A 18-year-old woman patient suffering from JCA was operated on non-dominant left shoulder joint destruction. The dysplasia of the affected side was clearly recognisable on the X-ray befor the operation as compared to the other side. The smallest of the prothesis typs (De Puy Global, Biomet Modular) couldn’t be implanted. So we have used an other method. We have achived good results for years by using Tuto-plast‚ Dura mater (Tutogen Medical GmbH) in operating interposition elbow arthtroplasty of RA patients. This was the basic idea in this case to apply shouldes joint interposition arthroplasty. There have been previous publications on other interposition tecniques. Operations technique:. Traditionally we approached the shoulder in deltopectoral sulcus. After the subscapular muscle tenotomy subtotal synovectomy happened, later pannus and osteophyts were removed from the humeral head. Then the surface of the head was refreshened, then arronund the anatomic neck titanium screws ( ORFI-II‚ anchor, Technomed) were placed and Tutoplast placed on the head was anchored to them. There are no shouldes pains 4 years after the operations, no radiologcal progression can be experienced. The range of motion is under the mesured value of the RA group of patient having shoulder prothesis. Despice of this fact the patient is able to look after herself and do the daily routine. The patient is fully satisfied with the operation. Conclusion:. Althaugh important conclusion can’t be drawn from one case but sometimes it gives a good alternativ solution in the area of prothetics in shoulder dysplasy of different origins

Dura mater is a thick membrane that is the outermost of the three layers of the meninges that surround the brain and spinal cord. Appropriate dural healing is crucial to prevent cerebrospinal fluid leaks but the entire process has been barely understood so far. Understanding of dural healing and tissue neoformation over the dural grafts, which are usually used for duraplasty, is still partial. Therefore, implantation of decellular dura mater (DM) to recipient from different donor and vitalization with recipient”s mesenchymal stem cells for the treatment of tissue on transplantation process is significant approach. This approach prevents immunological reactions and provides long-term stabilization. According to this study, it is believed that this approach will provide DM healing and become crucial in DM transplantation. The aim of this study was to develop a new construct by tissue engineering of the human DM based on a decellular allograft. Thus human DM collected from forensic medicine and decellularized using the detergent sodium dodecyl sulfate (SDS) in the multiple process of physical, enzimatic and chemical steps. Decellularization were exposing the tissue to freeze-thaw cycles, incubation in hypotonic tris-HCl buffer, 0.1% (w/v) SDS in hypotonic buffer and hypertonic buffer followed by disinfection using 0.1% (v/v) peracetic acid and final washing in phosphate-buffered saline. As a result of all these processes, cellular components of DM were removed by preserving the extracellular matrix without any significant loss in mechanical properties. Based on the histological analysis of the decellularized DM revealed the absence of visible whole cells. Collagen and glycosaminoglycan (GAG) contents of decellular DM evaluated histological staining by Masson Trichrome and Alcian blue respectively. Also biochemical tests were carried out by spectrophotometry (Quickzym Biosciences, The Netherlands) and total GAG content were analyzed by 1.9 dimethylmethylene blue assay. The histoarchitecture was unchanged, and there were no significant changes of total collagen and GAG content. Biomechanical properties were determined by tensile tests, which has confirmed the retention of biomechanical properties following decellularization. The mean tensile strengths were 7,424±4,20 MPa for control group, 5,254±2,068 MPa for decellularization group. There was no statistically significant difference between tensile strength (p=0,277) and tissue thickness (p=0, 520) for both group. In conclusion, this study has developed biomechanically functional decellularized DM scaffold for use in DM repair. In addition, this study is a part of the progressing study and additional studies investigating the biocompatibility performance of the decellularized DM scaffold and there is need for in vivo studies. Keywords. Dura mater, Decellularization, Allografts, Scaffolds, Tissue Engineering

Aims:. The interposition arthroplasty using dura mater has been applied by us as an alternative method to implantation of the prosthesis since 1997. This new surgical method was developed on the basis of ulnohumeral arthroplasty according to Kashiwagi to aspire to preserve the integrity of the joint. We used for interposition instead of lyophilized dura mater the Tutoplast° dura graft, which is treated with osmotic solvent and in this way differs from the lyophilised graft, as its tensile and pulling strength is greater, since it preserves its collagen structure and its three-dimensional fibrin structure. Material and methods:. The dura mater interposition was applied with 23 patients in 24 cases (one bilateral), from May 1997 up to July 2000, in 17 occasions on the dominant side. The average age of the patients was 52. 2 years (24–75 years). The basic diagnosis was rheumatoid arthritis in 83. 3 percent, juvenile chronic arthritis in 8. 3 percent and post-traumatic osteoarthritis in 8. 3 percent. All the patients appeared at the follow up examination and the average duration of the follow-up was 26. 6 months (from 8 to 45 months). The clinical evaluation was based on the Mayo performance score. Results:. Praeoperatively 71 percent of the twenty four patients had severe pain, while none of them had it at the follow up examination. 50 percent of patients were painless, 29. 2 percent had moderate and 21 percent of them had mild pain. The average decrease of point of Mayo performance score for pain was 5. 8 points, the difference is significant (p< 0. 001). Increase of range of movement is also remarkable. Praeoperatively only 4. 2 percent of the twenty four patients had an arc of 100 degrees or more, at the follow up examination this proportion improved to 66. 7 percent. Mean value of the increase was 28. 5 degrees, the difference is significant (p< 0. 001). Range of motion of supination and pronation improved significantly (p< 0. 001). Sixty seven percent of our patients were stable prae-operatively, this value decreased to 50 percent at the follow up. Grossly instability was observed 21 percent praeoperatively and 33 percent at follow up examination. Mean decrease of stability was 4. 2 degrees, the difference is significant (p< 0. 026). We have to notice at the same time that five of the eight grossly unstable patients had the same measurement of instability prae-operatively too, two had moderate instability and only one of them was stable before operation. The quality of life – as far as the basic vital functions are concerned- improved with 91. 6 percent. It is very important to notice at the evaluation of Mayo performance score that 95. 8 percent of patients falled to the group with poor classification before operation, but this value decreased to 12. 5 percent at the follow up, moreover 50 percent of patients had excellent and 79. 2 percent had excellent or good classification. Mean increase of Mayo performance score evaluated to 53. 2 points, the difference is significant (p< 0. 001). Conclusion:. One of the most serious complication of interposition arthroplasties is the absorption of the bone structures. Hence we mainly observed the radiological signs of this and employed the evaluation method of Ljung et al. reported by them in 1996. We observed the measurement of absorption of the trochlea with anteroposterior radiographs and the thinning of the olecranon with lateral radiographs. Ljung et al performed 35 joint preserver interposition arthroplasties with collegene membrane and observed 8 millimeters bone loss of humeral and 5 millimeters bone loss of ulnar part of the elbows. In our patient’s material the absorption of the trochlea occured in 33. 3 percent, in 5 occasions it was partial, and in 1 case in full degree. The rate of the partial absorption was 2. 2 mm on average. Thinning of the olecranon happened in 12. 5 percent, its average degree was 1. 6 mm. Consequently the value of the partial absorption is smaller in the case of trochlea and of the ulna too, like it was reported by Ljung et al. On the basis of the short-term clinical and radiological results the interposition using dura mater as an alternative way to the implant arthroplasty, may be applied with good results

1. Fifteen patients with spina bifida occulta are described in whom the fifth lumbar spinous process was pressing on the fibrous membrane that closes the spina bifida, or on the bony stumps of the defective lamina. 2. That this is a cause of low back pain, with or without pain referred to the lower limbs, is supported by the findings at operation and the results of treatment. 3. Eleven patients were treated by operation; in each the spinous process of the fifth lumbar vertebra pressed against the spina bifida, either directly or through the vestigial remnant of the first sacral spinous process. 4. In eight cases the fibrous membrane was adherent to the dura mater; in one case the nerve roots were adherent. 5. Excision of the fifth lumbar spinous process and the membrane across the breach of the spina bifida was an effective method of treatment

Purpose of the study: Diastematomyelia is a rare spinal cord malformation defined as the presence of two separate spinal cords separated or not by an osseous, cartilaginous, or fibrous septum. Spinal malformations are almost always associated, raising difficult therapeutic challenges. Material and method: We report three cases of congenital kyphoscoliosis associated with diastematomyelia in three girls aged 12, 14 and 15 years. The diastematomyelia was dorsal in one case, thoracolumbar in one and lumbar in the third. For all three patients, the indication for surgery was progression of the scoliosis with development of neurological signs of recent progressive aggravation. Preoperative distraction with a plaster cast was pursued for several months prior to posterior instrumentation. No attempt was made to correct the cord malformation nor achieve major correction of the spinal malformation. The instrumentation bridged the thoracolumbar scoliosis in one case and stopped above the malformation in the two others. Results: The postoperative period was uneventful. There were no neurological complications. Preoperative neurological signs improved after surgery. Control radiographs showed an improvement in the deformity. At mean 6 years follow-up, these patients were not bothered in their everyday life. They had stable deformities which a globally balanced trunk. There were no signs of neurological evolution. Discussion: The therapeutic strategy for diastematomyelia remains a subject of debate. For some authors, the spinal cord should be released systematically which for the majority, this is not necessary except if spinal distraction is planned or if there is a neurological problem. If there is an indication for spinal cord release, any spurs must be removed followed by the necessary dura mater plasty. In our three patients, and in agreement with the neurosurgery team, there was no need for neurosurgical release. The recent development of neurological deficits was explained by the important kyphosis rather by the intramedullary anomaly. Our therapeutic strategy thus focused on treatment of the scoliosis. This enabled us to stabilise the spine, protecting these patients from worsening neurological involvement and enabling good functional outcome. The zone of the malformation was not instrumented in all cases because the posterior arcs were deformed, but also to avoid compromising any future neurosurgical intervention

Purpose of the study: Surgery for lumbar canal stenosis is classically an intracanalar procedure with the risk of injury of the dura mater or nerve roots or of postoperative haematoma with secondary sequelae. Extracanalar surgery could be useful for the treatment of lumbar canal stenosis in older patients. Material and methods: The Farcy procedure is based on the observation that the root is compressed in the recessus by the tip of the upper facet. The foramen is too small. The tip can be cut with a chisel along a horizontal line plumb with the pedicle landmark on the upper border of the lateral mass. The tip of the facet and its osteophyte can be removed laterally to medially with a curette and separated from the capsule and the yellow ligament without exposing the root. Release of the foramen is verified with an elevator. From August 1999 to July 2000, 15 patients (ten women and five men) underwent the Farcy procedure in association with fusion-osteosynthesis. Mean age was 60.4 years (55–71). The patients had suffered a mean 8.5 years (1–30). All had lumbalgia. Radiculalgia involved one root in seven patients, two in four and three in four. The Beaujon score was 6.73 (0–14) before surgery. The procedure was performed at one level in five patients, at two in four, at three in four and at four in two. Laminectomy was associated in two patients early in our experience. Results: Postoperative Beaujon score was 15.2 (9–12) with cure of lumbalgia in eleven patients and cure of radiculalgia in ten patients. five patients had a 100% relative gain and only four had a gain of less than 50%. There were two failures explained by a history of stroke in two women (67 and 71 years). The only complications were one haematoma that was reoperated and one superficial infection. Discussion: These results are comparable with those obtained with intracanalar surgery. The procedure is equally effective and is more rapid without the risk of the classical complications. The one extradural haematoma observed was related to laminectomy which later was noted to be unnecessary. Conclusion: The Farcy procedure is a useful technique for the treatment of lumbar spine stenosis. Further experience is needed to determine whether this extracanalar technique should replace classical techniques with the risk of complications related to exposure of the canal

Introduction: Spinal cord injury (SCI) continues to challenge the healthcare and the adjunct social welfare systems. Significant advances have been made in our understanding of the pathological cascade following the initial insult. However, this has yet to be translated into clinically significant treatments and one possible reason for this is that little is known about the actual interaction between the cord and the spinal column at the moment of impact; a factor that is becoming increasingly recognised as important. Burst fractures are a common cause of SCI and are sufficiently well defined to allow significant advances to be made in developing laboratory models of the fracture process. Following on from these advances an in-vitro model of the interaction between the cord and burst fracture fragment was developed and used to perform preliminary experiments to establish those factors that are important in determining the extent of probable cord damage. Methods: A rig was developed that reliably reproduced a range of fragment-cord impact scenarios previously observed in the development of a model of the burst fracture process. In summary, a simulated bone fragment of mass 7.2 g was fired, transversely, at explanted bovine cord (within 3 hours of slaughter) with a velocity of 2.5, 5.0 or 7.5 ms-1. The cords were mounted in a tensile testing machine using a novel clamping system and held at 8 % strain. A surrogate posterior longitudinal ligament (PLL) was included and simulated in three biomechanically relevant conditions: absent, 0 % strain and 14 % strain. The posterior elements were represented by an anatomically correct surrogate. The impacts were recorded by using either a high speed video camera (4500 frames/s) or a series of fine pressure transducers. Results: The fragments were recorded to undergo the same occlusion profile as previously reported in the burst fracture model, except that the cord itself reduced the level of maximum occlusion possible. All tests displayed the fragment recoiling following maximum occlusion. The maximum occlusion and the time to this position were found to be significantly dependent on both the fragment velocity and the condition of the PLL. Similar results were observed for peak pressure. One surprising result was that maximum occlusion or time to this event did not change with or without the cord being encased in the dura mater; a structure that is thought to protect the cord from external impacts. Discussion: The model developed here of the cord-column interaction for the burst fracture produced useful initial insights into the factors that affect the impact on the cord. The PLL has a significant role to play in both reducing the peak pressures and the spreading the energy imparted over a longer period. The model has several areas in which it could be improved and these include 1) the incorporation of the perfusion pressure which tends to hydraulically stiffen the cord and 2) the inclusion of the cerebrospinal fluid, which may operate in unison with the dura in protecting the cord from impacts. Future work includes the incorporation of the CSF into the model, the development of surrogate cords and the generation of computational models using novel programming techniques

Aims

The optimal procedure for the treatment of ossification of the posterior longitudinal ligament (OPLL) remains controversial. The aim of this study was to compare the outcome of anterior cervical ossified posterior longitudinal ligament en bloc resection (ACOE) with posterior laminectomy and fusion with bone graft and internal fixation (PTLF) for the surgical management of patients with this condition.

Aims

This study, using a surgeon-maintained database, aimed to explore the risk factors for surgery-related complications in patients undergoing primary cervical spine surgery for degenerative diseases.

Diastematomyelia is a rare congenital abnormality of the spinal cord. This paper summarises more than 30 years’ experience of treating this condition. Data were collected retrospectively on 138 patients with diastematomyelia (34 males, 104 females) who were treated at our hospital from May 1978 to April 2010. A total of 106 patients had double dural tubes (type 1 diastematomyelia), and 32 patients had single dural tubes (type 2 diastematomyelia). Radiographs, CT myelography, and MRI showed characteristic kyphoscoliosis, widening of the interpedicle distance, and bony, cartilaginous, and fibrous septum. The incidences of symptoms including characteristic changes of the dorsal skin, neurological disorders, and congenital spinal or foot deformity were significantly higher in type 1 than in type 2. Surgery is more effective for patients with type 1 diastematomyelia; patients without surgery showed no improvement.

Aims

Cervical spondylosis is often accompanied by dizziness. It has recently been shown that the ingrowth of Ruffini corpuscles into diseased cervical discs may be related to cervicogenic dizziness. In order to evaluate whether cervicogenic dizziness stems from the diseased cervical disc, we performed a prospective cohort study to assess the effectiveness of anterior cervical discectomy and fusion on the relief of dizziness.

Little information is available about the incidence and outcome of incidental dural tears associated with microendoscopic lumbar decompressive surgery. We prospectively examined the incidence of dural tears and their influence on the outcome six months post-operatively in 555 consecutive patients (mean age 47.4 years (13 to 89)) who underwent this form of surgery. The incidence of dural tears was 5.05% (28/555). The risk factors were the age of the patient and the procedure of bilateral decompression via a unilateral approach. The rate of recovery of the Japanese Orthopaedic Association score in patients with dural tears was significantly lower than that in those without a tear (77.7% vs 87.6%; p < 0.02), although there were no significant differences in the improvement of the Oswestry Disability Index between the two groups. Most dural tears were small, managed by taking adequate care of symptoms of low cerebrospinal fluid pressure, and did not require direct dural repair. Routine MRI scans were undertaken six months post-operatively; four patients with a dural tear had recurrent or residual disc herniation and two had further stenosis, possibly because the dural tear prevented adequate decompression and removal of the fragments of disc during surgery; as yet, none of these patients have undergone further surgery.

Cite this article: Bone Joint J 2014;96-B:641–5.

Fibrin glue, also known as fibrin sealant, is now established as a haemostatic agent in surgery, but its role in orthopaedic surgery is neither well known nor clearly defined. Although it was originally used over 100 years ago, concerns about transmission of disease meant that it fell from favour. It is also available as a slow-release drug delivery system and as a substrate for cellular growth and tissue engineering. Consequently, it has the potential to be used in a number of ways in orthopaedic surgery. The purpose of this review is to address its use in surgery of the knee in which it appears to offer great promise.

We present the clinical and radiological results of percutaneous vertebroplasty in the treatment of 58 vertebral compression fractures in 51 patients at a minimum follow-up of two years. Group 1 consisted of 39 patients, in whom there was no associated intravertebral cleft, whilst group 2 comprised 12 patients with an intravertebral cleft. The Oswestry disability index (ODI) and visual analogue scale (VAS) scores were recorded prospectively. The radiological evidence of kyphotic deformity, vertebral height, leakage of cement and bone resorption around the cement were studied restrospectively, both before and after operation and at the final follow-up.

The ODI and VAS scores in both groups decreased after treatment, but the mean score in group 2 was higher than that in group 1 (p = 0.02 (ODI), p = 0.02 (VAS)). There was a greater initial correction of the kyphosis in group 2 than in group 1, although the difference was not statistically significant. However, loss of correction was greater in group 2. Leakage of cement was seen in 24 (41.4%) of 58 vertebrae (group 1, 32.6% (15 of 46); group 2, 75% (9 of 12)), mainly of type B through the basal vertebral vein in group 1 and of type C through the cortical defect in group 2. Resorption of bone around the cement was seen in three vertebrae in group 2 and in one in group 1. There were seven adjacent vertebral fractures in group 1 and one in group 2.

Percutaneous vertebroplasty is an effective treatment for osteoporotic compression fractures with or without an intravertebral cleft. Nonetheless, higher rates of complications related to the cement must be recognised in patients in the presence of an intravertebral cleft.

Bone allografts can be used in any kind of surgery involving bone from minor defects to major bone loss after tumour resection. This review describes the various types of bone grafts and the current knowledge on bone allografts, from procurement and preparation to implantation. The surgical conditions for optimising the incorporation of bone are outlined, and surgeon expectations from a bone allograft discussed.