Wound healing involves a series of carefully modulated steps, from initial injury and blood clot to the final reconstituted tissue or scar. A dynamic reciprocity exists throughout between the wound, blood elements, extracellular matrix, and cells that participate in healing. Multiple cytokines and signal transduction pathways regulate these reactions. A major component throughout most of the process is hyaluronan, a straight-chain carbohydrate extracellular matrix polymer. Hyaluronan occurs in multiple forms, chain length being the only distinguishing characteristic between them. Levels of hyaluronan in its high-molecular-weight form are prominent in the earliest stages of wound repair. Progressively more fragmented forms occur in a manner not previously appreciated. We outline here steps in the wound healing cascade in which hyaluronan participates, as well as providing a review of its metabolism. Although described by necessity in a series of quantum steps, the healing process is constituted by a smooth continuum of overlapping reactions. The prevalence of hyaluronan in the wound (initially termed "hexosamine-containing mucopolysaccharide"), particularly in its early stages, was pointed out over half a century ago by the Harvard surgeon J. Engelbert Dunphy. It appears we are now returning to where we started.
Case: A 54-year-old man presented with a comminuted left midclavicle fracture that progressed to a symptomatic nonunion after nonsurgical management. Nonunion open reduction and internal fixation (ORIF) was performed, but a left brachial plexopathy developed 48 hours postoperatively. Imaging failed to demonstrate an emergent cause. The patient was monitored and completely recovered, with occasional neuralgia and mildly limited forward elevation of the shoulder. Conclusion: Development of a brachial plexopathy 48 hours after routine clavicle nonunion ORIF using plate fixation is an unusual complication. Future studies are needed to determine if this “wait-and-see” approach can be generalized to similar cases.
The oblique lateral lumbar interbody fusion (OLLIF) is a relatively new method of lumbar interbody fusion (LIF) that utilizes a trans-Kambin approach to the disc space. The OLLIF can be performed from T12-S1 in the majority of cases but is occasionally obstructed at the L5-S1 level by osteophytes, an overgrown facet joint and/or prominent sacral ala. Transfacet OLLIF (TF-OLLIF) is a novel method for LIF in which the disc space is accessed by drilling through hypertrophic facets with an OLLIF approach. We provide a proof-ofconcept report on the TF-OLLIF surgical technique and report the clinical and perioperative outcomes for the first 29 patients who underwent this procedure. MethodsThis is a retrospective single surgeon cohort study of 29 patients with lumbar spinal stenosis (LSS) who underwent TF-OLLIF procedures between 8/2018 and 1/2021. The primary outcome was a change in the Oswestry Disability Index (ODI) one year after surgery. Secondary outcomes were surgery time, blood loss, hospital stay, and complications. The TF-OLLIF was performed using the approach and instrumentation of OLLIF. When osseous hypertrophy is reached during the approach, an 8 mm drill is used to drill through the obstructing bone with continuous neuromonitoring. Discectomy and interbody placement are performed with subsequent posterior pedicle screw fixation. ResultsODI improved from 49% pre-op to 31% at one-year follow-up. Estimated blood loss ranged from 97.6±93.3 ml for one level TF-OLLIF to 146.2±60.3 ml for a 3+ level TF-OLLIF. Operative time ranged from 57.4±19.5 minutes for a one-level TF-OLLIF to 102.9±27.8 minutes for a 3+ level TF-OLLIF. The average length of hospital stay (LOS) was 0.4±0.8 days for one-level TF-OLLIF and 1.6±1.9 days for 3+ level TF-OLLIF. Complications included five cases of nerve root irritation immediately postoperatively, with three of these patients still reporting mild L5 distribution numbness at the last follow-up, which was not clinically limiting. ConclusionThe first 29 cases of TF-OLLIF demonstrated that it is a safe method of interbody fusion that yields good clinical results. This is an important development for practitioners of OLLIF as it enables interbody placement with OLLIF instruments and approach even for challenging L5-S1 levels without compromising surgical outcomes.
Metal-on-metal (MoM) hip resurfacing/replacement is a highly discussed topic in arthropathy, and the impact of its complications is still being elucidated. We report the case of a patient who presented with severe stomach pain due to a symptomatic psoas fluid collection that was later shown to communicate with a MoM total hip prosthesis. A MoM pseudotumor presenting as persistent stomach pain due to an aseptic psoas fluid collection is a rare complication. The case may support an earlier diagnosis in at-risk patients, and it outlines a suggested workup and treatment plan.
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