Is calcar referenced tip-apex distance a better predicting factor for cutting out in biaxial cephalomedullary nails than tip-apex distance?

PURPOSE: To test the significance of calcar referenced tip-apex distance (CalTAD) and the length of anti-rotation screw (AR screw) as predictors for failure after biaxial cephalomedullary (CM) nailing of intertrochanteric fractures. METHODS: We retrospectively reviewed 190 consecutive fractures that had undergone biaxial CM nailing. Of these, 67 met the inclusion criteria of a non-pathological fracture with a minimum of 90 days radiological follow-up (mean 458 days; 91 days to 4.9 years). RESULTS: The overall failure rate was 15% (10 of 67). Failure was associated with a higher CalTAD in most of the patients (13%, p < 0.001). A higher tip-apex distance (TAD) was not significantly associated with failure ( p = 0.132), when the CalTAD was less than 25 mm. When the AR screw length exceeded a line connecting the tip of the nail and the lag screw, screw cutout occurred only in one patient ( p = 0.095). CONCLUSION: Our data provide the first reported clinical evidence that the CalTAD is a better predictor of cutout in biaxial CM nailing than TAD measurement. However, the length of anti-rotational element does not seem to be an independent predictor of CM nailing failure.

Expressing Cobb Angle as Linear Measurement in Scoliosis and Its Significance: A Clinical and Geometrical Analysis of Scoliosis.

OBJECTIVE: The aim of this study was to formulate an objective clinical and geometric relationship between Cobb angle and the difference between the lengths of convex and concave sides (convexo-concave vertebral difference) of the structural curve in scoliosis. Is it possible to express Cobb angle in such a way that it could be visualized as a length, especially while planning for surgical correction of scoliosis? METHODS: Thirty consecutive patients below the age of 19 years with a scoliosis of Cobb angle more than 10 degrees were included in the study. Convexo-concave vertebral difference of the structural curve was measured. Its relationship with the measure of Cobb angle was studied. RESULTS: Author obtained a significant linear correlation between the convexo-concave vertebral differences and the Cobb angle. Using the formula Y=2d.Sin (X/2) the convexo-concave vertebral difference could be predicted. The difference thus obtained gives a quantitative measure of the maximum length of correction possible in the structural curve. CONCLUSION: It is possible to express the Cobb angle as a function of linear measurement. The author proposes that this would aid the surgeons to accurately and predictably achieve the desired scoliosis correction.

A new surgical technique for extensive exposure of the proximal humerus and shoulder.

Different techniques have been described for surgical exposure of the shoulder and proximal humerus. However, the neurovascular and muscular anatomy in the proximity of the humerus precludes the use of a "safe" extensive approach. We here present a new technique for extensive exposure of the proximal humerus and shoulder for wide resection of tumors. By reflecting the deltoid with its origin as an osteomyocutaneous flap downwards and backwards, the entire shoulder, including the rotator cuff and proximal humerus, are exposed with minimal damage to the blood supply and function of the deltoid muscle. This approach, which is a logical combination of anterior, transacromial and deltoid splitting approaches, was used in 17 patients, 11 achieving satisfactory functional results. Our new surgical approach reduces intraoperative damage to the blood supply of the deltoid and results in better function of the shoulder postoperatively because both the powerful intermediate muscle fibers of the deltoid and its acromial origin remain intact.

Abductor pollicis longus tendon division with swan neck thumb deformity.

Swan neck thumb deformity can be caused by osteoarthritis, rheumatoid arthritis, systemic lupus erythematosus, tendon transfers and paralytic diseases. Abductor pollicis longus is one of the major stabilizing tendon of the carpometacarpal joint of thumb. To the best of our knowledge, swan neck thumb deformity owing to division of abductor pollicis longus tendon is rare. In this article, we describe a case of isolated division of abductor pollicis longus tendon presenting with swan-neck deformity of thumb and discuss the mechanism, management and outcome. The patient was treated by repair of the divided tendon using palmaris longus tendon graft. At approximately 107 weeks following treatment, the patient was having full range of thumb movement and the deformity completely disappeared. We also describe the unusual mechanism whereby an isolated division of abductor pollicis longus tendon results in swan neck thumb deformity. Level of clinical evidence IV.

Management of giant cell tumor of bone: computerized tomography based selection strategy and approaching the lesion through the site of cortical break.

OBJECTIVE: A retrospective study was carried out in patients with giant cell tumor of bone to compare the functional and radiographic outcome of curettage and bone grafting using a novel CT based selection strategy to that of patients of a similar age treated with anatomic/standard curettage and bone grafting. METHODS: Curettage and bone grafting after CT classification was performed in 31 patients and curettage and bone grafting without CT classification in 20. The surgical approach for curettage in the CT classified group of patients was through the site of the cortical break, irrespective of the standard approach to the particular region of bone involved. The aim of this approach was to achieve wide excision of the possibly involved soft tissue. RESULTS: At similar duration of follow up (72 months) in patients with a similar mean age (33 years), Musculoskeletal Tumor Society (MSTS) scores for CT classified patients were similar to those of patients who had undergone standard curettage. However, the postoperative recurrence rate in the CT classified group was significantly less (12.9%) than in the non-CT classified group. CONCLUSION: A CT based selection strategy is a valid preoperative tool for evaluation of giant cell tumor. Further, for curettage these lesions are better approached through the site of cortical break, irrespective of standard approaches, so that adequate soft tissue clearance can be achieved.

Gluteal Abscess: Diagnostic challenges and management.

Gluteal abscess is a well-documented presentation of a caries spine and other local bony foci of tuberculosis. Still, during a PUBMED data search, only one report of vertebral tuberculosis presenting only as a gluteal abscess in adults was found in English medical literature. The current article describes a case of tuberculosis of the lumbar spine with gluteal abscess as the only clinical feature, in an immunocompetent young adult.

Acute isolated dorsal midtarsal (Chopart's) dislocation: a case report.

UNLABELLED: Isolated midtarsal (Chopart's) joint dislocations are rare, although cases involving medial, lateral, plantar, and dorsal displacement have been reported. These dislocations are often associated with osteochondral fractures. To the best of our knowledge, isolated dorsal midtarsal dislocation owing to plantarflexion of the forefoot on the hindfoot with the ankle in a neutral or dorsiflexed position is rare. In this article, we describe a case of isolated Chopart's dorsal dislocation and discuss the mechanism of injury, management, and outcome. The patient was treated with open reduction and repair of ligamentous structures, and Kirschner wire transfixation. At approximately 96 weeks following treatment, the patient was walking without aid, despite the development of posttraumatic degenerative changes at the calcaneocuboid joint. In retrospect, primary arthrodesis of the calcaneocuboid joint may have been more beneficial for the patient. We also describe the unusual mechanism whereby a plantarflexory force applied to the forefoot, without ankle plantarflexion, results in dorsal dislocation of the midtarsal joint. LEVEL OF CLINICAL EVIDENCE: 4.

Gorham's disease of the fibula: a case report.

UNLABELLED: Gorham's disease, or massive osteolysis, is a rare condition characterized by the spontaneous onset of osteolysis in an otherwise healthy individual. Such osteolysis is related to localized endothelial proliferation of lymphatic vessels (lymphangiomatous osteolysis) resulting in destruction and absorption of bone, and is commonly thought to affect primarily cancellous bone. In this article, we describe a case of Gorham's disease involving the fibula in a 13-year-old boy with a 2-year history of pain and a 1-year history of muscle atrophy. The patient was treated with analgesics and anti-inflammatory drugs, and a period of immobilization. At the 3-year follow-up visit, the patient was ambulating without restrictions, although he experienced occasional episodes of pain and swelling localized to the left ankle; and follow-up radiographs revealed no further progression of the disease. Current literature suggests that the fibula, being primarily cortical bone, is not likely to be affected by Gorham's disease and that fibular grafts may be used in the treatment of the disorder. However, since this case depicts the disorder localizing to the distal fibula, we believe further studies are needed to validate the usefulness of fibular grafts in the treatment of the condition. Because the course of the disease is unpredictable and may arrest spontaneously, and based on the results observed in the patient described in this article, conservative treatment may be appropriate for Gorham's disease localized to the distal fibula. LEVEL OF CLINICAL EVIDENCE: 4.