A useful surgical technique for retrieval of a broken guide pin in the midfoot.

Perioperative instrument breakage is not an infrequent occurrence, even for experienced surgeons. The most commonly reported instrument breaks in orthopedic procedures are drill bits, followed by Kirschner wires and cannulated guide pins. The reasons for failure include improper technique and repetitive use. The retrieval of broken hardware can be technically challenging, particularly if the fragment has become embedded in bone. Retrieval methods have been described for cannulated guide pin fragments in the hip; however, no specific techniques have been described for the retrieval of guide pin fragments embedded in the bones of the foot. In the present report, we describe a technique we have found useful for retrieval of a guide pin fragment that had broken off during a Lisfranc fracture repair 6 weeks earlier. The technique was used in a delayed situation; however, we believe it would be even easier to use during an intraoperative breakage.

Functional outcome and limitation of sporting activities after bimalleolar and trimalleolar ankle fractures.

BACKGROUND: Ankle fractures are extremely common. However, the outcomes of operatively treated bimalleolar and trimalleolar ankle fractures remain unclear. We aimed to evaluate and compare the functional outcomes of operatively treated bimalleolar versus trimalleolar ankle fractures and the ability of patients to return to sporting activities. METHODS: A retrospective review of all patients with operatively treated ankle fractures for a period of 2 years was performed. Demographics, fracture pattern, operative details, postoperative radiographs, and complications were extracted and analyzed statistically. Outcome variables were union rates, pain ratings using the visual analogue scale (VAS) and the Olerud and Molander (O&M) score, ability to return to sporting activities, satisfaction with surgery, and surgical complications. RESULTS: Forty-seven patients with bimalleolar and trimalleolar ankle fractures were recruited. At 1 year postoperatively, most patients regained good function and had good to excellent O&M scores. There were no notable differences in terms of VAS and O&M scores for both the bimalleolar and trimalleolar group. However, 26 (55.3%) of 47 patients had residual pain. Twenty-nine (61.7%) patients complained of stiffness, and 21 (44.7%) patients had ankle swelling. Of 33 (70.2%) patients who were involved in sporting activities prior to the ankle injury, 9 of 33 (27.3%) were able to return to preinjury level of sporting activities with no difficulties. Of the 33 patients, 18.2% were unable to do sports activities at all. CONCLUSION: The majority of our patients recovered well in their second year despite some residual deficits. We found no difference in functional outcome between bimalleolar and trimalleolar ankle fractures, although it is of great concern that a notable number of patients will not return to sporting activities. Residual symptoms and functional limitation after ankle fracture must be emphasized to patients to manage postoperative expectations. LEVEL OF EVIDENCE: Level II, retrospective case series.

A modified suture technique for fixation of the Akin osteotomy.

The Akin osteotomy is a frequently performed medial closing wedge osteotomy of the proximal phalanx of the hallux. It is usually used as a complimentary procedure in the correction of hallux valgus. Various implants and techniques have been described for fixation. Suture fixation has the advantage of a lower implant signature and a reduction in cost. However, the thin cortex of the phalanx can be prone to failure during suture application. We describe a new technique for suture fixation, which we have found to be reliable and to reduce the risk of phalangeal cortical failure.

Efficacy of intra-articular tranexamic acid in blood loss reduction following primary unilateral total knee arthroplasty.

PURPOSE: The surgical stress of total knee arthroplasty (TKA) procedure and the application of intra-operative pneumatic thigh tourniquet increases local fibrinolytic activity, which contributes significantly to post-operative blood loss. Tranexamic acid, an antifibrinolytic drug, is commonly used to control post-operative blood loss. The recommended mode of administration of tranexamic acid is either oral or intravenous. However, the mechanism of action of the tranexamic acid points towards the possible effectiveness it may have following local/intra-articular application. This prospective, double-blinded, randomized preliminary study evaluated the efficacy of intra-articular tranexamic acid in reducing TKA-associated post-operative blood loss. METHODS: Fifty consenting patients with osteoarthritis of the knee scheduled for primary unilateral cemented-TKA were randomly allocated to one of the two groups: Tranexamic Acid (TA) group (n = 25, 500 mg/5 ml tranexamic acid) and the control group (n = 25, 5 ml 0.9% saline). The drug and control solution were administered intra-articularly through the drain tube immediately after the wound closure. Parameters related to blood loss (drop in haemoglobin, haematocrit differential) and the drain output [volume (ml)] were compared between the two groups. RESULTS: On a comparative basis, TA-group obtained significant reduction in the drain output [95% CI: 360.41-539.59, p < 0.001] at 48 h post-operatively. Even though the control group received sixfold more blood transfusion than TA-group, it showed a greater drop in haemoglobin and haematocrit (p < 0.05). CONCLUSIONS: Local application of tranexamic acid seems to be effective in reducing post-TKA blood loss as well as blood transfusion requirements. LEVEL OF EVIDENCE: Therapeutic study, Level II.

Brown Sequard Syndrome Secondary to a Spontaneous Cervical Epidural Hematoma - A Rare Entity.

INTRODUCTION: Brown Sequard syndrome resulting from compression due to an epidural hematoma is a relatively rare occurrence, more so with a spontaneous history. We report one such case. CASE REPORT: We present a 65yr old female presenting with hemiplegia with contralateral anesthesia. Magnetic resonance imaging showed a hematoma in the epidural space in the C3-C4 region. She underwent an open door laminoplasty for evacuation of the hematoma. Following surgery the patient responded rapidly and currently at 18 months follow up she is neurologically grade 5/5 with normal sensations. CONCLUSIONS: In the emergency room when a patient is clinically diagnosed as a case of Brown Sequard syndrome it is important to ask for an MRI scan of the cervical spine. Hematoma in the cervical epidural space should be considered in the differential diagnosis of Brown Sequard syndrome especially in the elderly with history of doubtful trivial trauma.

Treatment of Osteoporosis with Antiresoptive agent, Alendronate - warrants careful follow-up.

INTRODUCTION: Alendronate is the most popular bisphosphonate used to prevent fragility fracture of postmenopausal osteoporosis. There is common belief among physicians that Alendronates are very safe without many side effects and they continue it for long time. Recent papers have shown that, some patients who are on this drug from a long period suffered a rare type of fracture. We are reporting a similar type of case for the first time from Indian subcontinent but with a different associated medical condition. CASE PRESENTATION: A 75 years old female presented with spontaneous fracture of right femur diaphysis. She was on Alendronate for past six years. Her bone metabolic picture also revealed vitamin D insufficiency and secondary hyperparathyroidism. CONCLUSION: Alendronate induced atypical fracture in association with secondary hyperparathyroidism is an unusual presentation which has not been reported in any of the case reports till date as per our knowledge. This type of presentation may need future investigation both for disease pathophysiology and future outcome in this type of fracture treatment. Treatment of osteoporosis with antiresoptive agent, alendronate; warrants careful follow-up.

Unusual presentation of altered bone metabolism with long-term antiepileptic therapy: pathological fracture of neck of femur due to brown tumor at calcer.

The antiepileptic drugs are known to alter the bone metabolism and result in various range of pathological conditions (osteoporosis, osteomalacia, vitamin D deficiency, secondary hyperparathyroidism). These clinical conditions developed either due to direct effect of these therapeutic agents on bone or due to alteration in the homeostasis of other regulators of bone metabolism like serum calcium, vitamin D, and parathyroid hormone. Long-term therapy with antiepileptic agents results in higher incidence of pathological fracture, which is a consequence of either osteoporotic or osteomalasic (secondary to vitamin D deficiency) changes in bone produced by these drugs. Secondary hyperparathyroidism due to vitamin D deficiency following long-term polytherapy of antiepileptic drug ultimately leading to development of brown tumor and pathological fracture is very unusual.