since isolated cysticercosis is a rare entity we should always rule out other systemic involvement including central nervous system.

Effects of exercise therapy for the treatment of symptomatic full-thickness supraspinatus tears on in vivo glenohumeral kinematics

The high incidence of rotator cuff disease combined with high failure rates for nonoperative treatment of full-thickness rotator cuff tears underlines the importance of improving nonoperative management of rotator cuff tears. The study objective was to assess changes in invivo glenohumeral kinematics of patients with a symptomatic full-thickness supraspinatus tear before and after a 12-week exercise therapy program. It was hypothesized that successful exercise therapy would result in improved kinematics (smaller translations and increased subacromial space). Five patients were recruited for the study and underwent dynamic stereoradiography analysis before and after a 12-week exercise therapy protocol to measure changes in glenohumeral joint translations and subacromial space during coronal plane abduction. Strength and patient-reported outcomes (American Shoulder and Elbow Surgeons; Disabilities of the Arm, Shoulder and Hand; Western Ontario Rotator Cuff Index) were also evaluated. After therapy, no subject went on to receive surgery. It was found that the contact path length of the humerus translating on the surface of the glenoid was reduced by 29% from 67.2%±36.9% glenoid height to 43.1%±26.9% glenoid height (P=.036) after therapy. Minimum acromiohumeral distance showed a small increase from 0.9±0.6mm to 1.3±0.8mm (P=.079). Significant improvements in strength and patient-reported outcomes were also observed (P<.05). Successful exercise therapy for treatment of small full-thickness supraspinatus tears results in improvements in glenohumeral joint kinematics and patient-reported outcomes through increases in rotator cuff muscle strength and joint stability. This study may enable identification of prognostic factors that predict the response of a patient with a rotator cuff tear to exercise therapy.

Matrix changes due to the toxic effects of metronidazole in intestinal tissue of fish (Onchorhynchus mykiss).

Metranidazole (MTZ) is an antibiotic used for parasitic infections in a number of species. Accumulation of this drug in the environment and its interaction with fish of economic value makes this drug particularly important. In the present study, we examined the histopathological effects of MTZ on the intestinal tissue of Oncorhynchus mykiss. The fish in aquarium were exposed to MTZ at doses of 5, 10, 20 mg/L for 2, 4 and 8 days. At the end of the experiments, macroscopic pathology or death were not observed at these doses. Histochemical staining with Haematoxylene-Eosin, Periodic Acid Schiff and Gomori Trichrome showed, depending on increased dose and prolonged duration, areas of necrosis, edema, inflammation, small tears at the tips of the villi and excretion with heterogenic distribution of the Goblet cells. Moreover, changes in the connective tissue of the intestines due to toxicity of MTZ and decreases in immunostaining of matrix proteins such as laminin and collagen IV, especially in the epithelium were observed. Findings of the present study would be useful to demonstrate the adverse effects of MTZ use, emphasizing the importance of the effect on fish which could be very important public health.

Efficacy of platelet-rich plasma in arthroscopic repair of full-thickness rotator cuff tears: a meta-analysis

The use of platelet-rich plasma (PRP) is an innovative clinical therapy, especially in arthroscopic rotator cuff repair. The purpose of this study was to compare the clinical improvement and tendon-to-bone healing with and without PRP therapy in arthroscopic rotator cuff repair. A systematic search was done in the major medical databases to evaluate the studies using PRP therapy (PRP+) or with no PRP (PRP-) for the treatment of patients with rotator cuff tears. We reviewed clinical scores such as the Constant score, the American Shoulder and Elbow Surgeons score, the University of California at Los Angeles (UCLA) Shoulder Rating Scale, the Simple Shoulder Test, and the failure-to-heal rate by magnetic resonance imaging between PRP+ and PRP- groups. Five studies included in this review were used for a meta-analysis based on data availability. There were no statistically significant differences between PRP+ and PRP- groups for overall outcome scores (P > .05). However, the PRP+ group exhibited better healing rates postoperatively than the PRP- group (P = .03) in small/moderate full-thickness tears. The use of PRP therapy in full-thickness rotator cuff repairs showed no statistically significant difference compared with no PRP therapy in clinical outcome scores, but the failure-to-heal rate was significantly decreased when PRP was used for treatment of small-to-moderately sized tears. PRP therapy may improve tendon-to-bone healing in patients with small or moderate rotator cuff tears.

The Fate of Meniscus Tears Left In Situ at the Time of Anterior Cruciate Ligament Reconstruction

Background: The management of meniscus tears identified at the time of primary anterior cruciate ligament (ACL) reconstruction is highly variable and includes repair, meniscectomy, and nontreatment. Hypothesis/Purpose: The purpose of this study was to determine the reoperation rate for meniscus tears left untreated at the time of ACL reconstruction with a minimum follow-up of 6 years. The hypothesis was that small peripheral tears identified at the time of ACL reconstruction managed with “no treatment” would have successful clinical outcomes. Study Design: Cohort study; Level of evidence, 3. Methods: Patients with meniscus tears left untreated at the time of primary ACL reconstruction were identified from a multicenter study group with a minimum 6-year follow-up. Patient, tear, and reoperation data were obtained for analysis. The need for reoperation was used as the primary endpoint, with analysis performed to determine patient and tear characteristics associated with reoperation. Results: There were 194 patients with 208 meniscus tears (71 medial, 137 lateral) left in situ without treatment with a complete follow-up for analysis. Of these, 97.8% of lateral and 94.4% of medial untreated tears required no reoperation. Sixteen tears (7.7%) left in situ without treatment underwent subsequent reoperation: 9 tears (4.3%) underwent reoperation in the setting of revision ACL reconstruction, and 7 tears (3.4%) underwent reoperation for an isolated meniscus injury. The patient age was significantly lower in patients requiring reoperation, while tears measuring ≥10 mm more frequently required reoperation. Conclusion: Lateral and medial meniscus tears left in situ at the time of ACL reconstruction did not require reoperation at a minimum 6-year follow-up for 97.8% and 94.4% of tears, respectively. These findings re-emphasize the low reoperation rate after the nontreatment of small, peripheral lateral meniscus tears while noting less predictable results for medial meniscus tears left without treatment.

Endoscopic Repair of Gastrogastric Fistulas After Roux-en-Y Gastric Bypass

Introduction: Gastrogastric fistulas are a rare complication of Roux en Y gastric bypass. Several options exist for repair. Our goal was to present our experience with the use of an over the scope clip system for endoscopic intervention. This is a retrospective review from a university hospital where three patients have undergone endoscopic repair of gastrogastric (GG) fistulas using an over the scope clip (OTSC) system developed by OVESCOTM. Case Presentations: Patient 1, a 58 yo female, presented with increased food intake. She was found to have a GG fistula 2 months post Roux en Y bypass (RNY). Her postoperative course was complicated by a left subphrenic abscess and left empyema which necessitated a VATS procedure. Two fistulas were found at EGD, one of which measured 14 mm and the other 5 mm in diameter. Two hemoclips and one OTSC (12/6 GC) were applied to the larger defect and one hemoclip was applied to the smaller defect. Repeat upper GI series one month post EGD showed failure of fistula closure. Patient 2, a 69 yo female, presented with epigastric abdominal pain and was found to have a 4 mm GG fistula 34 months post RNY. She had lost ˜118lbs since bypass. On initial repair attempt the fistulous tract appeared to have closed after APC and hemoclip placement x 2, however the fistula was again noted on repeat upper GI series 4 months later. A follow up EGD was performed with successful OTSC deployment (12/6 GC). Patient 3, a 44 yo female, presented with epigastric abdominal pain, nausea, emesis, and weight gain and was found to have a 5 mm GG fistula 66 months post RNY. She had lost ˜ 435 lbs since bypass. Successful OTSC deployment was performed (12/6 GC). The patient experienced symptom relief on follow up. Discussion: The success of gastrogastric fistula repair using an OTSC system appeared to be influenced by several factors including size, acuity, and post operative complications. Smaller fistulas were closed with greater success. The time interval between bypass and fistula development seems to have influenced success as well with fistula closure achieved in patients with a mean development interval of 50 months. Small superficial mucosal tears, with no evidence of bleeding or perforation, were noted in the proximal esophagus in both successful cases. The use of an OTSC system represents a safe, minimally invasive strategy for endoscopic closure of gastrogastric fistulas ≤5 mm.Figure 1Figure 2Figure 3

Bioinformatics in tear proteome

SummaryTear is a complex fluid containing rich mixture of biomolecules. Current mass spectrometry based proteomic techniques are able to capture the expression of thousands of proteins from small tear volumes, opening possibility for data driven identification of predictive biomarkers. We have developed a bioinformatic approach for biomarker discovery that effectively finds associations between time course proteomic data and clinical phenotypic data. We first construct a feature matrix that contains the data and clinical information as well as various computationally derived features, for example pathway enrichments scores across thousands of pathways and various biologically motivated activity scores for master regulators. These feature matrices that can contain categorical, discrete or continuous data are then computationally analyzed to identify the strongest statistical associations with the phenotypes of interest. Cross validation strategy is utilized to make sure the identified associations are robust. Our approach has been applied to data from clinical patient samples to identify new candidate biomarkers.

Arthroscopic Repair for Chronic Massive Rotator Cuff Tears: A Systematic Review

To systematically review the available evidence for arthroscopic repair of chronic massive rotator cuff tears and identify patient demographics, pre- and post-operative functional limitations, reparability and repair techniques, and retear rates. Medline, Embase, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials were searched to identify all clinical papers describing arthroscopic repair of chronic massive rotator cuff tears. Papers were excluded if a definition of "massive" was not provided, if the definition of "massive" was considered inappropriate by agreement between the 2 reviewers, or if patients with smaller tears were also included in the study population. Study quality and clinical outcome data were pooled and summarized. There were 18 papers that met the eligibility criteria; they involved 954 patients with a mean age of 63 (range, 37 to 87), 48% of whom were female. There were 5 prospective and 13 retrospective study designs. The overall study quality was poor according to the Modified Coleman Methodology Score. Of the 954 repairs, 81% were complete repairs and 19% were partial repairs. The follow-up range was between 33 and 52 months, and the mean duration between symptom onset and surgery was 24 months. Single-row repairs were performed in 56% or patients, and double-row repairs were performed in 44%. A pooled analysis demonstrated an improvement in visual analog scale from 5.9 to 1.7, active range of motion from 125° to 169°, and the Constant-Murley score from 49 to 74. The pooled retear rate was 79%. Arthroscopic repair of chronic massive rotator cuff tears is associated with complete repair in the majority of cases and consistently improves pain, range of motion, and functional outcome scores; however, the retear rate is high. Existing research on massive rotator cuff repair is limited to poor- to fair-quality studies. Level IV, systematic review including Level IV studies.

Non-operative management versus operative management in high-grade blunt hepatic injury.

Surgery used to be the treatment of choice in cases of blunt hepatic injury, but this approach gradually changed over the last two decades as increasing non-operative management (NOM) of splenic injury led to its use for hepatic injury. The improvement in critical care monitoring and computed tomographic scanning, as well as the more frequent use of interventional radiology techniques, has helped to bring about this change to non-operative management. Liver trauma ranges from a small capsular tear, without parenchymal laceration, to massive parenchymal injury with major hepatic vein/retrohepatic vena cava lesions. In 1994, the Organ Injury Scaling Committee of the American Association for the Surgery of Trauma (AAST) revised the Hepatic Injury Scale to have a range from grade I to VI. Minor injuries (grade I or II) are the most frequent liver injuries (80% to 90% of all cases); severe injuries are grade III-V lesions; grade VI lesions are frequently incompatible with survival. In the medical literature, the majority of patients who have undergone NOM have low-grade liver injuries. The safety of NOM in high-grade liver lesions, AAST grade IV and V, remains a subject of debate as a high incidence of liver and collateral extra-abdominal complications are still described. To assess the effects of non-operative management compared to operative management in high-grade (grade III-V) blunt hepatic injury. The search for studies was run on 14 April 2014. We searched the Cochrane Injuries Group's Specialised Register, The Cochrane Library, Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), Embase Classic+Embase (Ovid), PubMed, ISI WOS (SCI-EXPANDED, SSCI, CPCI-S & CPSI-SSH), clinical trials registries, conference proceedings, and we screened reference lists. All randomised trials that compare non-operative management versus operative management in high-grade blunt hepatic injury. Two authors independently applied the selection criteria to relevant study reports. We used standard methodological procedures as defined by the Cochrane Collaboration. We were unable to find any randomised controlled trials of non-operative management versus operative management in high-grade blunt hepatic injury. In order to further explore the preliminary findings provided by animal models and observational clinical studies that suggests there may be a beneficial effect of non-operative management versus operative management in high-grade blunt hepatic injury, large, high quality randomised trials are needed.

Prognostic Factors Affecting Rotator Cuff Healing After Arthroscopic Repair in Small to Medium-sized Tears

Background: Small and medium-sized rotator cuff tears usually have good clinical and anatomic outcomes. However, healing failure still occurs in some cases. Purpose: To evaluate prognostic factors for rotator cuff healing in patients with only small to medium-sized rotator cuff tears. Study Design: Case-control study; Level of evidence, 3. Methods: Data were prospectively collected from 339 patients with small to medium-sized rotator cuff tears who underwent arthroscopic repair by a single surgeon between March 2004 and August 2012 and who underwent magnetic resonance imaging or computed tomographic arthrography at least 1 year after surgery. The mean age of the patients was 59.8 years (range, 39-80 years), and the mean follow-up time was 20.8 months (range, 12-66 months). The functional evaluation included the visual analog scale (VAS) for pain, American Shoulder and Elbow Surgeons score, Constant-Murley score, and Simple Shoulder Test. Results: Postoperative VAS for pain and functional scores improved significantly compared with preoperative values (P < .001). Forty-five healing failures occurred (13.3%), and fatty degeneration of the infraspinatus muscle, tear size (anteroposterior dimension), and age were significant factors affecting rotator cuff healing (P < .001, = .018, and = .011, respectively) in multivariate logistic regression analysis. Grade II and higher infraspinatus fatty degeneration correlated with a higher failure rate. The failure rate was also significantly higher in patients with a tear >2 cm in size (34.2%) compared with patients with a tear ≤2 cm (10.6%) (P < .001). A receiver operating characteristic curve was used to determine the predictive cut-off value for the oldest age and the largest tear size for successful healing, which were calculated as 69 years and 2 cm, respectively, with a specificity of 90%. Conclusion: In small to medium-sized rotator cuff tears, grade II fatty degeneration of the infraspinatus muscle according to the Goutallier classification could be a reference point for successful healing, and anatomic outcomes might be better if repair is performed before the patient is 69 years old and the tear size exceeds 2 cm.

Does Early Versus Delayed Active Range of Motion Affect Rotator Cuff Healing After Surgical Repair?

Background: The timing of passive range of motion (ROM) after surgical repair of the rotator cuff (RC) has been shown to affect healing. However, it is unknown if early or delayed active ROM affects healing. Purpose: To determine whether early versus delayed active ROM affects structural results of RC repair surgery. Study Design: Systematic review and meta-analysis. Methods: A systematic review of articles published between January 2004 and April 2014 was conducted. Structural results were compared for early (<6 weeks after surgery) versus delayed (≥6 weeks after surgery) active ROM using chi-square and Fisher exact tests, as well as relative risks (RRs) and 95% CIs. The analyses were stratified by tear size and repair method. Results: A total of 37 studies (2251 repairs) were included in the analysis, with 10 (649 repairs) in the early group and 27 (1602 repairs) in the delayed group. For tears ≤3 cm, the risk of a structural tendon defect was higher in the early versus delayed group for transosseous plus single-row suture anchor repairs (39.7% vs 24.3%; RR, 1.63 [95% CI, 1.28-2.08]). For tears >3 cm, the risk of a structural tendon defect was higher in the early versus delayed group for suture bridge repairs (48% vs 17.5%; RR, 2.74 [95% CI, 1.59-4.73]) and all repair methods combined (40.5% vs 26.7%; RR, 1.52 [95% CI, 1.17-1.97]). For tears >5 cm, the risk of structural tendon defect was higher in the early versus delayed group for suture bridge repairs (100% vs 16.7%; RR, 6.00 [95% CI, 1.69-21.26]). There were no statistically significant associations for tears measuring ≤1, 1-3, or 3-5 cm. Conclusion: Early active ROM was associated with increased risk of a structural defect for small and large RC tears, and thus might not be advisable after RC repair.

A Pilot Study to Assess Fatty Infiltration of the Supraspinatus in Patients with Rotator Cuff Tears: Comparison with Magnetic Resonance Imaging

The aim of this study was to quantitatively assess the echo intensity of the supraspinatus muscle and compare magnetic resonance imaging and ultrasound findings for 27 patients (12 women, 15 men, 65.8 ± 11.5 y). Tear size and fatty infiltration were determined by magnetic resonance imaging; five stages were assigned based on Goutallier's classification. Gray-scale histogram analysis was used for ultrasound assessment, which was performed in both subcutaneous fat and supraspinatus muscle in three different regions; the echo intensity ratio was the ratio of echo intensity in subcutaneous fat to that in the supraspinatus muscle. Sonograms of 27 shoulders revealed 3 shoulders with a partial tear, and 4 with a small tear, 6 with a medium tear, 6 with a large tear and 4 with a massive tear; 4 shoulders had no tear. Supraspinatus muscle echo intensity and echo intensity ratio were significantly lower in the stage 0 and 1 than in stages 2–4. Our study suggests that ultrasound can quantitatively and objectively assess fatty infiltration in the rotator cuff muscle.

Management of superior sagittal sinus injury encountered in traumatic head injury patients: Analysis of 15 cases.

Background:Significant dural sinus injury occurs in 1.5- 5% of all head injuries and injury to superior sagittal sinus accounts for 70-80% of these. Its management is also a challenging issue to every neurosurgeon.Materials and Methods:In a period of one year (Aug 2011 to july2012) out of 549 cases of head injuries operated in our department analysis of 15 cases (2.73%) shown to have superior sagittal sinus injury. Three dimensional reconstruction of skull bone during CT scan helped us to diagnose possible dural sinus injury pre-operatively.Results:SSS injury was due to direct impact of fracture segment (5 cases), extension of fracture line over sinus area (4 cases) or due to coronal suture diastases (6 cases). Injury to anterior third of sagittal sinus occurred in 12 cases (80%) and injury to middle third occurred in 3 cases (20%). Small tear over superior sagittal sinus was found in 7 cases (46.66%) and was managed with Gelfoam® compression only and in two cases (13.33%) were large tear, which was managed with sinoraphy. In four cases (36.34%) hitch stitches over Gelfoam® to adjacent bone given and in rest two cases (13.33%) a strip of bone was left over the sinus area and bilateral hitch stitches were applied.Conclusion:Injury to SSS in traumatic head injury patient though rarely encountered during surgery, the management is challenging to every neurosurgeon. Preoperative suspicion and combination of surgical techniques rather than one single technique may be effective in decreasing the sinus related mortality rate.

Perforation of a nasoseptal flap does not increase the rate of postoperative cerebrospinal fluid leak.

The nasoseptal flap (NSF) has been shown to be a valuable addition to the reconstructive armamentarium of the endoscopic skull-base surgeon. We aimed to evaluate the rate of postoperative cerebrospinal fluid (CSF) leak after use of a NSF that had a small tear during harvest. After Institutional Review Board (IRB) approval, we analyzed our database of patients undergoing skull-base resection. We included all patients who had a NSF reconstruction, septoplasty, and/or spur on preoperative computed tomography (CT) imaging. We then evaluated video of each procedure to determine if a tear occurred in the NSF during harvest. Patient records were reviewed to determine if a postoperative CSF leak occurred. We evaluated video of 21 patients who underwent a skull-base resection, were reconstructed with a NSF, and had either a septoplasty or evidence of a septal spur on CT imaging. Of these 21 cases, 11 small tears occurred during harvest of the NSF flap and none of the patients with a torn NSF had a postoperative CSF leak. Our series shows a 0% postoperative CSF leak rate in patients undergoing skull-base reconstruction with a NSF that was torn during harvest. Small tears in the NSF do not seem to affect postoperative CSF leak rates.

Treatment of Lumbar Intervertebral Disc Prolapsed with Fragmentectomy, more than Ten Years Follow Up

Background: Open lumbar discectomy is the most commonly performed surgical procedure in the spine. Conventional microdiscectomy was developed to excise the herniated and non-herniated parts of the disc, but these results in early degeneration of the disc and spine instability. Fragmentectomy was developed to excise only the herniated disc part. Objectives: To evaluate the results of fragmentectomy and more than ten years follow up of 71 patients operated at our university hospital. Methods: Seventy one patients; 43 males and 28 females with age 17 and 63 (average 36.49) years; were operated for disc prolapsed at the lumbar area. All patients were operated by single surgeon and evaluated pre and post-surgery by many surgeons. Patients were followed up for more than 10 years (on discharge, 0.25, 0.5, 1, 2, 3, 5 and 10 years). Oswestry Disability Index and the Stanford Score were used to evaluate patient outcomes. Results: Operating time ranged between 25 and 120 (average 71) minutes, blood loss 5-70 (average 35) cubic centimeters and hospital stay ranged 3-5 (4.21) days. Intraoperative a small dural tear was seen in 6 cases and postoperative hematoma in 4 cases in whom one had permanent paralysis below the know. Seven patients (0.099) needed fusion after 1-3 years. ODI decreased from around 80/100 before surgery to 20/100 after 10 years with P-Value <0.001. The Stanford score shows dramatic improvement from around 2/10 pre operation to around 9.2/10 after 10 years of follow up, P-value < 0.001 (P-value <0.001 is considered insignificant). Conclusion: Fragmentectomy or sequesterectomy is effective with fewer complications while our study size is moderate; the utility of this study is in demonstrating the long-term results of this novel intervention.

Monitoring of progression of nonsurgically treated rotator cuff tears by magnetic resonance imaging

BackgroundNonsurgically treated rotator cuff tears sometimes become irreparable in the lead up to surgical repair. The purposes of our study were to identify predictive factors in the progression of tear size, and determine the changes in tear location. MethodsEighty shoulders from 71 patients (mean age 69.4 years) diagnosed with rotator cuff tears by MRI were treated nonsurgically. MRI was repeated after more than 1 year of initial diagnosis. Tear size was measured from the edge of the tear to the lateral aspect of the greater tuberosity. Tears were classified into 5 groups based on tear size and 4 groups based on tear location. Changes in tear size and location were examined. ResultsThe mean follow-up period was 22.3 months. Theaverage progression of tear size was 5mm during followup, averaging 3mm per year. Tears that were initially <1 or ≥4cm were unlikely to progress in tear size. On the other hand, 1- to 2-cm tears on the initial MRI exhibited the greatest progression in tear size, followed by 2- to 3-cm tears. Furthermore, 62.5 % of localized tears in the posterior of the superior facet spread anteriorly, whereas 88.9 % of localized tears in the anterior of the superior facet did not change. ConclusionsMedium-sized tears are at high risk of tearprogression. In contrast, there is little risk of early development of irreparable damage in partial tear or small fullthickness tears. In addition, typical tears may start in the posterior of the superior facet, and subsequently spread anteriorly. Our present findings may serve as a useful reference in determining the treatment course for rotator cuff tears. Level of evidenceLevel IV, Case Series, Prognosis Study.

The Incidence and Management of Dural Tears and Cerebrospinal Fluid Leakage during Corrective Osteotomy for Ankylosing Spondylitis with Kyphotic Deformity.

ObjectiveTo present the incidence and management of dural tears and cerebrospinal fluid leakage during corrective osteotomy [Pedicle Subtraction Osteotomy (PSO) or Smith-Petersen Osteotomy (SPO)] for ankylosing spondylitis with kyphotic deformity.MethodsA retrospective study was performed for ankylosing spondylitis patients with fixed sagittal imbalance, who had undergone corrective osteotomy (PSO or SPO) at lumbar level. 87 patients were included in this study. 55 patients underwent PSO, 32 patients underwent SPO. The mean age of the patients at the time of surgery was 41.7 years (21-70 years). Of the 87 patients, 15 patients had intraoperative dural tears.ResultsThe overall incidence of dural tears was 17.2%. The incidence of dural tears during PSO was 20.0%, SPO was 12.5%. There was significant difference in the incidence of dural tears based on surgical procedures (PSO vs. SPO) (p<0.05). The dural tears ranged in size from 12 to 221 mm2. A nine of 15 patients had the relatively small dural tears, underwent direct repair via watertight closure. The remaining 6 patients had the large dural tears, consequently direct repair was impossible. The large dural tears were repaired with an on-lay graft of muscle, fascia or fat harvested from the adjacent operation site. All patients had a successful repair with no patient requiring reoperation for the cerebrospinal fluid leak.ConclusionThe overall incidence of dural tears during PSO or SPO for ankylosing spondylitis with kyphotic deformity was 17.2%. The risk factor of dural tears was complexity of surgery. All dural tears were repaired primarily using direct suture, muscle, fascia or fat graft.

Arthroscopic Changes of the Biceps Pulley in Rotator Cuff Tear and Its Clinical Significance in Relation to Treatment

BackgroundIn the case of rotator cuff tears, the biceps pulley can be stressed by the unstable biceps tendon, and this can subsequently affect the stability of the subscapularis tendon. Therefore, it is important to distinguish between normal variations and lesions of the biceps pulley that affect anterosuperior lesions in cases of rotator cuff tears.MethodsFrom January 2002 through November 2010, we observed biceps pulley and associated anterosuperior lesions in 589 of 634 cases (93%) of arthroscopic rotator cuff repair, including 72 cases (12.2%) of small tears, 219 cases (37.2%) of medium tears, 134 cases (22.8%) of large tears, and 164 cases (27.8%) of massive tears. We classified normal stretched biceps pulleys as type I, stretched biceps pulleys with mild changes as type II, those with a partial tear as type III, and torn pulleys as type IV.ResultsWe were able to classify 589 cases of biceps pulleys as type I, II, III, or IV associated lesions in rotator cuff tears. Type I was seen in 91 cases (15.4%), type II in 216 cases (36.7%), type III in 157 cases (26.7%), and type IV in 101 cases (17.1%); unidentified cases numbered 24 (4.1%). Nearly three-quarters, 73.3%, of the cases (432/589) had associated anterosuperior lesions, and combined treatment for the associated lesions was administered in 29.2% (172/589) of cases.ConclusionsBiceps pulley lesions with more than partial tears were identified in 48% of rotator cuff tear cases. The incidence and severity of pulley lesions were related to the rotator cuff tear size, the status of the long head of the biceps tendon and subscapularis tendon lesion, and the treatment methods.

Arthroscopic Repair of Partial-Thickness and Small Full-Thickness Rotator Cuff Tears

Background: The healing failure rate is high for partial-thickness or small full-thickness rotator cuff tears. Purpose: To retrospectively evaluate and compare outcomes after arthroscopic repair of high-grade partial-thickness and small full-thickness rotator cuff tears and factors affecting rotator cuff healing. Study Design: Cohort study; Level of evidence, 3. Methods: Included in the study were 55 consecutive patients (mean age, 57.9 ± 7.2 years) who underwent arthroscopic repair for high-grade partial-thickness (n = 34) and small full-thickness (n = 21) rotator cuff tears. The study patients also underwent magnetic resonance imaging (MRI) preoperatively and computed tomography arthrography (CTA) at least 6 months postoperatively, and their functional outcomes were evaluated preoperatively and at the last follow-up (>24 months). All partial-thickness tears were repaired after being converted to full-thickness tears; thus, the repair process was almost the same as for small full-thickness tears. The tendinosis of the torn tendon was graded from the MRI images using a 4-point scale, and the reliabilities were assessed. The outcomes between high-grade partial-thickness tears that were converted to small full-thickness tears and initially small full-thickness tears were compared, and factors affecting outcomes were evaluated. Results: The inter- and intraobserver reliabilities of the tendinosis grade were good (intraclass correlation coefficient, 0.706 and 0.777, respectively). Failure to heal as determined by CTA was observed in 12 patients with a high-grade partial-thickness tear (35.3%; complete failure in 4 and partial failure in 8) and in 3 patients with a small full-thickness tear (14.3%; complete failure in 1 and partial failure in 2). The patients with high-grade partial-thickness rotator cuff tears showed a higher tendinosis grade than did those with small full-thickness tears (P = .014), and the severity of the tendinosis was related to the failure to heal (P = .037). Tears with a higher tendinosis grade showed a 7.64-times higher failure rate (95% CI, 1.43-36.04) than did those with a lower tendinosis grade (P = .013). All functional outcome scores improved after surgery (all P < .001); however, there was no difference between groups. Conclusion: The high-grade partial-thickness rotator cuff tears showed more severe tendinosis compared with the small full-thickness tears in this study. Contrary to previous impressions that tear size or fatty infiltration is the factor that most influences healing, tendinosis severity assessed by preoperative MRI was the only factor associated with failure to heal, given the numbers available for analysis, in patients with partial-thickness and small full-thickness rotator cuff tears. Surgeons should pay more attention to tendon quality during repair surgery or rehabilitation in smaller rotator cuff tears, especially in high-grade partial-thickness tears with severe tendinosis.

Intravesical Explosion Resulting in Bladder Rupture During Transurethral Resection of Bladder Tumors

Explosion in the bladder during transurethral resection of a bladder tumor is an extremely rare complication of urologic surgery. The damage to the bladder can range from small mucosa tears to bladder rupture. A case of intravesical explosion with extensive intraperitoneal bladder rupture during transurethral resection of a bladder tumor is described. The literature is reviewed, and the mechanism of bladder rupture, as well as the possible preventive measures are discussed.