Silicone ring tourniquet versus pneumatic cuff tourniquet in carpal tunnel release: a randomized comparative study.

BACKGROUND: The aim of the present study was to compare the pain levels resulting from the use of a silicone ring tourniquet (SRT) to those resulting from the use of a classic pneumatic cuff tourniquet (PT) in patients undergoing carpal tunnel release under local anesthesia. MATERIALS AND METHODS: Fifty patients that underwent carpal tunnel release under local anesthesia were randomized using the technique of stratified randomization by minimization. A forearm tourniquet was applied: a standard PT was used in 25 patients, and an SRT was used in the other 25 patients (the model of SRT used was selected according to the standard systolic blood pressure). Patient demographics and complications were recorded. Pain levels were assessed with the visual analogue scale and were recorded (a) just after tourniquet application, (b) 5 min after tourniquet application, and (c) just before tourniquet removal. RESULTS: There was no statistical significant difference in patient demographics between the two groups. The mean tourniquet time was similar for both groups (p = 1.000). The difference between the mean final pain level and the mean initial pain level was statistically significant for the SRT group (p = 0.010) and highly statistically significant for the PT group (p < 0.001). The mean final pain level for the PT group was higher than that for the SRT group (p = 0.043). CONCLUSIONS: According to the findings of this study, in patients who underwent carpal tunnel release under local anesthesia, the pain levels at the end of the operation and those just before the removal of the tourniquet were higher in the PT group than in the SRT group of patients.

Mechanical characterization of bone graft substitute ceramic cements.

The aim of this laboratory work was to study the compressive and flexural characteristics of various commercially available bone graft substitute (BGS) ceramic cements, in their initial as-mixed condition, and compare them to polymethylmethacrylate (PMMA). The tested biomaterials were two different calcium phosphate cements, two different calcium sulphate cements, one nanocrystalline hydroxyapatite and one PMMA cement. All biomaterials were prepared according to manufacturers instructions and the methodology described in ISO 5833 (2002) for acrylic bone cement was followed, as the one closest approaching in vivo requirements. All BGS cements had a brittle behaviour and when subjected to mechanical stress they all failed under sudden crack propagations in their bulk. Both in compression and bending, all BGS cements failed under loads lower than those of PMMA. In compression, the calcium sulphate extra strength cement showed a strength value of approximately 60% of PMMA, the other cements following at a distance. In bending, all BGS cements showed strengths below 22% of PMMA. However, due to limited number and fragility of specimens, calculated bending strengths can only be considered as indicative figures with limited comparative value. The results of this in vitro study showed a varying mechanical performance between tested BGS ceramic cements, whilst all of them exhibited lower compression and bending strength than the selected PMMA. These findings, of course, cannot be directly extrapolated to surgical or clinical implications, since the adopted in vitro context does not necessarily reflect the actual in vivo conditions met by such biomaterials.

Bilateral transient bone marrow edema or transient osteoporosis of the knee in pregnancy.

Transient osteoporosis or transient bone marrow edema is an uncommon self-limiting condition of unknown etiology. The most commonly affected joint is the hip, followed by the knee, ankle, and the foot. Simultaneous involvement of both hips has been reported exclusively in pregnant women. Bilateral knee involvement during pregnancy seems to be extremely rare. We present a case of bilateral transient bone marrow knee edema during pregnancy with complete resolution of symptoms and radiological findings after 10 months.

Polymorphisms of the vitamin D receptor gene and stress fractures.

Our aim was to evaluate the association between VDR polymorphisms and calcaneal Stiffness Index (SI) with stress fractures in a case control study including male military personnel. Thirty- two patients with stress fractures were matched with 32 uninjured healthy volunteers (controls), by gender, age, height, body weight, and level of physical activity. The two groups were genotyped for the FokI, BsmI, ApaI, and TaqI polymorphisms of the VDR gene with PCR-RFLP method. In addition, calcaneal SI was measured by heel quantitative ultrasound in both groups. Data were analyzed by chi-squared test and logistic regression analysis. The f allele was significantly more frequent in patients than in controls (p=0.013), while the B allele showed such a tendency without reaching statistical significance (p=0.052). Among the entire cohort, a 2.7-fold and a 2.0-fold increase in risk of stress fractures was associated with the f and B alleles (OR, 2.7, 95% CI, 1.2-5.9; p=0.014 and OR, 2.0, 95% CI, 1.0-4.1; p=0.053, respectively). No statistically significant association was found between the incidence of stress fractures and t or a alleles. Decreased T-scores were also associated with the presence of f and B alleles. Mean values of T-scores of SI were statistically significantly lower in patients than in controls (p=0.018). These results suggest that the FokI and BsmI polymorphisms of the VDR gene could be associated with increased risk of stress fractures among military personnel. Moreover, a low calcaneal SI could represent a measurable index of this increased risk.

Simultaneous dislocation of the radial head and distal radio-ulnar joint. A case report.

Isolated dislocation of the distal radio-ulnar joint and isolated dislocation of the radial head in adults are not common injuries. A simultaneous dislocation of the radial head and distal radio-ulnar joint with no other injury seems to be extremely rare since only one report was found in the English literature. A similar case, but with some differences in presentation and treatment is reported.

Maggot infestation (myiasis) of external fixation pin sites in diabetic patients.

Diabetic patients, and especially elderly patients in a low-nutritional or immunocompromised state, are prone to a variety of opportunistic infections. 'Myiasis' is a term that refers to non-iatrogenic infestation of tissues by larvae, commonly known as maggots, of dipterous flies. Myiasis as a complication of fracture treatment by means of external fixation of long bones has not been reported. We present three diabetic patients, who suffered maggot infestation of their external fixation pin holes, and their outcome. Diabetes, immobilization, poor hygiene and low immune status are predisposing factors for developing myiasis, an extremely rare complication for external fixation of fractures.

Stress fractures in military men and bone quality related factors.

The aetiology of stress fractures is multifactorial, and many risk factors have been implicated. The aim of this study was to explore the relationship between stress fractures, factors and biochemical markers related to bone metabolism, and calcaneal stiffness index measured by quantitative ultrasound in a case control study including male military personnel beyond basic training. Thirty-two male patients with stress fractures were matched with 32 uninjured-healthy volunteers by age, height, body weight and level of physical performance. A questionnaire concerning the calcium intake, alcohol consumption and smoking was completed, the values of several biochemical markers were measured from blood samples, and calcaneal quantitative ultrasound was measured by heel ultrasound for all participants. Statistically significant higher levels of albumin (4.59 +/- 0.28 vs. 4.40 +/- 0.25, p = 0.006) and lower levels of serum osteocalcin (6.26 +/- 1.74 vs. 7.40 +/- 1.80, p = 0.012), mean values of T-scores (- 0.21 +/- 0.95 vs. 0.33 +/- 0.82, p = 0.018) and Z-scores (- 0.14 +/- 0.81 vs. 0.33 +/- 0.71, p = 0.016) were found among patients compared to controls. Based on the results, it seems that a decreased bone turnover and a low calcaneal stiffness index may be related to the incidence of stress fractures amongst male military personnel.

Post-operative pain after knee arthroscopy and related factors.

The aim of this study was to explore the intensity of post-arthroscopy knee pain during the first 24 hours, and to study the influence of pre-operative pain, tourniquet time and amount of surgical trauma on post-arthroscopy pain. In 78 male patients that underwent elective arthroscopic menisectomy or diagnostic arthroscopy of the knee, preoperative and post-operative pain were registered using the Visual Analogue Scale. Variance for repeated measures and for independent observations was analysed. Supplementary analgesia was required for 23% of the patients, more often in the recovery room and between 2 and 8 hours postoperatively. Of all factors analyzed, only time was statistically significant in determining the level of post-operative pain. Supplementary analgesia was required only in patients that underwent operative arthroscopy, and more often in patients with tourniquet time of more than 40 minutes. In conclusions, post-operative time is the most significant factor related to the post-arthroscopy knee pain.

Intramuscular haemangioma of the extensor pollicis brevis muscle with periosteal reaction of the radius: a case report and review of the literature.

We report the rare case of a histologically proven mixed-type intramuscular haemangioma, adjacent to the periosteum of the radius, that caused a periosteal reaction. We also carried out a review of the literature relevant to this case. A 28-year-old male professional drummer presented with an 8-month history of pain and swelling of the dorsal aspect of the right radius. Diagnosis was established on the basis of plain radiographs and magnetic resonance imaging, and was confirmed by histology. The lesion was treated solely by resection of the soft-tissue mass. The patient remained asymptomatic 4 years post-operatively, with no radiographic signs of recurrence. From a review of the literature, it is evident that the terminology for haemangiomas causing regional bone changes is unclear. A new classification of the intramuscular haemangiomas is proposed in order to distinguish between lesions that, according to current knowledge, exhibit radiological and clinical areas of overlap.

Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures.

As there is little information on the factors that influence fracture union following intramedullary nailing of the tibia we retrospectively investigated patient-, injury- and treatment-related factors in 161 patients with closed or grade I open fractures of the tibial diaphysis. The patients were reviewed until clinical and radiological evidence of union at a mean of 13.3 months (4 to 60). Multivariate statistical analysis using a Cox proportional hazards model showed that the risk of failure of union increased by 2.38 times for highly comminuted fractures, by 3.14 times when nail dynamisation was applied, and by 1.65 times when the locking screws failed. In fractures with no or only minimal comminution the risk of nonunion increased if the post-reduction gap was > or = 3 mm.

Haemangiomas around the knee mimicking medial meniscal tears. Report of two cases and review of the literature.

There are few reports in the English literature of extra-articular lesions simulating intra-articular pathology of the knee. Two cases of histologically confirmed haemangiomas related to the distal femur, presenting with knee pain suggestive of medial meniscal damage, are reported. A 27-year-old woman presented with persistent anteromedial right knee pain despite having undergone two arthroscopies for medial meniscal damage. An MRI showed a soft tissue mass on the medial side of the distal femoral metaphysis. The symptoms resolved only after open resection of the lesion. Histology showed a periosteal haemangioma. The second patient, a 24-year-old woman, complained of posteromedial left knee pain for 3 months. Although a medial meniscal tear was suspected, an MRI showed a soft tissue mass close to the bone of the distal femoral diaphysis. The symptoms resolved after open resection of the lesion. Histology showed a soft tissue haemangioma. Both patients were asymptomatic with normal MRI scans 6 to 12 months postoperatively. Although meniscal tears can present in young patients without a history of trauma, an MRI is extremely useful in diagnosing other lesions causing similar symptoms. Haemangiomas around the knee are rare, in particular periosteal haemangiomas of the distal femur as no report has been found in the English literature.

The causes and mechanisms of meniscal injuries in the sporting and non-sporting environment in an unselected population.

The aim of this study was to establish the aetiology and circumstances of meniscal injuries in the general adult population. We studied a group of patients who underwent arthroscopy under the care of the same surgeon between 1991 and 1998 (1236 patients). The study group included 392 patients, aged 18 to 60 years, with no previous knee injury, surgery or arthritis, with normal X-rays and meniscal injuries proven at arthroscopy. No professional athletes were included in the study group. The patients with Sports injuries (mean age 33 years) accounted for 32.4% of cases. The patients with Non-sporting injuries (mean age 41 years) accounted for 38.8% of tears. 71.9% of these happened in activities of daily living (and half of this group sustained their tear by squatting or ascent from this position). Patients without identifiable injury (mean age 43 years) represented 28.8% of cases. Male:Female ratio was 4:1. Medial tears accounted for two thirds of cases. This type of study, not undertaken since the advent of MRI or arthroscopy, shows that in the general population, two thirds of meniscal tears occurred in the absence of sporting activities, frequently within the ambit of every day activities and in the absence of the classic injury mechanism. Ascent from a squat is a common mechanism of injury not widely described or emphasised.

"Floating thumb metacarpal" or complete dislocation of the thumb metacarpal: a case report and review of the literature.

We present a case of a patient with a simultaneous dislocation of the metacarpophalangeal (MP) and the carpometacarpal (CMC) joint of the thumb as an isolated injury, and we review the relevant literature. We found only three previous reports in the literature, two reports as an isolated injury and another similar injury combined with a carpometacarpal fracture-dislocation of all four fingers. A closed reduction of both joints followed by an open repair of the torn ulnar collateral ligament of the MP joint and Kirschner-wire (K-wire) stabilization of the CMC joint led to a good result at 1 year. This rare injury has been described as a "complete dislocation of the thumb metacarpal" or as a "simultaneous dislocation of the MP and CMC joints of the thumb". We suggest it is a "floating thumb metacarpal".

Intra-articular morphine and postoperative analgesia after knee arthroscopy.

The aim of this study was to evaluate the postoperative analgesic effect of intra-articular administration of a low- and a high-dose morphine solution after knee arthroscopy. Thirty patients who underwent diagnostic arthroscopy or arthroscopic meniscectomy were allocated in three groups. At the end of the arthroscopic procedure patients in Group A received intra-articularly 20 ml normal saline (N/S), Group B received 5 mg morphine in 20 ml N/S and Group C received 15 mg morphine in 20 ml N/S. The postoperative pain was assessed using a visual analogue scale for 24 h, while all the patients stayed at hospital. Side effects from the central action of opioids were not detected. Although the pain scores in the group of low-dose morphine were lower than in the control group, we failed to detect any significant differences in pain scores among the three groups. There was evidence that a high-dose can cause hyperalgesia.