The management of post-traumatic osteoarthritis.

Posttraumatic arthritis primarily affects younger individuals, leading to reduced physical activity, chronic pain, and prolonged symptomatic treatments. The management of post-traumatic arthritis after fracture, dislocation or ligament rupture continues to be one of the most challenging clinical entities in orthopaedic and trauma surgery. Therapies to address early symptoms include anti-inflammatory agents, pain killers, corticosteroid or hyaluronic acid joint injections but these offer only temporary pain relief with hardly any mid or long term benefit. There are many surgical options for the treatment of posttraumatic arthritis. For the early stages, arthroscopic debridement should be considered. At late stages, corrective osteotomies or arthrodesis are strongly recommended for the young patients. In older patients arthroplasties remain the treatment of choice.

Fractures of hamate: a clinical overview.

Hamate fractures are exceedingly rare clinical entities. However, the diagnosis and treatment of these injuries are often delayed and can severely handicap the performance of affected laborers or athletes. This review focuses on fractures of the hamate and provides an update on the current consensus as to mechanism, diagnosis, management, and complications after such injuries.

Axillary artery injury associated with proximal humerus fractures.

Penetrating trauma is the primary cause of upper extremity vascular injury almost in 95% of cases. Blunt trauma due to traffic or industrial accidents and falls account for the remaining 5% to 10%. However axillary artery injury from blunt trauma to the shoulder is extremely rare. The location of the axillary artery, surrounded by the bones and muscles of the shoulder girdle, explains the low incidence of trauma suffered by this arterial segment. But its anatomical proximity to the humeral head makes it quite vulnerable to blunt trauma during shoulder injury. Herein we report two cases of axillary artery injury after proximal humerus fracture, discussing their diagnosis and management.

Acute renal failure due to rhabdomyolysis after proximal humerus fracture associated with axillary artery rupture.

The anatomical proximity of axillary artery to the humeral head makes it quite vulnerable to blunt trauma during shoulder injury. Axillary artery rupture and prolonged ischemia may lead to rhabdomyolysis and acute renal failure. Herein we present a case of a patient who sustained proximal humerus fracture associated with axillary artery rupture and acute renal failure due to rhabdomyolysis.

Complications of clavicle fracture and acromioclavicular joint rupture. What the general surgeon should know.

Fractures of the clavicle and acute dislocations of the acromioclavicular joint are common seen in the emergency room. Displaced or comminuted clavicle fractures and acromioclavicular joint ruptures (types III-VI) are associated with complications, such as subclavian vessels injury, hemopneumothorax, scapula-thoracic dissociation or brachial plexus paresis. Herein we discuss the usually complications seen after these injuries and underline whatever a trauma surgeon should know in order to avoid fatal situations.

Lower extremity infections by vibrio vulnificus.

BACKGROUND: Vibrio vulnificus is a Gram-negative pathogen which is found in seawater and shellfish during warm months and can cause local infections in healthy individuals or septicemia in patients with chronic liver disease. MATERIALS-METHODS: Clinical and laboratory records of four complicated cases are presented, with a 4.2 mean year follow-up. RESULTS: Three patients underwent urgent leg amputation because of of irreversible necrotic changes with septic complications and failure of incisional drainage to control the infection. Another one patient underwent only excision of necrotic soft tissue but he developed calcaneus osteomyelitis after three years of the initial fish bone injury. DISCUSSION: Clinicians must maintain a high index of suspicion, especially in regions endemic for vibrio necrotising fasciitis and antibiotic prophylaxis must be given to swimmers before or during bathing.

Fournier's gangrene: exists and it is still lethal.

BACKGROUND: Fournier's gangrene is an aggressive form of necrotizing fascitis of the perineal, perianal or genital regions, caused by a polymicrobial infection that includes virulent organisms. PATIENTS AND METHODS: Eleven cases of Fournier's gangrene were treated in our department during the last 20 years. Portals of entry were ischiorectal abscess, perirectal abscesses, scrotal abscess and trauma in the perianal area. The documents were analyzed according to clinical and epidemiologic patterns. RESULTS: We dispensed systemic chemotherapy with broad-spectrum antibiotics, and performed surgical debridement for all patients. In addition, one patient was treated by local use of 100% oxygen, with excellent results in wound healing. All patients made a full recovery, except one who died of sepsis. CONCLUSION: These cases are presented with some notes underlying the reasons for the persisting incidence and mortality of this disease.

Diagnostic and therapeutic aspects in medullary thyroid carcinoma.

Medullary thyroid carcinoma (MTC) is a rare and particularly aggressive type of thyroid cancer with several distinctive features that distinguish its management from other thyroid cancers. Since MTC was first recognised as a distinct tumour in 1959, it became clear that MTC is more difficult to cure than differentiated thyroid cancer and has higher rates of recurrence and mortality, but it is usually a slow growing tumor compared with other malignancies. In addition, unlike differentiated thyroid cancer, there is no known effective systemic therapy for MTC.

Pancreatic abscess due to perforation of duodenal diverticulum.

Duodenal diverticula are usually incidental findings, but some times could be complicated with inflammatory or pressures effects to pancreas tissue. We present a rare case of pancreatic abscess caused by a perforated diverticulum, arising from the distal end of the second part of the duodenum.

Complications of thyroid surgery.

Thyroid surgery has a history of significant changes in the technique and the incidence of complications. Since then continuous developments in surgical techniques and better understanding of thyroid anatomy and pathology have increased the safety of thyroid surgery and reduced the incidence of complications. Nowadays, the rate of postoperative mortality is extremely low. Nevertheless, the incidence of postoperative complications varies in literature from 7.4% to 53% of the operations performed. The most common and potentially life-threatening complications in thyroid gland surgery are vocal cord palsy and hypocalcemia. Herein we discuss the common complications in thyroid gland surgery and their proper management.

Changes of CPK and CPK-MB levels after open and laparoscopic cholecystectomy.

According to the World Health Organization, an increased ratio (more than 6%) of CPK-MB to total CPK may indicate the diagnosis of an acute infarction. But false elevation of CPK and CPK-MB levels after noncardiac operation, because of soft tissue damage, may confuse the clinicians in detecting myocardial infarction in early postoperative period. In order to determine the usefulness of CPK-MB to total CPK ratio in detecting myocardial infarction after open and laparoscopic cholecystectomy, we measured the serum levels of these markers in 135 patients, immediately after the operation and for the next five days. Patients were divided into four groups according to type of surgical procedure, as follows: Group I: a right oblique subcostal (Kocher's) incision was performed in 29 patients, Group II: a right paramedian transrectal incision was performed in 52 patients, Group III: a vertical high midline incision was performed in 17 patients, Group IV: laparoscopic cholecystectomy was performed in 37 patients. Although we found increased levels of CPK and CPK-MB after all the types of cholecystectomy, but in any case the CPK-MB exceeded more than 6% of total serum CPK. Furthermore we noticed that the patients who underwent open cholecystectomy with right oblique subcostal incision had the most elevated CPK and CPK-MB levels comparing to the other types of cholecystectomy. In conclusion, tissue damage after elective cholecystectomy is minimal and CPK-MB to total CPK ratio is a secure marker in detection of myocardial infarction during early post-operation period, after cholecystectomy.

Emphysematous cholecystitis. Review of five cases and report of septic musculoskeletal complications.

A variant of acute cholecystitis is emphysematous cholecystitis. Here in we reviewed useful clinical data of five cases of this entity. Clinical outcomes were uncomplicated for three patients who were treated with open cholecystectomy. But on the other hand we faced two septic musculoskeletal complications in two patients who were treated with percutaneous trans gallbladder drainage. We believe that we must be aware of musculoskeletal complications, whenever a patient with emphysematous cholecystitis is treated with percutaneous trans gallbladder drainage.

Management of bone infections in adults: the surgeon's and microbiologist's perspectives.

Bone infection in adults is a potentially devastating complication following trauma or surgery. The clinician should diagnose osteomyelitis based on certain clinical manifestations and on laboratory and imaging findings. For pathogen identification, the treating surgeon should take appropriate tissue samples. Close collaboration with microbiologists is of paramount importance to dictate the appropriate duration and type of antibiotics to be administered. Treatment of acute osteomyelitis requires surgical debridement and prolonged course of antibiotics. Debate exists regarding the maintenance or the removal of any internal fixation device. Treatment of chronic osteomyelitis is more complicated. For its eradication the treatment course is often prolonged and frustrating. Based on the current literature an algorithm of treatment for both acute and chronic bone infections is recommended.

An undiagnosed bilateral anterior shoulder dislocation after a seizure: a case report.

INTRODUCTION: Late diagnoses of orthopaedic injuries after epileptic crisis are a matter of concern. The rarity of correlation between seizure and specific trauma incidences such as bilateral anterior shoulder dislocation, may lead to improper estimation of the patient's clinical state, wrong treatment and unpleasant complications. CASE PRESENTATION: We report the rare case of an undiagnosed bilateral anterior shoulder dislocation in an epileptic young man of 25 years of age. The way of treatment is described as well as the treating alterations, if needed, because of the 3 weeks delay from injury. The article focuses on the reasons of the non-diagnosis at the first place and proposes a possible explanation for the mechanism of the injury. This is the second documented case of a missed bilateral anterior shoulder dislocation following a seizure and the first one that was treated not earlier than 3 weeks post injury. CONCLUSION: Although not a matter of routine, the high importance of radiographic control after seizure, in case of suspicion, is concluded. The etiology causing the injury shall not disorientate the doctors from the possible diagnoses.

The use of freeze-dried cancelous allograft in the management of impacted tibial plateau fractures.

The purpose of this study is to assess the behaviour of freeze-dried cancellous allograft used for supporting the reconstructed articular surface in impacted tibial plateau fractures. Freeze-dried cancellous allograft was used as metaphyseal defect filling agent in twenty-three patients (fifteen men and eight women, mean age 53 years), who suffered impacted tibial plateau fractures. According to Schatzker classification, ten fractures were classified as type II, six as type III, three as type V and four as type VI. All fractures were treated with open reduction-internal fixation after restoration of the tibial plateau surface and insertion of freeze-dried allograft chips for subchondral support. The mean follow-up was 13 months. The clinical and radiological outcome was assessed according to the modified Rasmussen system. The freeze-dried allograft incorporated soundly in all cases within 12 weeks from surgery and no complications that could relate to the graft were recorded. Freeze-dried allograft has specific advantages in comparison to autograft or other grafts and the results of the present study justify its use in the treatment of impacted tibial plateau fractures.

Extracorporeal shock wave treatment for shoulder calcific tendonitis: a systematic review.

The treatment of patients with calcific tendonitis is typically conservative, including physical therapy, iontophoresis, deep friction, local or systemic application of noninflammatory drugs, needle irrigation-aspiration of calcium deposit, and subacromial bursal steroid injection. If the pain becomes chronic or intermittent after several months of conservative treatment, arthroscopic and open procedures are available to curette the calcium deposit, and additional subacromial decompression can be performed if necessary. As an alternative, minimally invasive extracorporeal shock wave therapy (ESWT) has been postulated to be an effective treatment option for treating calcific tendinitis of the shoulder, before surgery. Herein we discuss the indications, mechanism of therapeutic effect, efficacy of treatment, and complications after ESWT application.

Spontaneous bilateral subcapital hip fracture due to multiple myeloma: an 18-month follow-up.

We present a rare case of bilateral subcapital hip fracture as a first sign of multiple myeloma in a young man. Right femoral neck fracture was treated by three Asnis screws and the left one by hemiarthroplasty. In order to avoid implant failure, we used zoledronic acid, a bisphosphonate compound, instead of methacrylate cement. After an 18-month follow-up, there was no evidence of avascular necrosis, no implant failure and no periprothetic fracture.

Changes of bone turnover markers after marathon running over 245 km.

We evaluated bone turn over markers, cortisol and parathyroid hormone (PTH) levels in male athletes after 245 km of marathon running. Sixteen athletes were studied five days before, immediately after, and 1, 3, and 5 days after the run. We used T-test and Pearson correlation for statistical analysis. Osteocalcin levels were significantly decreased from 4.6 microg/lit to 3.8 microg/lit (p < 0.05). Activity of b-ALP was significantly decreased from 66 U/lit to 61.5 U/lit (p < 0.05). PICP levels were also significantly decreased from 168 microg/lit to 153 microg/lit (p < 0.05). Hydroxyproline levels decreased after the run from 70 mmol/min to 65 mmol/min (p < 0.05). ICTP levels increased after the run but without being statistically significant, from 6.62 microg/lit to 7.0 microg/lit. Urine calcium decreased significantly by 68 %, immediately after the run. Cortisol increased from 212 ng/ml to 455 ng/ml, and PTH levels increased from 12 pg/lit to 16 pg/lit immediately after the race (p < 0.05). Cortisol levels were significantly negatively correlated with osteocalcin (r = - 0.61, p < 0.05) and b-ALP (r = - 0.98, p < 0.05). PTH levels were significantly negatively correlated only with serum osteocalcin (r = - 0.8, p < 0.05). These findings suggest a transient suppression in osteoblast function during the marathon run probably due to cortisol and PTH levels elevation.