Central band reconstruction for the treatment of Essex-Lopresti injury : A novel technique using the brachioradialis tendon.

Longitudinal stability of the forearm is mainly provided by three structures: the radiocapitellar contact, which acts as the primary stabilizer, the central band of the interosseous ligamentous complex (IOLC) and the intact triangular fibrocartilage complex (TFCC). In an Essex-Lopresti lesion the forearm becomes fully destabilized, since all of these three components are injured. Fixation or replacement of the radial head with a metallic prosthesis along with repair of the TFCC and stabilization of the distal radioulnar joint (DRUJ) are well-established treatment goals. However the reconstruction of the central band of the IOLC remains to some extent controversial. The authors believe that the reconstruction of the central band, particularly in active patients, is crucial in order to restore normal load distribution through the forearm, thus ensuring both transverse and longitudinal stability. In this article, we present a case with an Essex-Lopresti lesion, which was effectively treated acutely with restoration of all three components of the injury (radial head prosthesis, DRUJ repair and reconstruction of the central band of the IOLC). A novel technique by rerouting the brachioradialis tendon is described in detail.

Bilateral reverse total shoulder arthroplasty-functional outcome and activities of daily living.

BACKGROUND: Reverse total shoulder arthroplasty (rTSA) has gained popularity in recent years, providing good shoulder elevation, yet less predictable rotations. Good rotations are crucial for performance of activities of daily living (ADLs), including personal hygiene. Concerns remain regarding bilateral rTSA over lack of rotations bilaterally and resultant difficulties with ADLs. This study examined the outcome of patients with bilateral rTSA in restoration of function and ADLs. METHODS: Data were prospectively collected for 19 patients (15 women, 4 men; 38 shoulders), with a mean age of 74.5 years, who underwent staged bilateral rTSA between 2007 and 2013. Mean follow-up was 48.4 months (range, 24-75 months). Patients were evaluated clinically using the Constant score, patient's satisfaction, Subjective Shoulder Value, and the Activities of Daily Living External and Internal Rotations (ADLEIR) score. Video clips were also recorded for documentation at all visits. RESULTS: Mean duration between staged operations was 18.2 months (range, 3-46 months). The Constant score improved from 18.7 to 65.1 points (age- and sex-adjusted, 100.2). Elevation improved from 57.5° to 143°, internal rotation (IR) from 9° to 81° (30 shoulders could reach above the sacroiliac joint), and external rotation (ER) from 20° to 32° (35 shoulders had >20° ER in adduction, 31 shoulders had full ER in elevation). The Subjective Shoulder Value improved from 2.1 of 10 to 9.2 of 10. Mean ADLEIR score was 33 of 36 (P < .001 for all). Most patients resumed their leisure and sport activities (gardening, golf, swimming, bowling). CONCLUSION: Bilateral rTSA results in marked and predictable improvement in all movements, pain relief, and functional outcomes, with high patient satisfaction and high ADLEIR score. All patients were able to perform perineal hygiene after their rTSA. Most patients had no limitation in ADLs and their leisure activities.

Congenital C1 arch deficiency: Grand Round presentation.

INTRODUCTION: We present an uncommon and yet interesting congenital anomaly and discuss the difficulties with diagnosis and controversies in management. C1 arch deficiency is an important consideration in the differential diagnosis of neck pain in children. MATERIAL AND METHODS: A 12-year-old girl presented initially with a loud clicking emanating from the cervical spine during nappy changes in early childhood. Subsequent investigation by way of CT and MRI revealed her to have a deficient posterior arch of the C1 vertebra, and due to persistent and painful clicking she was placed into a cervical brace, which was worn for approximately 1 year. At age 12, her clicking had all but completely resolved but she continued to complain of minor neck pain. She is advised to avoid contact sports and her parents are instructed to observe any new worrying symptoms. CONCLUSION: No definitive guidelines exist for the management of this congenital anomaly. Indications for surgical intervention prior to any neurological disturbance are unclear, and restricting a child from partaking in healthy activity may not be necessary. We discuss the anomaly and identified management strategies as reported in the literature so far.

Irreducible Lisfranc dislocation due to the interposition of the tibialis anterior tendon: case report and literature review.

We report a case of a lateral type A (according to Myerson) Lisfranc dislocation irreducible by closed manipulation. Upon surgical exploration the lateral slip of the tibialis anterior tendon was found trapped between the medial and the middle cuneiform. Once the tendon was reduced, the dislocated first ray spontaneously reverted to its anatomical position and the joint was fixed with Kirschner wires. Seven similar cases have been reported in the literature. After analysis of all the reported cases we were able to describe a pattern of injury that may predict tibialis anterior interposition: (a) lateral type A according to Myerson dislocation; (b) after closed manipulation the 1st ray remains dislocated while the 5th metatarsal reduces; (c) there is a gap between the medial and the middle cuneiform or a fracture at the base of the 2nd metatarsal.

Dislocation of the lateral cuneiform. Report of two cases: one with dorsal and one with plantar displacement.

We present two cases of lateral cuneiform dislocation, one dorsal and one plantar. Both were the result of high-energy trauma, accompanied by other injuries and were missed at initial examination. Open reduction and fixation with Steinmann pins were necessary. The midterm results were satisfactory, although the cuneiform that dislocated plantarly ended up in developed avascular necrosis.

Very late in-stent restenosis in a bare metal stent.

Restenosis after coronary artery stenting is a common phenomenon and represents a topic of great interest. Although a great volume of research is referring to restenosis, still many issues are not fully understood by the cardiological community. Here we present a case of very late restenosis, after a bare metal stent implantation.

The Role of Reverse Shoulder Arthroplasty in Management of Proximal Humerus Fractures with Fracture Sequelae: A Systematic Review of the Literature.

Fracture sequelae of the proximal humerus poses a complex management decision due to the frequent deformity and its consequences on the peri-articular soft tissues. These patients are frequently elderly with significant medical comorbidities. Due to the age of the patient there is frequently rotator cuff deficiency and therefore the reverse shoulder arthroplasty (RSA) becomes the arthroplasty of choice. We have performed a systematic review of the literature and report nine studies presenting RSA for the treatment of fracture sequelae of the proximal humerus. It is clear that RSA can improve the range of movement and function following proximal humerus fracture sequelae. However, there is a risk of significant complications including dislocation (16.7%), infection (6.7%), intra-operative fracture (3%) and neurological injury (2.6%). There is a need to invest in future prospective comparative studies and randomised trials to further test RSA in fracture sequelae patients. This will provide us with information regarding the longevity of different prosthesis, outcomes and cost-effectiveness of treatment.

Retroperitoneal abscess: an extra-abdominal manifestation.

Retroperitoneal abscesses are unusual occurrences with occult and insidious presentations. There is often a lack of abdominal signs, leading to delays in drainage and high mortality rates. We report a case of thigh emphysema in an 88-year-old patient with diabetes. Prior to admission the patient reported a vague 4-week history of left thigh pain and an inability to fully weight bear. She presented to our emergency department with sepsis and acute kidney impairment. An X-ray of her left femur revealed widespread gas between muscular planes. A retroperitoneal abscess involving the left renal fossa, psoas, iliacus and upper thigh muscles was revealed on an urgent CT scan. The patient was transferred to intensive care unit (ICU) and underwent an emergency drainage. Despite ICU the patient died 2 days after admission.

Reoperation rates in the surgical treatment of spinal metastases.

BACKGROUND CONTEXT: The surgical treatment in spinal metastases has been shown to improve function and neurologic outcome. Unplanned hospital readmissions can be costly and cause unnecessary harm. PURPOSE: Our aim was to first analyze the reoperation rate and indications for this revision surgery in spinal metastases from an academic tertiary spinal institute and, second, to make comparisons on outcome (neurology and survival) against patients who underwent single surgery only. STUDY DESIGN/SETTING: This was an ambispective review of all patients treated surgically over an 8-year period considering their neurologic and survival outcome data. Statistical analysis was performed using IBM SPSS 20. Because all scale values did not follow the normal distribution and significant outlier values existed, all descriptive statistics and comparisons were made using median values and the median test. Crosstabs and Pearson correlation were used to calculate differences between percentages and ordinal/nominal values. For two population proportions, the z test was used to calculate differences. The log-rank Mantel-Cox analysis was used to compare survival. PATIENT SAMPLE: During the 8 years' study period, there were 384 patients who underwent urgent surgery for spinal metastasis. Of these, 289 patients were included who had sufficient information available. There were 31 reoperations performed (10.7%; mean age, 60 years; 13 male, 18 female). Exclusion criteria included patients treated solely by radiotherapy, patients who had undergone surgery for spinal metastasis before the study period, and those who had other causes for neurologic dysfunction such as stroke. OUTCOME MEASURES: The outcomes considered in this study were revised Tokuhashi score, preoperative/postoperative Frankel scores, and survival. METHODS: We performed an ambispective review of all patients treated surgically from our comprehensive database during the study period (October 2004 to October 2012). We reviewed all patient records on the database, including patient demographics and reoperation rates. RESULTS: Reoperations were performed in the same admission in the majority of patients (n=20), whereas 11 patients had their second procedure in subsequent hospitalization. The reasons for their revision surgery were as follows: surgical site infection (SSI; 13 of 31 [42%]), failure of instrumentation (9 of 31 [29%]), local recurrence (5 of 31 [16%]), hematoma evacuation (2 of 31 [6%]), and others (2 of 31 [6%]).When comparing the "single surgery" and "revision surgery" groups, we found that the median preoperative and postoperative Frankel scores were similar at Grade 4 (range, 1-5) for both groups (preoperative, p=.92; postoperative, p=.87). However, 20 patients (8%) from the single surgery group and 7 (23%) from the revision group had a worse postoperative score, and this was significantly different (p=.01). No significant difference was found (p=.66) in the revised Tokuhashi score. The median number of survival days was similar (p=.719)-single surgery group: 250 days (range, 5-2,597 days) and revision group: 215 days (range, 9-1,352 days). CONCLUSION: There was a modest reoperation rate (10.7%) in our patients treated surgically for spinal metastases over an 8-year period. Most of these were for SSI (42%), failure of instrumentation (26%), and local recurrence (16%). Patients with metastatic disease could benefit from revision surgery with comparable median survival rates but relatively poorer neurologic outcomes. This study may help to assist with informed decision making for this vulnerable patient group.

The surgical management of metastatic spinal tumors based on an Epidural Spinal Cord Compression (ESCC) scale.

BACKGROUND CONTEXT: There have been no previous studies looking at the outcome of surgical decompression (+/-stabilization) for various grades of epidural spinal cord compression (ESCC) due to spinal metastases. PURPOSE: The aim of this study was to determine the outcome of surgical treatment in patients with ESCC using the Bilsky six-point scale. STUDY DESIGN/SETTING: This was a retrospective cohort review of prospectively collected data. PATIENT SAMPLE: A consecutive series of 101 patients managed over the period of 3 years for ESCC due to spinal metastases in a tertiary spine surgery referral unit were included. METHODS: Data on age, gender, revised Tokuhashi score, preoperative Frankel grade, tumor histology, magnetic resonance imaging scan-based Bilsky cord compression grade, postoperative Frankel grade at last follow-up, complications, and survivorship were collected. OUTCOME MEASURES: Frankel grading system for function was used to evaluate the patient's preoperative and postoperative neurologic status. Patient survival and postoperative complications were also collected. RESULTS: Average patient age was 64.7 years (13-88 years): 62 males and 39 females. Mean follow-up was 7.3 months (3-23.3 months). Most primary tumors were in prostate, breast, renal, lung, and the blood dyscrasias. Within the lower grade of compression (Group 1; Bilsky Grades 0,1a, 1b, and 1c; n=40), 29 patients (72.5%) had no improvement in Frankel grade, seven patients (17.5%) improved, whereas four patients (10%) deteriorated neurologically after surgery. Within the higher compression grade (Group 2; Bilsky Grades 2 and 3; n=61), 37 patients (60%) did not experience neurologic change, 20 (33%) improved, whereas neurology worsened in four patients (7%). When compared with Group 2 patients, Group 1 patients had better preoperative Frankel scores but a greater number of patients in Group 2 improved their Frankel scores significantly postoperatively. The mean revised Tokuhashi score for Groups 1 and 2 was 10 and 9.1, respectively (p=.1). The complication rate for Groups 1 and 2 was 25% and 42.6%, respectively (p=.052). Survival analysis showed no difference between the groups (Group 1: median 376 days [12-1052]; Group 2: median 326 days [12-979]; p=.62). CONCLUSIONS: Surgery can achieve improvements in neurology even in higher grades of cord compression. There is a trend toward more complications and worse survival with spinal surgery in patients with higher grades of compression.

P53 expression as a prognostic marker in giant cell tumor of bone: a pilot study.

P53 is the best known tumor suppressor gene. If p53 is mutated, the ability of the cell to sense and repair DNA defects is lost. Failure of this mechanism increases the risk of malignant transformation and tumorigenesis. P53 overexpression is implicated in many carcinomas. P53 alterations appear to be frequent in bone and soft tissue sarcoma and have a strong negative impact on survival in various subtypes of sarcoma like Ewing's sarcoma, synovial sarcoma, and myxoid liposarcoma. There is also evidence in the literature that p53 may be implicated in bone giant cell tumor behavior. The goal of this pilot retrospective study was to detect p53 mutation in giant cell tumor of bone and correlate it with clinical outcome. We analyzed the presence of p53 mutation in 39 patients with giant cell tumor of bone by means of immunohistochemical staining; 8 tumors expressed mutated p53 protein. Seven of them recurred locally (P<.001) and 2 metastasized to the lung (P<.05). In multivariate analysis/subgroup analysis, local recurrence was still strongly correlated, while metastasis had a weaker correlation. Our findings suggest that p53 mutation in giant cell tumor of bone can be useful in predicting tumor behavior, especially in regard to local recurrence. Limitations of this study include the retrospective data collection, the limited number of patients, and the multifactorial nature of the disease; tumor grade, surgical margins, use of adjuvant therapy, and thoroughness of excision may influence the therapeutic outcome. Despite these limitations, this correlation should be further investigated with larger clinical studies. P53 may be used as a marker for the biologic behavior of giant cell tumor of bone.

External fixation and pseudoaneurysm: report of a case related to tibial lengthening.

External fixators provide a mechanically stable environment to allow fracture stabilization or limb lengthening. Most complications are related to pin or wire insertion. This article presents the case of a 33-year-old man who sustained an open fracture of his left tibia with consequent infection and bone loss. The procedure of tibial lengthening was complicated by late formation of a pseudoaneurysm of the distal popliteal artery after exchange of the proximal pins of the fixator.

Isolated right ventricular infarction presenting with ST-segment elevation in precordial leads V1-V3.

We describe a rare case of a patient presenting with ST-segment elevation in precordial leads V1-V3 due to occlusion of the ventricular branch of the right coronary artery during primary percutaneous coronary angioplasty.