bluuebunny/crossref_metadata_2025 huggingface dataset:
Diagnosis of Post-Traumatic Complex Regional Pain Syndrome of the Hand: Current Role of Sympathetic Skin Response and Three-Phase Bone Scintigraphy
Authors: Pankaj A , Kotwal PP , Mittal R , Deepak KK , Bal CS
Published: October 2016

Purpose.

To evaluate the role of sympathetic skin response (SSR) and three-phase bone scintigraphy (TPBS) in the diagnosis of complex regional pain syndrome (CRPS).

Methods.

60 patients with CRPS of the hand were recruited. TPBS was performed using a bolus injection of 20 mCi of Tc-99m methylene diphosphonate in an antecubital vein and blood flow (first phase) image, blood pool (second phase) image, and delayed (third phase) image obtained. Patients were considered to have CRPS when the blood pool and blood flow images showed diffuse asymmetric uptake, or when the delayed image indicated increased asymmetric periarticular uptake. SSR was measured simultaneously in the affected and unaffected hands. Standard surface electromyogram disc electrodes were applied to the palm and dorsum of both hands. Electrical stimuli were applied to the skin at the base of little and ring fingers of the unaffected hand. Patients were considered abnormal when response was absent or the peak-to-peak amplitude was <50% of the contralateral hand in at least 2 readings.

Results.

The delayed phase of TPBS tested positive in all; the first and second phases tested positive in 54 (90%) and 56 (93%) of the patients, respectively. Four of the 6 patients with a negative first phase had had symptoms persisting for more than 6 months, and the other 2 for about 3 to 6 months. No patient presenting within 3 months had a negative scan. SSR was absent in 16 (27%) patients and normal in 44 (73%). 11 (79%) of 14 patients who presented more than 6 months after symptom onset displayed an abnormal SSR, while only 10% of those presenting within 3 to 6 months and 11% of those presenting within 3 months had an abnormal SSR. 12 (75%) of the 16 patients with abnormal SSR had associated decreased sweating, compared with 2 (4.5%) of the 44 patients with a normal SSR.

Conclusion.

TPBS is a very sensitive corroborative test to confirm the clinical suspicion of CRPS during the initial stages, but not in late cases. SSR can be used to document the sympathetic dysfunction in cases having an associated sweating abnormality and may have some diagnostic value in late cases of CRPS, when TPBS is less reliable.
Thumb Polydactyly: Clinical Outcome after Reconstruction
Authors: Yen CH , Chan WL , Leung HB , Mak KH
Published: October 2016

Purpose.

To evaluate clinical and cosmetic outcomes of reconstruction in thumb polydactyly and prognostic value of the Wassel classification.

Methods.

Between 1993 and 2000 inclusive, out of the patients with thumb polydactyly (involving 80 thumbs) operated on, 34 patients (36 thumbs) were available for review and underwent clinical and radiological assessment. Outcomes in terms of the Tada score and complications were recorded.

Results.

The mean age of patients at the time of operation was 2.8 (range, 0.6–47) years. The mean follow-up period was 5 (range, 2.4–10) years. According to the Wassel classification, 12 were type-II thumb polydactyly, 3 type-III, 11 type-IV, 6 type-V, one type-VI, and 3 type-VII. There was no perioperative mortality or wound infection. More than 88% of the patients were satisfied or very satisfied with functional and cosmetic outcomes. Postoperative complications such as scar hypertrophy, pulp atrophy, joint deformity, and instability were common but minor. Ridge nail deformity after the Bilhaut Cloquet procedure was amenable to secondary corrective procedures. All types of operated thumb polydactyly achieved similar mean Tada scores (14.7–16.6 out of 20). The Wassel classification category, age, and surgical procedures were found to have no prognostic value with regard to the Tada score and presence of complications.

Conclusion.

Surgery on thumb polydactyly is rewarding. The Wassel classification category can be used as a guide for treatment, although it fails to predict the occurrence of postoperative complications or Tada scores. Our patients' results can serve as guidelines of expected outcomes after reconstructive procedures in different sub-types of thumb polydactyly.
One-Stage Lateral Rhachotomy and Posterior Spinal Fusion with Compression Hooks for Pott's Paralysis in the Elderly
Authors: Wang B , Ozawa H , Tanaka Y , Matsumoto F , Aizawa T , Kokubun S
Published: October 2016

Purpose.

To evaluate the safety and effectiveness of one-stage lateral rhachotomy and posterior fusion with compression hooks, for the treatment of Pott's paralysis in the elderly.

Methods.

11 elderly patients underwent lateral rhachotomy (costotransversectomy and pediculectomy) to debride the tuberculosis focus extending into the epidural space and to decompress the spinal cord. After debridement, the interbody cavity was packed with autologous iliac bone chips. For stabilisation, posterior fusion was performed using a compression lamina hook system. Patients were followed up for at least 2 years for complications. Neurological status was assessed using the Frankel score. The kyphotic deformity was measured on lateral radiographs taken before surgery and at follow-up.

Results.

During separation of the adhesion around the abscess, a dural tear occurred in one patient and a pleural tear in another. Both tears were successfully repaired. One patient had mild pneumonia after surgery. The Frankel scores of the 11 patients improved from C or D before surgery to D or E after surgery. No relapse of spinal tuberculosis was encountered. The mean deformity angle was 25.5 degrees before surgery and 23.2 degrees at the final follow-up. Spinal fusion was achieved in all patients.

Conclusion.

Without the need of thoracotomy, one-stage lateral rhachotomy with posterior spinal fusion using compression hooks was an effective option for treating Pott's paralysis in the elderly.
Comminuted Simultaneous Bilateral Tibial Tubercle Avulsion Fractures: A Case Report
Authors: Slobogean GP , Mulpuri K , Alvarez CM , Reilly CW
Published: October 2016

A 16-year-old male had simultaneous bilateral tibial tubercle avulsion fractures after making a sudden stop while running at full speed. The left knee injury (type V) was minimally displaced, was treated conservatively with closed reduction, and the patient recovered uneventfully. The right tibial tubercle injury was unusual. The tuberosity and anterior aspect of the proximal epiphysis remained as one, but there was severe intra-articular comminution posterior to the displaced tubercle fragment. The right knee injury (type III) required open reduction and internal fixation to reduce the apophyseal fragment and 2 intra-articular displaced fragments. The patient's recovery was complicated by a severe, persistent flexion deformity on the right side. Eventually, the patient required manipulation under anaesthesia, extensive continuous passive mobilisation and a turnbuckle extension splint. A residual 5-degree flexion deformity remained at 16 months post-injury. This case highlights the importance of identifying any intra-articular fragments, their careful anatomical reduction, and aggressive mobilisation when treating tibial tubercle avulsion fractures.
Tarsal Tunnel Syndrome Caused by a Talocalcaneal Joint Amyloidoma in a Long-Term Haemodialysis Patient: A Case Report
Authors: Sekiya H , Arai Y , Sugimoto N , Sasanuma H , Hoshino Y
Published: October 2016

We present a case of tarsal tunnel syndrome caused by an amyloidoma arising from the talocalcaneal joint in a 64-year-old man with a long history of haemodialysis. He presented with numbness in the medial plantar area of the right foot without any antecedent trauma. The numbness was minimal at rest but gradually worsened, causing difficulty, when walking. Paraesthesia was present on the medial sole of the right foot. A positive Tinel-like sign was noted 2.5 cm below the medial malleolus. Magnetic resonance imaging demonstrated a round lesion, 1 cm in diameter, in the calcaneus, which was hypointense on T1-weighted images and hyperintense on T2-weighted images. In addition, a mass, 1 cm in diameter with a signal isointense to that of muscle was found adjacent to the talocalcaneal joint. The medial plantar nerve was decompressed after removing a solid, 1-cm diameter mass from the talocalcaneal joint. At 6 months post surgery, the numbness had completely resolved. No recurrence was observed at the 24-month follow-up.
Fracture of the Os Trigonum: A Case Report
Authors: Kose O , Okan AN , Durakbasa MO , Emrem K , Islam NC
Published: October 2016

The os trigonum is an inconsistently present accessory bone of the foot situated at the posterolateral aspect of the talus. It may be radiographically confused with fractures of the posterior process of the talus. Fracture of the os trigonum per se is extremely rare. Hyperplantarflexion of the ankle is the mechanism of injury in which the os trigonum is compressed between the posterior malleolus of the tibia and the tuber calcaneus. Computed tomography is the choice of imaging modality in cases where fractures of posterior talus structures, including the os trigonum, are suspected. A high index of suspicion is necessary to diagnose a fracture of the os trigonum after a severe plantarflexion injury to the ankle. Conservative treatment is usually successful. We report a case of a fracture of the os trigonum, its clinical features, treatment and significance.
Isolated Dorsal Midtarsal (Chopart) Dislocation: A Case Report
Authors: Ip KY , Lui TH
Published: October 2016

A case of isolated dorsal midtarsal (Chopart) dislocation resulting from blunt trauma is reported. The mechanism of injury, management, and long-term outcome are discussed. A 45-year-old inebriated man fell from a 4-m height and landed on his feet. He had immediate bilateral foot and back pain. Radiographs showed a burst fracture of the second lumbar vertebra, a left Pott's fracture, and an isolated dorsal dislocation of the right midtarsal (Chopart) joint. No neurovascular deficits or signs of compartment syndrome were noted. The image intensifier showed the unstable midtarsal joint with dorsal translation of the navicular and cuboid from the talus and calcaneum, respectively. Closed reduction of the midtarsal joint was performed with 2 transfixing 3.5-mm AO cortical screws. The right foot was immobilised in a short leg cast for 6 weeks; screws were removed 14 weeks later. At 76-month follow-up, the patient had returned to work as a construction worker, but still had right midfoot pain on prolonged walking or standing, because of persistent plantar opening up and dorsal ossification of the midtarsal joints and degenerative change at the talonavicular joint. With hindsight, open reduction may have led to a better outcome through repair of the plantar ligamentous structures, especially the plantar calcaneonavicular (spring) ligament.
Open Reduction for Late-Presenting Posterior Dislocation of the Elbow
Authors: Mehta S , Sud A , Tiwari A , Kapoor SK
Published: October 2016

Purpose.

To evaluate results of open reduction for late-presenting (more than 3 weeks) posterior dislocation of the elbow in 10 patients.

Method.

Elbow stiffness was the main indication for surgery. The mean age of the patients was 34 (range, 13–65) years; the mean time since injury was 4 (range, 2–6) months. All patients had non-functional elbow movement for any activity of daily living. Three patients had associated fractures around the elbow joint.

Results.

At a mean follow-up of 19 (range, 11–28) months, 8 patients regained a functional range of movement for activities of daily living and maintained a median arc of flexion of 100 degrees and a supination-pronation arc of 140 degrees. According to the Mayo Elbow Performance Index, the results of 5 patients were excellent, 3 were good, and 2 were poor. Complications included pin site infection (n=2), ulnar neuritis (n=1), and delayed wound healing (n=1).

Conclusion.

In patients with late-presenting, unreduced elbow dislocation occurring up to 6 months earlier, open reduction is effective in restoring the joint to a painless, stable and functional state.
Traction and Spica Casting for Closed Femoral Shaft Fractures in Children
Authors: Lee YHD , Lim KBL , Gao GX , Mahadev A , Lam KS , Tan SB , Lee EH
Published: October 2016

Purpose.

To evaluate the treatment outcome of skin traction followed by spica casting for closed femoral shaft fractures in children.

Methods.

Between September 1997 and December 2001 inclusive, outcomes of 63 children aged one month to 15 (mean, 5.3) years with closed femoral shaft fractures managed with skin traction and spica casting were reviewed. Depending on age, patients were kept in traction from 2 to 15 (median, 9) days, then in spica casts for 2 to 8 (median, 5) weeks.

Results.

Bony union took 3 to 12 (median, 6) weeks. There were no malunion, nonunion, or rotational deformities. Nor were there any significant limb length discrepancies, pressure sores, or nerve palsies. On no occasion was a spica cast removed and reapplied for loss of fracture reduction. At final follow-up, limb length discrepancy was noted in 14 (22%) of the patients, but none had a discrepancy of greater than 1.5 cm or a short-legged gait.

Conclusion.

Skin traction followed by spica casting for closed femoral shaft fractures in children is safe, cost-effective and associated with a low complication rate. It is effective in children below 5 years of age and no less effective in older children, except in instances of open fracture, multiple fractures, or older children with large statures, which conditions render them intolerant to spica casts.
Adductor Strain and Hip Range of Movement in Male Professional Soccer Players
Authors: Ibrahim A , Murrell GAC , Knapman P
Published: October 2016

Purpose.

To determine whether hip range of movement (ROM) can predict the occurrence of adductor strain among male professional soccer players.

Methods.

120 subjects were prospectively selected from 6 professional soccer clubs in Australia. Internal rotation, external rotation, and ROM of the hip were measured using a goniometer before and during the course of a soccer season (2003–2004). When adductor strain occurred, further assessments of the hip were performed. Injured subjects' hip ROMs were measured again at the end of the season.

Results.

Eight of the 120 subjects had 9 adductor strains (one bilateral). There was a correlation between preseason decreased hip ROM and occurrence of adductor strain. The mean preseason hip ROM was 44.7 degrees in the injured group and 53.7 degrees in the uninjured group. Once the subjects were able to resume playing soccer, their hip ROM increased to near pre-injury levels.

Conclusion.

Decreased hip ROM may be considered an aetiological factor in the occurrence of adductor strain in male professional soccer players.
Intra-Operative Iso-C3D Navigation for Pedicle Screw Instrumentation of Hangman's Fracture: A Case Report
Authors: Rajasekaran S , Vidyadhara S , Shetty AP
Published: October 2016

Pedicle screw instrumentation of the upper cervical spine is rarely performed in trauma surgery because of the risk of damaging neurovascular structures. We report successful treatment of an unstable hangman's fracture with posterior pedicle screw fixation using Iso-C3D fluoroscopy-based computer navigation guidance. Postoperative computed tomographic images confirmed accurate placement of the pedicle screws. The navigation system is useful, especially in an unstable upper cervical spine injury where the likelihood of change in the inter-segmental relationship is maximal before and after positioning for surgery. The navigation system has the advantage of data acquisition after patient positioning, thus making safe pedicle fixation of the C1 and C2 vertebrae possible despite fractured posterior elements.
Medial Collateral Ligament Avulsion from Both Tibial and Femoral Attachments: A Case Report
Authors: Naik AM , Rao SK , Rao PS
Published: October 2016

The medial collateral ligament (MCL) is the most commonly injured ligament of the knee joint. Proximal MCL tears occur more frequently than do distal ones. We report a 28-year-old man with a valgus injury of his left knee joint after a fall from a motorcycle. Magnetic resonance imaging of the affected knee joint revealed complete avulsion of the superficial MCL from both its femoral and tibial insertions. The meniscofemoral portion of the deep part of the MCL was also torn and the medial meniscus was subluxated. Such a pattern, an MCL tear with subluxation of the medial meniscus, is rare.
Traumatic Anterior Knee Dislocation and Tibial Shaft Fracture: A Case Report
Authors: Gupta S , Fazal MA , Haddad F
Published: October 2016

We report a case of traumatic anterior dislocation of the left knee with an ipsilateral tibial shaft fracture in association with popliteal artery and common peroneal nerve injuries. To our knowledge, such a combination of injuries has not been reported before. All components of this injury were recognised and treated promptly with rehabilitation commencing early, resulting in a good functional outcome. We discuss the possible injury mechanism and management of this unusual case.
Intra-Osseous Ganglion of the Proximal Humerus: A Case Report
Authors: Nishimura T , Tsujii M , Kusuzaki K , Hoki Y , Uchida A , Hirata H
Published: October 2016

We report a 72-year-old woman with a type-1 intra-osseous ganglion in the proximal humerus, extending to the bone surface. We conducted a systemic review of intra-osseous ganglion cases in Japan to identify clinical features and pathogenesis of this condition. The anatomical distribution between intra-osseous ganglia without a communicating soft tissue ganglion (type 1) and those with (type 2) is different. The origins of intra-osseous ganglia vary and depend on their anatomical location. They can arise from within the bone or in the adjacent soft tissue, and can progress to a type-2 lesion in either an outside-in or inside-out fashion.
Acquired Radial Club Hand with Humero-Ulnar Dislocation: A Rare Sequel to Infantile Compartment Syndrome following Venous Cannulation: A Case Report
Authors: Kanojia RK , Sharma N , Kataria H
Published: October 2016

Acquired radial club hand caused by infection has been reported occasionally. We report a rare case of acquired radial club hand with an associated septic dislocation of the elbow, primarily caused by compartment syndrome following venous cannulation. The deformity and instability were treated with distraction using an external fixator followed by a centralisation procedure. At the 2-year follow-up the appearance and functions of the left forearm had improved considerably and the wrist was stable. There was no deterioration in ulnar growth.
A Primary Hydatid Cyst of the Gracilis: A Case Report
Authors: Durakbasa MO , Kose O , Islam NC , Kilicoglu G
Published: October 2016

Primary hydatid disease of the skeletal muscle without systemic involvement is rare. A 40-year-old woman presented with a painful mass in her medial left upper thigh. She was misdiagnosed as having a deep intramuscular abscess and a fine needle aspiration was performed, but the fluid came out crystal clear. Further inquiry revealed that her 16-year-old daughter had been operated on twice for liver and lung hydatid disease. Thus, a provisional diagnosis of hydatid disease was made. An echinococcal haemagglutination test was positive. Ultrasonography and magnetic resonance imaging findings were consistent with a type-2 hydatid cyst showing a ‘water-lily’ sign. The cystic mass within the left gracilis was resected en bloc. Adjunctive albendazole chemotherapy (400 mg/day) was prescribed for 3 months. At the 22-month follow-up, the patient remained free of symptoms.
Small Wire External Fixation for High-Energy Tibial Plateau Fractures
Authors: Kataria H , Sharma N , Kanojia RK
Published: October 2016

Purpose.

To assess results of small wire external fixation using a ligamentotaxis technique for high-energy tibial plateau fractures.

Methods.

Between April 2002 and May 2004, 38 consecutive patients aged 21 to 60 (mean, 32) years underwent small wire external fixation for high-energy tibial plateau fractures. 15 involved the right and 23 the left knee. 34 were closed and 4 were open injuries. Fractures were classified according to Schatzker's staging system. After a minimal of 2 years' follow-up (range, 24–42 months), each affected knee was evaluated using Rasmussen's (1) 30-point clinical grading system and (2) radiological evaluation.

Results.

There were 22 type-VI and 16 type-V Schatzker tibial plateau fractures. Complications consisted of: 2 superficial infections, 3 pin site infections, and 4 peroneal nerve palsies. No soft tissue necrosis or devitalisation occurred. The mean range of knee movement was 132°. The mean Rasmussen radiological score was 14 (range, 10–18): excellent in 6, good in 26, and fair in 6. The mean Rasmusssen functional score was 26 (range, 17–30): excellent in 19 patients, good in 17, and fair in 2. Clinical results did not parallel the radiological results.

Conclusion.

Small wire external fixation allows anatomical reconstruction of the articular surface, stable fixation of fracture fragments, early movement of the joint, and care of associated soft tissue injuries, without a high rate of complications.
Medial Humeral Epicondylar Fracture in Children and Adolescents
Authors: Ip D , Tsang WL
Published: October 2016

Purpose.

To assess treatment outcomes of young patients with medial epicondylar fracture of the elbow using standard operative protocols.

Methods.

24 consecutive patients with medial humeral epicondylar fracture underwent surgery by one of the 3 methods: (1) 2 parallel Kirschner wires, (2) 2 parallel Kirschner wires plus a tension-band wire, and (3) a screw plus an anti-rotation Kirschner wire. Fractures displaced less than 5 mm were treated conservatively (casting for 3 weeks). Outcome was assessed clinically and radiologically. The Mayo Clinic Elbow Performance Index was measured.

Results.

The 3 patients with undisplaced fractures had good radiological results and scores. One patient with a displaced fracture refused surgery and subsequently developed pseudarthrosis and cubitus valgus. All operatively treated patients had good scores, but 2 treated with 2 parallel Kirschner wires alone developed pseudarthrosis. Patients in this group needed longer rehabilitation to attain a functional range of movement than those in other groups (treated together with a tension-band wire or screw).

Conclusion.

Surgery is recommended for children with displaced medial epicondylar fractures of more than 5 mm. The use of a tension-band wire, instead of a screw, together with Kirschner wires is the preferred treatment for younger children.
Treatment of Flexion-Type Supracondylar Humeral Fracture in Children
Authors: Garg B , Pankaj A , Malhotra R , Bhan S
Published: October 2016

Purpose.

To assess the results of treatment for flexion-type supracondylar humeral fracture in children.

Methods.

The treatment of 14 children with flexion-type supracondylar humeral fracture was reviewed. Severity was classified according to the Gartland system for extension-type fractures. Type-I fractures were treated with immobilisation in an extension cast. For type-II and -III fractures, closed reduction was first attempted followed by percutaneous pinning. If closed reduction failed, open reduction and internal fixation was performed.

Results.

Patients were followed up for at least one year (range, 14–36 months). Treatment results were excellent in 7 patients, good in 4, fair in 3, and poor in none. Patients were pain-free and satisfied and none suffered any activity restriction.

Conclusion.

Closed reduction and percutaneous pinning is a good treatment option for type-II and -III flexion-type supracondylar humeral fractures.
Surgical Management for Late Presentation of Supracondylar Humeral Fracture in Children
Authors: Tiwari A , Kanojia RK , Kapoor SK
Published: October 2016

Purpose.

To report the results of surgical management for late-presenting displaced supracondylar fractures of the humerus in children.

Methods.

Between February 2002 and June 2003, 40 children (mean age, 7 years) with late presentation (range, 2–12 days) of displaced supracondylar humeral fractures were prospectively recruited. Gentle closed manipulation under image intensification was attempted in all patients, except one with a compound open fracture. Manipulation was successful in 25 patients and percutaneous skeletal stabilisation with Kirschner wires was performed. The remaining 15 patients were treated with open reduction and Kirschner wire fixation, using a mediolateral approach.

Results.

The mean delay in presentation was approximately 4 days. No patients presenting more than 7 days after injury had the fracture reduced by closed manipulation. The mean hospital stay was 41 hours. At the final follow-up (mean, 18 months), 88% of the patients had a satisfactory result, according to Flynn's criteria.

Conclusion.

Operative treatment for late presentation of supracondylar humeral fractures in children is effective. It minimises the risk of complications and the need for continuous traction or corrective osteotomy.
Computed Tomographic Measurement of Cervical Pedicles for Transpedicular Fixation in a Malay Population
Authors: Yusof MI , Ming LK , Abdullah MS
Published: October 2016

Purpose.

To measure the cervical pedicles and assess the feasibility of transpedicular fixation in a Malay population.

Methods.

960 computed tomography (CT) scans of bilateral C2 to C7 pedicles of 80 Malays were compared. 22 men and 24 women aged <60 (mean, 37.3; range, 18–56) years were defined as young patients, whereas 18 men and 16 women aged ≥60 (mean, 63.9; range, 60–76) years as elderly patients. An inner diameter of <3.0 mm (85% of a 3.5-mm screw) was defined as ‘unfeasible’ and a medial or lateral wall thickness of <1.0 mm as ‘unsafe’ for cervical pedicle screw fixation.

Results.

In the respective young versus elderly groups, the inner diameters ranged from 1.94 to 2.80 mm versus 2.51 to 3.37 mm in men, and from 1.52 to 2.31 mm versus 1.64 to 2.46 mm in women. Medial wall thickness ranged from 1.25 to 1.46 mm versus 1.13 to 1.48 mm in men, and from 1.28 to 1.72 mm versus 1.10 to 1.24 mm in women. Lateral wall thickness ranged from 0.80 to 0.90 mm versus 0.66 to 0.88 mm in men, and from 0.85 to 0.99 mm versus 0.59 to 0.86 mm in women.

Conclusion.

The cervical spine of Malays may not be adequate to accommodate a 3.5-mm pedicle screw for transpedicular fixation, as this procedure may risk adjacent vital structures.
Arthroscopic Subacromial Decompression for Stage-II Impingement
Authors: Lim KK , Chang HC , Tan JL , Chan BK
Published: October 2016

Purpose.

To evaluate outcomes of arthroscopic subacromial decompression for stage-II impingement.

Methods.

Records of 42 consecutive patients with stage-II impingement treated by arthroscopic subacromial decompression from January 2000 to February 2002 were reviewed. Clinical outcomes were measured using the UCLA shoulder rating scale, and radiological outcomes using anteroposterior and supraspinatus outlet shoulder radiographs.

Results.

The mean follow-up period was 14.6 (range, 12–30) months. Using the UCLA scale, 14 (33%) patients had an excellent result, 21 (50%) had a good result, 4 (10%) had a fair result, and 3 (7%) had a poor result. Mean component scores for the UCLA scale were: 8.0 for pain, 8.8 for function, 4.5 for forward flexion, and 4.5 for strength. The mean extent of resection was 2.9 mm in the anteroposterior and 2.0 mm in the supraspinatus outlet radiographs. There was no correlation between the extent of acromial resection and the UCLA shoulder rating scores.

Conclusion.

Short-term results of arthroscopic subacromial decompression for stage-II impingement are favourable.
A Combined Use of a Free Vascularised Flap and an External Fixator for Reconstruction of Lower Extremity Defects in Children
Authors: Segev E , Wientroub S , Kollender Y , Meller I , Amir A , Gur E
Published: October 2016

Purpose.

To describe a combined use of a free vascularised flap and an external fixator for reconstruction of lower extremity defects in children, and correction of equinus contracture developed after removal of the external fixator using a circular dynamic frame.

Methods.

Seven children (4 males) aged 4 to 12 (mean, 8) years were treated with 9 free vascularised flaps for 8 limbs (bilaterally in one patient and for a failed flap in another). Patient pathologies included: 3 soft tissue degloving injuries, one soft tissue and bone avulsion, one severe burn contracture, one resurfacing of soft tissue and bone necrosis, and one osteosarcoma resection defect. Free flap reconstruction was delayed in 6 patients (range, 3 weeks to 4 years). Static external fixators were used to stabilise the free vascularised flaps at the time of reconstruction, with the ankle in a neutral position.

Results.

The mean follow-up was 5 (1–10) years. All flaps but one survived; the failed one was immediately reconstructed with a contralateral, latissimus dorsi flap. One anastomosis following a Kirschner-wire injury was successfully revised. Six patients had pin tract infections and were treated with oral antibiotics. Two patients developed equinus contracture 6 and 3 years later, after removal of the external fixator, and were corrected by distraction, using a dynamic Ilizarov frame.

Conclusion.

The combined use of a free flap and an external fixator for salvage of lower extremities is useful in children. Late development of equinus contracture can be safely corrected by distraction, without compromising flap viability.
Dynamic Treatment for Proximal Phalangeal Fracture of the Hand
Authors: Rajesh G , Ip WY , Chow SP , Fung BKK
Published: October 2016

Purpose.

To assess a protected mobilisation programme (dynamic treatment) for proximal phalangeal fracture of the hand, irrespective of the geometry.

Methods.

Clinical and radiological results of 32 consecutive patients with proximal phalangeal fracture of the hand treated from January 2001 to February 2007 were evaluated. Our supervised rehabilitation programme was strictly followed to gain full range of movement of the proximal interphalangeal joint and to prevent the development of an extension lag contracture. Patients were followed up for a mean period of 15 (range, 13–16) months. Results were evaluated using the Belsky classification.

Results.

The results were excellent in 72% of the patients, good in 22%, and poor in 6%. Some patients defaulted follow-up, which made long-term assessment difficult. The poor results may have been related to patient non-compliance or default from rehabilitation. Many good results upgraded to excellent following further rehabilitation.

Conclusion.

Skeletal stability, not rigidity, is necessary for functional movements of the hand. Proximal phalangeal fractures can be effectively treated by closed methods, using the stabilising effect of soft tissues (zancolli complex–metacarpophalangeal retention apparatus) and external devices (metacarpophalangeal block splint), thus enabling bone healing and movement recovery at the same time.
Primary Aneurysmal Bone Cyst of the Patella: A Case Report
Authors: Oh JH , Kim HH , Gong HS , Lee SL , Kim JY , Kim WS
Published: October 2016

Aneurysmal bone cysts account for less than 1% of primary bone tumours and have a predilection for the metaphyses of the long bones of the leg. Only 1% of all aneurysmal bone cysts occur in the patella. We report on a 30-year-old man with a primary aneurysmal bone cyst in the right patella treated with curettage. The defect was filled with demineralised bone matrix and allogeneic cancellous bone graft. At the 1.5-year follow-up, the bone graft was well incorporated, the patient experienced no pain or tenderness and had a full range of knee movement.
Anti-Platelet Agents and Surgical Delay in Elderly Patients with Hip Fractures
Authors: Harty JA , McKenna P , Moloney D , D'Souza L , Masterson E
Published: October 2016

Purpose.

To assess the risk of surgical delay in elderly hip fracture patients on anti-platelet agents.

Methods.

Records of 180 patients aged over 65 years with either an intertrochanteric or femoral neck fracture were reviewed. The clopidogrel group included 10 patients on clopidogrel alone and 11 others on clopidogrel and aspirin, whereas the control group included 69 on aspirin alone and the remaining 90 not on any anti-coagulants. The 2 groups were compared with regard to time to surgery, preoperative American Society of Anesthesiologists (ASA) score, pre- and post-operative haemoglobin levels, in-patient complication rates, duration of hospital stay, and 30-day mortality.

Results.

In the clopidogrel and control groups respectively, the mean times to surgery were 7.2 and 2.1 days (p=0.03, t-test), the mean preoperative ASA scores were 3.35 and 2.8 (p=0.29, t-test), the mean preoperative haemoglobin levels were 119 and 115 g/l (p=0.5, t-test), the mean postoperative haemoglobin levels were 98 and 96 g/l (p=0.68, t-test), the mean durations of hospital stay were 7.4 and 3.1 days (p=0.02, t-test). The 30-day mortalities were 6/21 (29%) and 6/159 (4%) [p=0.0003, Fisher's exact test].

Conclusion.

Surgical delay in elderly patients on anti-platelet agents with hip fracture was associated with higher mortality. Despite the risk of increased blood loss, we suggest early surgery be carried out by an experienced surgeon to expedite the operating time. Pooled platelets should be given intravenously one to 2 hours preoperatively.
Salter Innominate Osteotomy for Treatment of Developmental Dysplasia of the Hip
Authors: Tukenmez M , Tezeren G
Published: October 2016

Purpose.

To compare the results of Salter innominate osteotomy (SIO) for treatment of developmental dysplasia of the hip (DDH) in children.

Methods.

Between 1994 and 2002, 53 girls and 8 boys with DDH underwent open reduction and SIO; 21 were on the left side, 22 on the right side, 18 bilateral. They were divided into 2 groups: group 1 included 35 patients aged younger than 3 years (46 hips) and group 2 included 26 patients aged 3 years or older (33 hips). Clinical outcomes were assessed using the modified McKay criteria to measure pain symptoms, gait pattern, Trendelenburg sign status, and the range of hip joint movement. Radiographic outcomes were evaluated using the Severin method to measure the Sharp acetabular angle and the centre-edge angle.

Results.

Group-1 children achieved slightly better reduction and stabilisation of the hip joint empirically, but clinical and radiographic results and complication rates in the 2 groups were not significantly different.

Conclusion.

Open reduction and SIO without preoperative traction is effective for the management of DDH in children younger than 6 years.
Surgical Management of Metastatic Disease of the Proximal Femur
Authors: Hattori H , Mibe J , Matsuoka H , Nagai S , Yamamoto K
Published: October 2016

Purpose.

To review the surgical treatment for metastatic disease of the proximal femur.

Methods.

Records of 8 patients who underwent endoprosthetic replacement with tumour resection (group 1) and 8 others who underwent intramedullary nailing without tumour resection (group 2) were reviewed. Treatments were based on the disease progression and patient's condition.

Results.

In groups 1 and 2, the respective mean survival periods were 16 and 4 months. All patients in group 1 regained preoperative mobility, but only one patient in group 2 was able to walk with crutches.

Conclusion.

This was a retrospective, rather than comparative study of endoprothetic replacement and intramedullary nailing for metastatic disease of the proximal femur. Both procedures are considered palliative, and not curative. The longer survival period in group 1 was mainly due to selection of patients with better preoperative medical status.
Management of Acute Achilles Tendon Ruptures in the United Kingdom
Authors: Worth N , Ghosh S , Maffulli N
Published: October 2016

Purpose.

To survey the management of acute Achilles tendon ruptures in the United Kingdom.

Methods.

A questionnaire with 4 different Achilles tendon rupture scenarios affecting patients of different ages and activity levels was sent to orthopaedic consultants specialised in sports trauma, foot and ankle surgery. Their treatment methods including surgical techniques, immobilisation and rehabilitation regimens were surveyed.

Results.

The response rate was 22% (51/231). Among the 51 respondents, 25 had managed less than 6 such patients in the preceding year. 26 (51%) used clinical examination (e.g. calf squeeze test) to make the diagnosis, 16 (31%) used ultrasonography, and 4 (8%) used magnetic resonance imaging. Surgical management was preferred for younger and more functionally demanding individuals. Open repairs were used more often than percutaneous repairs (72 vs 19%). Across the 4 scenarios, the mean time to return to full activity was 17 (range, 12–32) weeks for conservative to 19 (range, 10–40) weeks for surgical management.

Conclusion.

Variation in opinion among respondents was wide. Randomised controlled trials are needed to assess optimal treatment.
Gamma Nail Breakage: A Report of Four Cases
Authors: Kasimatis GB , Lambiris E , Tyllianakis M , Giannikas D , Mouzakis D , Panagiotopoulos E
Published: October 2016

Gamma nails have been used extensively for the treatment of proximal femoral fractures. Nail breakage at the level of the aperture of the lag screw is rare. We report 4 such cases mainly associated with a large posteromedial cortex gap and nonunion. The need for adequate reduction to avoid such a complication is emphasised.
Spontaneous Spinal Epidural Haematoma in a 15-Month-Old Boy Presenting with a Wry Neck: A Case Report
Authors: Fok WM , Sun LK , Wong NM , Lau PY , Cheung HM
Published: October 2016

A 15-month-old boy presented with a 2-day history of a wry neck (bent to the left side) with no definite trauma. He had bilateral upper limb weakness and was afebrile, conscious, and stable. There was no spontaneous movement in both upper limbs. Magnetic resonance imaging of the cervical and thoracic spine demonstrated an extensive spontaneous spinal epidural haematoma from C3 to T8. 23 hours after admission, the patient underwent an emergency right-sided C3 to T8 hemi-laminectomy and haematoma evacuation. The patent's strength gradually recovered and he attained full power 3 weeks after operation. Spontaneous spinal epidural haematoma is a rare disease in children. A high index of suspicion is essential for its effective management as the interval to operation is the most important prognostic factor.
Discal Cysts of the Lumbar Spine: A Case Report
Authors: Murata K , Ikenaga M , Tanaka C , Kanoe H , Okudaira S
Published: October 2016

Discal cysts—intraspinal cysts communicating with an adjacent intervertebral disc—are an uncommon cause of lumbar radiculopathy. We report a case of discal cyst of the lumbar spine. The cyst contents were bloody and clotted rapidly; no disc materials were seen. Communication between the cyst and the intervertebral disc was detected. Histopathology of the cyst wall revealed fibrous connective tissue without synovial lining cells. We hypothesise that the discal cyst was formed by haemorrhage of the epidural venous plexus caused by separation of the peridural membrane by mechanical force transmitted by an annulus fibrosis fissure. The minute segmental motion caused by the affected disc may have stimulated continuous bleeding.
Ilizarov External Fixator for Burst Fracture of the Lumbar Spine: A Case Report
Authors: Matsubara H , Tsuchiya H , Kawahara N , Kobayashi T , Morinaga T , Tomita K
Published: October 2016

A 50-year-old man presented with severe back pain and tenderness throughout the lumbar area after falling from a ladder. He had an unstable type-B burst fracture, with a spinal canal narrowing of 36% and an anterior height loss of 65%. His lower-limb neurological function was intact. An Ilizarov external spinal fixator was used; the pedicular half pins were inserted into the bilateral T11, T12, L2, and L3 pedicles; bilateral pedicular half pins were fixed at each level with external plates and rods. Postoperatively, the patient had a lordosis of 2° and was able to walk 7 days later. The external fixator was removed at 10 weeks. Six years and 10 months after surgery, the patient had a kyphosis of 19° that did not affect his activities of daily living.
Anterior Cervical Fusion Using the IntExt Combined Cage/Plate
Authors: Keogh A , Hardcastle P , Ali SF
Published: October 2016

Purpose.

To review our first 30 patients who underwent anterior cervical fusion using IntExt and xenograft.

Methods.

Records of 23 men and 7 women aged 18 to 83 (mean, 40) years were reviewed by a single researcher. 23 patients had traumatic fracture-dislocations and 7 had degenerative disease. Pain, range of movement, neurological status, return-to-work status, kyphosis, and lordosis were recorded. Radiography and computed tomography were used to assess integration of the xenograft with the host bone, intervertebral fusion around the cage, and any screw loosening.

Results.

The mean follow-up duration of the 30 patients was 14 (range, 1–47) months. There was no evidence of screw loosening or breakage. 20 of the 28 patients had no neck pain. Radiographs and/or computed tomographic scans of 23 patients showed bone union or clinical evidence of stability.

Conclusion.

The IntExt is effective in stabilising traumatic fractures. Although the literature does not support single-level plating in degenerative fractures (because of high success rates with autologous bone grafting), the IntExt has advantages of avoiding grafting complications, donor-site morbidity, and resorting to a postoperative collar.
Balloon Kyphoplasty for Vertebra Plana with or without Osteonecrosis
Authors: Becker S , Tuschel A , Chavanne A , Meissner J , Ogon M
Published: October 2016

Purpose.

To compare efficacy of balloon kyphoplasty in restoring vertebral height and correcting kyphosis in patients having vertebra plana with or without osteonecrosis.

Methods.

12 women and 3 men (mean age, 76 years), who had a complete vertebra plana with or without osteonecrosis (n=8 vs n=7), underwent balloon kyphoplasty. No external manoeuvres were performed before or during balloon kyphoplasty, except for positioning the patients in a prone posture on the operating table. The anterior, middle, and posterior vertebral height and the kyphotic angle were measured pre- and post-operatively with a digital imaging system. The vertebral height was measured as a percentage of the adjacent normal vertebral height.

Results.

Respectively in vertebra plana patients with or without osteonecrosis, the mean corrections of (1) kyphosis were 10° and 4° (p=0.099), (2) anterior vertebral height were 33% and 5% (p<0.001), (3) middle vertebral height were 38% and 18% (p=0.004), and (4) posterior vertebral height were 19% and 2% (p=0.031).

Conclusion.

In patients with vertebra plana, it is important to identify any osteonecrosis, which is an indication for balloon kyphoplasty to restore vertebral height and correct kyphosis.
Dextrose Prolotherapy for Recalcitrant Coccygodynia
Authors: Khan SA , Kumar A , Varshney MK , Trikha V , Yadav CS
Published: October 2016

Purpose.

To present the results of dextrose prolotherapy undertaken for chronic non-responding coccygodynia in 37 patients.

Methods.

14 men and 23 women (mean age, 36 years) with chronic coccygodynia not responding to conservative treatment for more than 6 months were included. 27 of them had received local steroid injections. A visual analogue score (VAS) was recorded for all patients before and after injection of 8 ml of 25% dextrose and 2 ml of 2% lignocaine into the coccyx. In 8 patients with a VAS of more than 4 after the second injection, a third injection was given 4 weeks later.

Results.

The mean VAS before prolotherapy was 8.5. It was 3.4 after the first injection and 2.5 after the second injection. Minimal or no improvement was noted in 7 patients; the remaining 30 patients had good pain relief.

Conclusion.

Dextrose prolothearpy is an effective treatment option in patients with chronic, recalcitrant coccygodynia and should be used before undergoing coccygectomy. Randomised studies are needed to compare prolotherapy with local steroid injections or coccygectomies.
Chondroblastoma
Authors: Garin IE , Wang EHM
Published: October 2016

Purpose.

To review all patients with chondroblastoma treated in our hospital between 1993 and 2004.

Methods.

Six men and 4 women aged 13 to 33 (mean, 21) years with histologically proven chondroblastomas were retrospectively reviewed through our tumour registry, patient records, radiographic and histopathologic reports. All patients underwent intralesional curettage and bone grafting with or without bone cement. The mean follow-up period was 5.5 (range, 2–11.8) years. Functional outcome was measured according to the Enneking scoring system.

Results.

The proximal tibia and femur were the most frequently involved sites. All patients presented with pain but only 2 with joint effusion. In 3 patients the lesions were aggressive, in 3 others it was active, and in 4 it was latent. In 2 patients the lesions recurred at 5 and 28 months; both resolved after repeat surgeries without further recurrence. Functional outcomes were either good or excellent, except for one patient with a compartment syndrome of the contralateral leg. No patients had metastasis to lungs or collapse of articular surfaces.

Conclusion.

Chondroblastoma is a rare benign bone tumour commonly presenting with pain. Outcomes are usually good after curettage and reconstruction with bone grafting.
Patient Expectations for Hallux Valgus Surgery
Authors: Tai CC , Ridgeway S , Ramachandran M , Ng VA , Devic N , Singh D
Published: October 2016

Purpose.

To determine preoperative patient expectations and their relative importance for hallux valgus surgery using a patient-derived questionnaire, and whether such expectations are influenced by age, gender, or occupation.

Methods.

Two patient-derived questionnaires were developed using open-ended interviews. The 19 most commonly stated expectations were included in the Patient Expectation Questionnaire: 2 related to improvement in appearance, 2 to pain reduction, and 15 to functional improvements in performing daily and recreational activities. The top 9 expectations were included in the Patient Priority Questionnaire for prioritising.

Results.

153 eligible patients aged 16 to 79 (mean, 47) years completed the questionnaires; 29 (19%) aged less than 40 years, 84 (55%) aged 40 to 60 years, and 40 (26%) aged more than 60 years. 86% were women and 81% were Caucasian. 62% were housewives or retired pensioners. Overall, the most important expectation was improved walking, followed by reduced pain over the bunion and wearing daily shoes. These expectations varied according to age and gender but not occupation.

Conclusion.

Patient expectations differ from those of surgeons, and vary according to patient age and gender. Understanding preoperative patient expectations is crucial to achieve better clinical outcomes and satisfaction by selecting the most appropriate operation for each patient.