Abstract: Transverse carpal ligament (TCL) reconstruction after open carpal tunnel release has been advocated to restore wrist kinematics and grip strength. This study investigates the effect of TCL reconstruction in carpal tunnel volume (CTV). Thirty-eight cadaveric wrists were volarly approached and TCL was exposed to its proximal and distal edges. Carpal tunnel contents were removed and the CTV was measured considering that carpal tunnel resembled the shape of a truncated cone. TCL was then dissected and subsequently reconstructed by using 4 different surgical lengthening techniques. Three of these techniques were retrieved from the literature. The fourth was proposed and performed by the authors. Postreconstruction calculation of CTV was done with the same method. In 6 cadavers, a magnetic resonance imaging-based measurement of CTV was performed to assess the validity and reliability of simulation method. The average increase of CTV ranged from 31% to 44% (P < 0.001 for all techniques). However, no statistical significant difference was found between the 4 techniques (P = 0.097). Magnetic resonance imaging volumetric values were equal to simulation measured values before and after reconstruction of TCL (P = 0.224 and P = 0.674, respectively). Lengthening of TCL substantially increases the carpal tunnel capacity regardless the applied surgical technique. The simulation model method seems to be an accurate, precise, and cost-effective approach for the evaluation of CTV.
Abstract: Treatment of complex distal humeral fractures in older patients with osteopenic bone remains a major surgical challenge. We report the results of 11 patients over 75 years of age who underwent semiconstrained sloppy-hinge total elbow arthroplasty (TEA) due to comminuted intraarticular fractures of the distal humerus. There were 9 women and 2 men with a mean age of 79.6 years. The mean duration of follow up was 2.8 years. According to AO classification, there were 8 type C3 and 3 type C2 fractures. The mean time from injury to operation was 4.3 days and the mean length of hospital stay was 9.8 days. The elbow flexion/extension and forearm pronation/supination arc of motion averaged 107(0) and 121(0) respectively. The mean Mayo Elbow Performance Score (MEPS) was 90 points, equivalent to excellent result. One patient sustained a periprosthetic humeral fracture and signs of non-progressive radiolucency were found in 8 out of the 11 elbows. Our search in the English and International literature revealed 9 other clinical studies describing the results of TEA in 167 patients with 168 distal humeral fractures. The mean age of patients varied from 69 to 84.6 years and the mean follow up from 17.8 months to 7 years. The mean MEPS among the studies was between 85 and 95 points. Wound infection was diagnosed in 9 cases (5.4%) but component removal and subsequent reimplantation was only applied in 3 elbows (1.8%). Partial ulnar nerve lesions were reported in 11 patients (6.5%) and reflex sympathetic dystrophy was developed in 5 patients (3%). In 3 elbows (1.8%) a periprosthetic fracture after a fall was recorded. Radiolucent lines between the cement mantle and bone interface were described in 24 cases (14.3%) but the majority of them (17 cases) were stable and asymptomatic. In conclusion, TEA constitutes a viable treatment option for the complex distal humeral fractures in elderly and medically compromised patients. Careful patient selection and regular follow up evaluation are mandatory for achieving an optimal result and eliminating the risks of mismanagement and early implant failure.
Abstract: The need for reaming and the number of locking screws to be used in intramedullary (IM) tibial nailing of acute fractures as well as routine bone grafting of tibial aseptic nonunions have not been clearly defined. We describe the results of reamed interlocked IM nails in 233 patients with 247 tibial fractures (190 closed, 27 open and 30 nonunions). Ninety-six percent of the fractures were united at review after an average of 4.9 years. No correlation was found between union and nail diameter (P = 0.501) or the number of locking screws used (P = 0.287). Nail dynamization was effective in 82% of fractures. Locking screw(s) breakage was associated with nonunion in 25% of cases. Bone grafting during IM nailing was found not to increase the healing rate in tibial nonunions (P = 0.623). None of the IM nails were removed or revised due to infection. A dropped hallux and postoperative compartment syndrome were found in 0.8 and 1.6% of cases, respectively. Anterior knee pain was reported in 42% of patients but nail removal did not alleviate the symptoms in almost half. This series confirms the place of reamed intramedullary nailing for the vast majority of tibial diaphyseal fractures. It provides an optimum outcome and minimizes the need for supplementary bone grafting in aseptic nonunions.
Abstract: Some physicians advocate that aspiration of elbow joint hematoma in radial head fractures is helpful not only for determining a mechanical block to motion from a fracture fragment but also for improving the elbow motion and pain. However, the supplementary role of intra-articular anaesthetic injection is unclear.
Abstract: A case of 65-year-old farmer who presented with Brucella-related cervical spondylitis is described. Because of the advanced form of the infection resulted in neurological impairment, cervical vertebra corpectomy and debridement of the paravertebral granulomatous tissue deposits were performed followed by stabilization with anterior plating and bone grafting. In addition, double antimicrobial chemotherapy regimen was administered for 12 weeks. After one year, follow up evaluation demonstrated resolution of the infection. The authors recommend that brucellosis should be included in the differential diagnosis of cervical spondylitis, particularly in patients who reside in countries where the zoonosis is still endemic.
Abstract: Disappearing bone disease (DBD) is a rare condition of unknown etiology that may cause massive hand deformity due to severe osteolysis and soft-tissue atrophy. Bone grafting of the affected metacarpal bones or wrist has been described with moderate success in only 4 cases, but phalanx reconstruction has not been attempted. We report a case with multicentric DBD that was treated with staged intercalary iliac bone grafting of the phalanges of the dominant thumb and index finger. After 3 years, no graft resorption was noticed and the patient reported considerable functional improvement.
Abstract: Giant cell tumors of the distal radius have been frequently described as difficult to treat, chiefly because of their close proximity to multiple tendons, median nerve, radial artery and carpus.The aim of treatment is to remove the tumor completely and preserve the radiocarpal and radioulnar joints.However, this is not always feasible as giant cell tumors seem to behave more aggressively and have a higher recurrence rate in the distal radius, even if local adjuvant treatment with phenolmethylmethacrylate or liquid nitrogen is applied. The above incidence is increased in Campanacci grade III lesions, which are characterized by fuzzy borders, loss of cortical continuity, and extension into soft tissues. In these cases, wide excision instead of intralesional excision may be advocated, particularly when the tumor breaks through the cortex, violates the articular surface, and destroys >50% of the surrounding metaphysis. Several reconstructive options (e.g., resection arthroplasty, prosthetic replacement, arthrodesis, ulnar translocation, centralization of the carpus over the remaining ulna, use of a nonvascularized, or vascularized fibular graft [with or without arthrodesis], and allograft replacement) have been described for the treatment of either recurrent or primary grade III giant cell tumor with destruction of the bone cortex and associated soft tissue mass. Ulnar translocation has been mentioned rarely in the literature, and, according to our knowledge, only 10 cases have been previously reported. This article presents a case of a woman with a grade III giant cell tumor of the distal radius. Wide excision of the tumor followed by reconstruction of the distal forearm with a modified ulnar translocation technique and wrist arthrodesis led to optimum results and no mass recurrence at 13 years postoperatively.
Abstract: We report a case of 1-stage ipsilateral shoulder and elbow arthroplasty after comminuted fractures of both joints in a 77-year-old woman. The postoperative course was uneventful, and the patient showed prompt functional improvement and a good clinical result. Despite the higher risk of periprosthetic humeral fracture in cases of ipsilateral shoulder and elbow arthroplasty, the 1-stage procedure may be a promising and reliable solution for the treatment of complex upper limb fractures in elderly inactive patients.
Abstract: ABSTRACT: INTRODUCTION: Posterior shoulder fracture-dislocation is a rare emergency condition with poor prognosis when there is a delay in diagnosis and presence of associated injuries. CASE PRESENTATION: We present a case of a neglected four-part fracture-dislocation of the proximal humerus in a 34-year-old Greek woman. Except from the substantially displaced and comminuted tuberosity fractures, an anterolateral defect of approximately 50% of the articular surface was apparent. Open reduction of the humeral head was followed by reconstruction of the proximal humerus with allograft impaction, transfer of lesser tuberosity to the humeral defect and anatomic fixation of the greater tuberosity and humeral neck fractures. At two and a half years postoperatively, the humeral head was revascularised and properly articulated with the glenoid fossa. CONCLUSION: The presented case underlines the variability of injury pattern, the potential of missed diagnosis and the need for preserving the humeral head in young patients regardless of the amount of articular surface defect and disruption of soft tissue attachments.
Abstract: ABSTRACT: BACKGROUND: Tension band wiring (TBW) remains the most common operative technique for the internal fixation of olecranon fractures despite the potential occurrence of subjective complaints due to subcutaneous position of the hardware. Aim of this long term retrospective study was to evaluate the elbow function and the patient-rated outcome after TBW fixation of olecranon fractures. METHODS: We reviewed 62 patients (33 men and 29 women) with an average age of 48.6 years (range, 18-85 years) who underwent TBW osteosynthesis for isolated olecranon fractures. All patients were assessed both clinically with measurement of flexion-extension and pronation-supination arcs and radiologically with elbow X-Rays. Functional outcome was estimated using the Mayo Elbow Performance Score (MEPS), Visual Analogue Scale (VAS) subjective pain score and VAS patient satisfaction score. Follow up: 6-13 years (average 8.2 years). RESULTS: There was a higher prevalence of fractures among men until the 5th decade of life and among women in elderly (p = 0.032). Slip or simple fall onto the arm was the main mechanism of injury for 38 fractures (61.3%) while high energy trauma, such as fall from a height (> 2 m) or road accident, was reported in 24 fractures (38.7%). Hardware removal performed in 51 patients (82.3%) but 34 of them (66.6% of removals) were still complaining for mild pain during daily activities. The incidence of pin migration and loosening was not statistically decreased when penetration of the anterior ulnar cortex was accomplished (p = 0.304). Supination was more often affected than pronation (p = 0.027). According to MEPS, 53 patients (85.5%) had a good to excellent result, 6 (9.7%) fair and 3 (4.8%) poor result. The average satisfaction rating was 9.3 out of 10 (range, 6-10) with 31 patients (50%) to remain completely satisfied from the final result. Degenerative changes recorded in 30 elbows (48.4%). However, no correlation could be found between radiographic findings and MEPS (p = 0.073). CONCLUSION: Tension band wiring fixation remains the "gold standard" for the treatment of displaced and minimally comminuted olecranon fractures. In long term, low levels of pain may be evident regardless of whether the metalware is removed and degenerative changes have been developed.
Abstract: The purpose of this study was to evaluate the long-term results after acute treatment of clavicle fractures. We reviewed 139 patients with an average age of 39.3 years (range: 18 to 74) who sustained a clavicle fracture either isolated or as part of a polytrauma. Besides demographic data, both clinical result and residual symptoms were also recorded. The average follow-up was 7.2 years (range: 4 to 13). The fracture showed a higher prevalence in young men and older women. The most frequent mechanism of injury was a fall (39.6%) and coexisting injuries were found in 12.9% of patients. Conservatively treated fractures united in 96.9% of cases and the time to union was no different with a sling or figure-of-eight bandage. Fracture location did not influence the functional outcome. One third of patients were still complaining of mild pain and discomfort during overhead activities and polytrauma patients had a lower Constant score.
Abstract: Anterior shoulder dislocation is a disabling injury affecting all ages, young and old alike. Recently, the treatment of traumatic shoulder dislocation has included immobilisation for varying periods of time followed by physiotherapy. This study is the first in this country to address the demographic data and recurrence rates of shoulder dislocation. Three hundred and eight patients (170 men and 138 women) were followed up for an average of 5.9 years. The most frequent mechanism of injury was a fall (65.66% of cases), and in 92.1% of the patients, the shoulder was reduced in the Emergency Department without the need for sedation or general anaesthesia. The overall recurrence rate in all ages was 50%, but rose to 88.9% in the 14-20-year age group. The duration of immobilisation did not affect the rate of re-dislocation of the humeral head. We believe that conventional shoulder immobilisation in a sling offers no benefits, and it would be preferable not to immobilise the shoulder at all.
Abstract: ABSTRACT: BACKGROUND: Leiomyomas of the deep soft tissue are quite uncommon and occur even more rarely in upper extremity. CASE PRESENTATION: A 32-year old manual laborer man presented with a two-year history of numbness, tingling and burning pain in the palmar surface of the left hand and fingers. His medical history was unremarkable and no trauma episode was reported. According to the clinical examination and the result of median nerve conduction study (NCS) the diagnosis of carpal tunnel syndrome was established. Operative release of the transverse carpal ligament was subsequently performed but the patient experienced only temporary relief of his symptoms. MRI examination revealed a deep palmary located mass with well-defined margins and ovoid shape. Intraoperatively, the tumor was in continuity with the flexor digitorum superficialis tendon of the middle finger causing substantial compression to median nerve. Histopathological findings of the resected mass were consistent with leiomyoma. After two years the patient was pain-free without signs of tumor recurrence. CONCLUSION: Despite the fact that reports on deep soft tissue leiomyoma are exceptional, this tumor had to be considered as differential diagnosis in painful non-traumatic hand syndromes especially in young patients.
Abstract: A 12 years follow-up of a case of bilateral volar lunate dislocation treated by open reduction and K-wire stabilisation of both wrists six days after injury is described. Despite aseptic necrosis of both lunates, the patient is pain free and has useful function, without the development of lunate ischaemia and collapse, carpal instability or posttraumatic osteoarthritis.
Abstract: Epineural ganglia are considered to be a usual cause of peripheral nerve compression. In this report, we present a rare case of ulnar nerve compression by an epineural ganglion in the cubital tunnel. A 28-year-old right-handed female secretary developed progressive pain, numbness, and weakness in her right elbow, forearm, and hand for 6 months. Atrophy of the adductor pollicis and the first dorsal interosseous muscles was apparent. Clinical examination revealed a cystic mass at the posterior side of the elbow. Magnetic resonance imaging identified a ganglion while electrophysiologic studies revealed a severe conduction block of the ulnar nerve at the elbow. During surgery a 2-cm diameter epineural ganglion was identified compressing the ulnar nerve and was excised using microsurgery techniques. Two months postoperatively, the clinical recovery of the patient was very satisfactory, although the postoperative electrophysiologic studies demonstrated a less dramatic improvement.
Abstract: High-grade dysplastic spondylolisthesis is extremely rare and always involves the L5-S1 level. It is attributed to congenital dysplasia of the superior articular process of the sacrum. It can remain asymptomatic for a long time and can progress to a more severe grade of olisthesis and spondyloptosis. Surgical treatment has varied from posterior-only in situ fusion to anterior and posterior fusion with complete reduction. Three cases of symptomatic high-grade (4th and 5th grade) dysplastic spondylolisthesis treated surgically with reduction and fusion are presented. Interbody fusion at the level of olisthesis is crucial.
Abstract: Intranasal administration of calcitonin (CT) avoids the problem of daily injections in the long-term treatment of osteoporosis. We examined the effect of nasal CT on bone and calcium metabolism in postmenopausal osteoporotic women in a double-blind design. 46 women, 55-75 years in age, and in good general health were included in the study. All patients were at least 6 months postmenopausal and had at least 1 vertebra fracture, bone mineral density (BMD; g/cm2) lower than 0.850 in L2-L4 in a dual energy x-ray absorptiometry (DEXA) AP view of the spine and showed biochemical indications of a fast bone loser. The patients were randomly treated with either nasal CT 200 IU per day, divided in 2 doses (n = 23) or placebo (n = 23) for 1 year. All participants received a daily calcium supplement of 1 g. Clinical and laboratory follow-up every 3 and 6 months, respectively, assessed the clinical picture, bone mineral density measured by DEXA, serum alkaline phosphatase, fasting urinary calcium, creatinine and hydroxyproline. BMD was measured in 4 sites (spine and cervical, Ward's triangle, and the trochanteric area of the hip) before treatment and after 6 and 12 months of treatment. In the placebo group, mean values at the 4 sites showed a 3.3% decrease in BMD after 6 months and a 5.0% decrease after 12 months. In contrast, the calcitonin group showed a 6.8% increase in BMD after 6 months and 11% increase after 12 months (p < or = 0.005). No patient experienced side-effects and there were no complaints of local irritation. We conclude that nasal administration of 200 IU calcitonin daily, continuously for 1 year had a positive effect on the bone mass density in osteoporotic postmenopausal women.
Abstract: The mode of action of the periosteum in the growth of the long bones was investigated by comparing the activity of the growth plate after hemicircumferential and longitudinal periosteal incisions. Twenty-eight rabbits were divided into three groups. A longitudinal periosteum incision was made on the medial upper tibia in rabbits of Group A, and a hemicircumferential periosteum incision was made in Group B. An incision of the skin and superficial tissue only, similar to the skin incision of Groups A and B, was performed on rabbits in Group C. Certain differences in the development of the right tibia compared to the control side were observed in rabbits of Group B: (1) valgus deformity, 5 degrees-10 degrees; (2) overgrowth, 1-2 mm; (3) an S-shaped tibia deformity. The dynamics of the deformity support the mechanical theory because the direction of periosteum division was an important factor in the appearance of growth disturbances.
