Center for Orthopaedics

Upper Lumbar Disc Herniation (ULDH) is a rare form of lumbar disc herniation, but its symptoms are more severe due to the conus medullaris and the tight spinal canal. Surgical intervention for these fragments is also considered demanding once they demonstrate high-grade downward migration into the "hidden zone" medial to the pedicle. Obstructions due to bone or dangers of damaging nerve tissue by retraction are common limitations of the classical minimally invasive methods. We report on the case of a 69-year-old man with an extreme down-migrated L1-L2 disc herniation (Lee classification Zone 4). The patient had severe left thigh pain and numbness and was unable to walk, with preoperative VAS and ODI scores of 7/10 and 74, respectively. A modified posterior transpedicular approach utilizing Unilateral Biportal Endoscopy (UBE) was successfully conducted. The use of the medial cortical wall of the pedicle as a natural navigational "Cortical Guidance" guides a direct path to the ventral pathology through minimal bone removal and results in true "Zero-Retraction" of the neural structures. Herniated fragments were totally resected postoperatively and the discectomy patient showed significant symptomatic improvement with VAS and ODI scores reduced to 1/10 and 12, respectively. At the 6-month follow-up, the patient had complete neurological recovery. The modified posterior transpedicular UBE technique is a safe, simple, and effective approach for the treatment of highly migrated ULDH and enables extensive decompression with maximal preservation of spinal stability.

ObjectiveTo explore the surgical method and clinical efficacy of free superficial circumflex iliac artery perforator osteocutaneous flap in repairing combined bone and soft tissue defects of the hand and foot.MethodsFrom October 2011 to June 2023, 62 patients with combined bone and soft tissue defects of the hand and foot were treated with free superficial circumflex iliac artery perforator osteocutaneous flap, including 16 cases in the hand and 46 cases in the foot. The causes of injury included 18 cases of machine crush injury, 7 cases of traffic accident injury, and 37 cases of donor foot lesions after thumb/finger reconstruction. The area of skin defects ranged from 4 cm × 2 cm to 13 cm × 5 cm, and the length of bone and/or joint defects was 2 cm–8 cm. The flap harvesting range was 4.5 cm × 3.0 cm to 14 cm × 5.5 cm, and the volume of the iliac bone flap was 2 cm × 1 cm × 1 cm to 8 cm × 2.0 cm × 1.5 cm.ResultsPostoperatively, 58 flaps survived uneventfully, and 4 cases developed vascular crisis, all of which survived after symptomatic treatment. The postoperative follow-up period was 10–59 months. The appearance and texture of the flap were good in 49 cases, and 13 cases underwent secondary revision surgery due to flap bulkiness. Bone union time was ≤3 months in 46 cases, 3–6 months in 12 cases, and more than 6 months in 4 cases. The last x-ray examination showed that 56 cases had complete morphology of the iliac bone flap, 3 cases had bone resorption, 1 case had non-union, and 2 cases had secondary fractures. The scar at the hip donor site was well-concealed, without obvious deformity or pain.ConclusionThe superficial circumflex iliac artery perforator osteocutaneous flap is an effective method for repairing combined bone and soft tissue defects of the hand and foot, with significant advantages at the donor site, while also posing certain technical challenges.

BackgroundIncidental durotomy and the subsequent cerebrospinal fluid (CSF) leak are well-recognized complications of spine surgery. While primary repair can be effective, persistent symptomatic leaks may necessitate more advanced interventions, and some patients continue to experience refractory headaches after spine surgery-related CSF leak treatment.Case DescriptionThis case report describes two patients who presented with chronic headaches following CSF leak resolution and symptoms indicative of intracranial hypertension (ICH), including tinnitus, visual disturbances, and dizziness. Case 1 was a 46-year-old male who suffered from a continual low-grade headache that intensified when lying down, particularly disturbing him during the early hours of the morning. A myelogram revealed excessive intradural pressure. Case 2 was a 55-year-old female who required a temporary lumbar drain as part of her treatment for a persistent CSF leak; she experienced headaches that were particularly severe at night and worsened with exertion or prolonged activity.ConclusionsBoth patients reported tinnitus and visual changes closely aligned with headache symptoms. They were treated for ICH using a 4 weeks regimen of acetazolamide, followed by a tapering period of 4 weeks. With the initiation of acetazolamide, both patients experienced near-complete relief from their symptoms and were successfully weaned off. It is hypothesized that both individuals may have developed an overproduction of CSF following their prior leaks, leading to ICH, which effectively mitigated Acetazolamide’s established role in reducing intracranial pressure.

Aim. To study the clinical and morphological risk factors for the development of radioiodine resistance in patients with highly differentiated thyroid cancer.Materials and methods. The study was conducted among patients treated at the radionuclide therapy department of the Centre for Nuclear Medicine and Oncology of the Abay Regional Health Department. For the analysis, a database of patients who underwent radioiodine therapy was created, which included 630 patients who underwent treatment for thyroid cancer between January 2021 and December 2023. Of these, 373 medical records met the established criteria for inclusion in the study. The statistical analysis was performed using the SPSS 20.0 program.Results and discussion. During the analysis of 373 patients, 60 were assigned to the main group with resistance to radioiodine therapy, and the remaining 313 were in the control group. When assessing the volume of surgery, total thyroidectomy with fascial-caseal excision of the neck tissue was performed for 58.3% of patients in the main group, characterized by resistance to radioiodine therapy, whereas in the control group, this volume of intervention was performed only in 29.1% (p<0.001). The main histological types of thyroid cancer in the study groups were papillary cancer (74.5%) and follicular cancer (25.5%). The presence of microcarcinoma against the background of these histological types of cancer was found in 8 patients of the control group. The presence of distant metastases was significantly more common in the main group (23.3% vs 7.3%) compared with the control (p<0.001).Conclusions. Based on the analysis, it can be concluded that, in particular, total thyroidectomy with lymph node dissection is statistically more often observed in patients with resistance to radioiodine therapy. However, surgical treatment itself is not a causal factor in the development of radioiodine resistance. Most likely, the expanded scope of surgery reflects a more aggressive course of the disease, which is initially associated with the risk of developing radioiodine-resistant forms of tumor. Histological examination data, detection of microcarcinoma, and the presence of distant metastases should be considered as clinical and morphological factors associated with the risk of developing resistance to radioiodine therapy in patients with highly differentiated thyroid cancer.

This study evaluates the quality and readability of responses given by ChatGPT 4 relating to common patient queries on Developmental Dysplasia of the Hip (DDH) and Periacetabular Osteotomy (PAO). Frequently asked questions on DDH and PAO were selected from online Patient Education Materials and posed to ChatGPT 4. The responses were evaluated by four high-volume PAO surgeons using a well-established evidence-based rating system, categorizing responses from ‘excellent response not requiring clarification’ to ‘unsatisfactory requiring substantial clarification’. Readability assessments were subsequently conducted to determine the required literacy level to understand the content provided. Responses from ChatGPT 4 varied significantly between preoperative and postoperative queries. In the postoperative category, 50% of responses were rated as ‘excellent’, showing no need for further clarification, while the preoperative responses frequently required minimal to moderate clarification. The overall median response rating was ‘satisfactory requiring minimal clarification’. Readability tests showed that the average Reading Grade Level was 13.44, considerably higher than the recommended sixth-grade level for patient education materials, indicating a substantial barrier to comprehension for the general public. While ChatGPT delivers generally reliable information, the complexity of its language is a major barrier to widespread utilization as a tool for patient education. Future iterations of ChatGPT should aim to utilize more simplistic language, as such enhancing accessibility without compromising content quality.

Compared to other long bones, non-unions of the tibia after fractures are more likely. Due to surgical debridement, the residual bone stock in the distal part of the bone may be insufficient for adequate fixation of an implant. Thus, treatment with a retrograde nail with the additional performance of an arthrodesis of the hindfoot may be an alternative. The aim of this study was to examine the consolidation and reinfection rates of non-unions of the distal tibia treated with a retrograde arthrodesis nail. A total of 27 patients between 2010 and 2018 were included according to our inclusion criteria. The modified Lane Sandhu Score was used for the radiographic evaluation. The osseous consolidation was validated after 1 year as well as after 2 years. Furthermore, we investigated differences in surgical treatment and treatment-associated complications. One year after the initial therapy 48% of the patients showed osseous consolidation, 75% showed consolidation after two years. 14% underwent amputation later. The majority of the patients (77%) received the ETN PROtect (Expert Tibia Nail PROtect) retrogradely, while the rest were obtained with the HAN (Hindfoot Arthrodesis Nail). Major revision surgeries were required in 26% of patients, while minor revisions were necessary in 15% of patients. In conclusion, treatment with a retrograde nail is a safe treatment option for distal tibia non-unions with a satisfactory overall fusion rate. Therefore, it can be an effective option especially in cases, where the fixation of the implant is difficult, in order to prevent amputation.

Bacterial endophthalmitis is a severe infection of the aqueous or vitreous humor of the eye that can lead to permanent vision loss. Due to the rapid emergence of antibiotic resistance and dose-limiting toxicities, the standard treatment of bacterial endophthalmitis via the intravitreal injection of broad-spectrum antibiotics remains inadequate. Membrane active cationic antimicrobial peptides (AMPs) have emerged as a promising class of effective and broad-spectrum antimicrobial agents with potential to overcome antibiotic resistance. In this work, we investigate, for the first time, the use of omiganan (IK-12), a 12-amino acid indolicidin derivative for the treatment of bacterial endophthalmitis. Additionally, IK-12 was used as a template to perform amino acid rearrangements, without altering the length or type of amino acids, to yield a series of new derivative AMPs with varying extents of secondary structure formation under membrane mimicking conditions. IK-12 and its derivatives demonstrated strong and broad-spectrum antibacterial activities against a panel of clinically isolated Gram-positive and Gram-negative bacteria, including methicillin-resistant Staphylococcus aureus commonly implicated in bacterial endophthalmitis. Interestingly, two of the new IK-12 derivatives, IP-12 and WP-12, showed lower geometric mean minimum inhibitory concentration and higher 50% hemolysis concentration values, which effectively translated into 2- to 3.4-fold higher bacterial selectivity than the parent IK-12. Furthermore, the intravitreal injection of IK-12, IP-12, and WP-12 in a rabbit model of MRSA-induced endophthalmitis led to considerably improved clinical presentation and reduced recruitment of inflammatory cells. In all, these results demonstrate the potential of IK-12 and its derivatives, IP-12 and WP-12, as promising candidates for the treatment of bacterial endophthalmitis.

Relatively little attention has been paid to the underlying mechanisms determining the dominance of non-indigenous species (NIS) once established, despite being regarded as a proxy of invasion success and potential impacts in recipient communities. To bridge this knowledge gap, here we evaluate the potential direct and indirect effects of community filters on the dominance of two widespread NIS in the Baltic Sea: Marenzelleria spp. and the round goby (Neogobius melanostomus) within their corresponding communities. We applied a structural equation modelling approach to assess the direct and indirect effects amongst multiple abiotic and biotic variables on the relative biomass (as proxy of dominance) of NIS. The biotic variables represented the taxonomic- and functional diversity of the recipient communities, as well as the trait similarity between NIS and native species. We observed a comparable influence of abiotic and biotic drivers on the dominance of both NIS, with biotic variables having a somewhat stronger overall direct effect. Specifically, the dominance of both NIS was similarly affected negatively by the richness and positively by the evenness of the native communities. However, we also detected that both NIS might need different ecological strategies to become dominant in their recipient communities, which underwent similar assembly processes. Such strategies were partly highlighted by the different degrees of trait similarity between each NIS and their respective co-occurring native species. A better understanding of the underlying processes affecting NIS dominance is of high relevance to mitigate potential impacts of NIS once established. Furthermore, the provided approach could be further applied to unveil the potential strategies that NIS might follow in other regions and ecosystem types.

We provide a historical and technical perspective on the evolution of Kambin's triangle as a safe working corridor for percutaneous access to the intervertebral disc to an anatomically expanded space to accommodate and facilitate open lumbar total joint replacement. The nearly 6-decade progression from intradiscal access in the intact lumbar spine to an enlarged working space following facetectomy to accommodate a transforaminal lumbar interbody fusion, and eventual further expansion via pedicle vertebral body osteotomy to support motion preservation with total joint replacement, represents a unique evolutionary pathway in surgical technique development. For each of these steps in evolution, we detail and provide the historical context of the corresponding surgical modifications required to expand the original anatomical boundaries of Kambin's triangle. It is postulated that the introduction of machine learning technologies coupled with innovations in robotics, materials science, and advanced imaging will further accelerate and refine the adaptation of more complex, precise, and efficacious surgical procedures to treat spinal degeneration via this working corridor.

The initial healing stages of bone fracture is a complex physiological process involving a series of spatially and temporally overlapping events, including pathogen clearance, immunological modulation, and osteogenesis. In this study, we have developed a piezoelectric and aligned nanofibrous scaffold composed of ZnO@PCL/PVDF with multiple antibacterial, immunomodulatory, and osteogenic effects using electrospinning technology. This scaffold's piezoelectric signal output under ultrasound (US) control can be similar to the physiological electrical signals of healthy bone tissue, creating a truly biomimetic electrical microenvironment in the bone defect. In vitro studies have shown that ZnO@PCL/PVDF scaffold significantly enhances the proliferation, migration, and osteogenic differentiation of MC3T3-E1 cells under piezoelectric drive provided by ultrasound. Furthermore, the scaffold exhibits inhibitory effects on the growth of E. coli and S. aureus, as well as the ability to induce M2 macrophage polarization, indicating potent antibacterial and immunomodulatory properties. In vivo experiments demonstrated that the ZnO@PCL/PVDF scaffold can accelerate the repair of mandibular defects in rats, effectively inhibit bacterial colonization, and reduce inflammatory responses. Altogether, this study confirms that the newly developed ZnO@PCL/PVDF scaffold effectively promotes bone repair by truly mimicking the endogenous electrical microenvironment and precisely regulating the temporospatial disorders of initial bone healing, thus providing a simple and effective solution for bone defects.