A review of the aetiological factors and results of trans-ankle (Syme) disarticulations.

INTRODUCTION: Ever since James Syme described his amputation at the ankle joint, most authors have agreed that Syme's amputation should not be considered for patients with diabetic vascular disease (DVD). The aim of the study was to record our experience with Syme's amputations and to search for any predictive criteria that may enhance successful results. PATIENTS AND METHODS: Seventy patients underwent a Syme amputation between the years 1980 and 2000 in our department, 51 owing to DVD. The other 19 patients had their amputations because of other pathologies. RESULTS: The 19 patients of the non-DVD group showed a success rate of 94.7% (18/19). The overall success rate of the DVD patients was 49% (25/51). When we analysed the DVD group by age, the cut-off point was 65 years old. Patients aged 65 or less had a success rate of 68.2% (15/22), and over the age of 65 years the success rate was only 30.8% (8/26). CONCLUSIONS: Patients with DVD should be considered good candidates for a Syme amputation if they are younger than 65 years old.

The inhibitory effects of colchicine on cell proliferation and mineralisation in culture.

Colchicine is often used in the treatment of diseases such as familial Mediterranean fever (FMF) and gout. We have previously reported that patients with FMF who had colchicine on a daily basis and who had a total hip arthroplasty showed no heterotopic ossification after surgery. The mechanism by which colchicine causes this clinical phenomenon has never been elucidated. We therefore evaluated the effect of various concentrations of colchicine on cell proliferation and mineralisation in tissue culture, using rat and human cells with and without osteogenic potential. Cell proliferation was assessed by direct cell counts and uptake of (3H)thymidine, and mineralisation by measuring the amount of staining by Alizarin Red. Our findings indicate that concentrations of colchicine of up to 3 ng/ml did not affect cell proliferation but inhibition was observed at 10 to 30 ng/ml. Mineralisation decreased to almost 50%, which was the maximum inhibition observed, at concentrations of colchicine of 2.5 ng/ml. These results indicate that colchicine at low concentrations, of up to 3 ng/ml, has the capacity to inhibit selectively bone-like cell mineralisation in culture, without affecting cell proliferation. Further clinical and laboratory studies are necessary to evaluate the effects of colchicine on biological processes involving the proliferation of osteoblasts and tissue mineralisation in vivo, such as the healing of fractures, the formation of heterotopic bone and neoplastic bone growth.

Evaluation of prosthetic usage in upper limb amputees.

PURPOSE: Upper limb amputations cause severe functional disability and lower the patient's self body image, with severe psychological implications. Many parameters are involved in the successful rehabilitation of upper limb amputations. The aim of this study was to investigate whether there are any parameters that might predict the successful prosthetic rehabilitation of upper limb amputees. METHOD: The records of 45 patients who had undergone an upper limb amputation were traced. The patients were evaluated according to four parameters: (1) Modified upper extremities amputees' questionnaire; (2) Pain level according to Visual Analog Scale (VAS), range from 1 (lowest) up to 10 (highest); (3) Pain type - phantom or pain in the stump; (4) Functional assessment of prosthetic usage. RESULTS: Thirty (71.43%) of the patients reported difficulties with prosthesis usage. Twenty-three patients (54.76%) were satisfied with their prosthesis - 19 had cosmetic prosthesis and four had body-powered prosthesis. CONCLUSION: No significant affect of the amputation level except for trans-wrist amputation with 100% prosthesis use. No significant difference was found between prosthesis type and the correlation to stump problems. The above-elbow amputees, with dominant hand amputation, who used functional prosthesis (body-powered), achieved the best functional outcome and result.

Achilles tendon pain and related pathologies: diagnosis by ultrasonography.

BACKGROUND: When encountering complaints of pain in the area of the Achilles tendon, the clinician seldom reaches a correct and precise diagnosis based solely on the grounds of physical examination and standard X-rays. OBJECTIVES: To assess the usefulness of ultrasound in diagnosing pathologies of the Achilles tendon. METHODS: We conducted a retrospective review of patients presenting at our orthopedic clinics. RESULTS: Sonography was used to evaluate 41 patients with achillodynia. This modality enabled the diagnoses of 19 abnormal tendons (46%), peritendinous and other lesions; a complete rupture in two patients (5%); a partial rupture of the Achilles tendon in 3 (7%); various degrees of calcification of the tendon in 7 (17%); and peritendinous lesions discerned by the tendon's hypoechoic regions with disorganized arrangement of collagen fibrils in 4 patients (10%). Other lesions included tendonitis (3 patients, 7%), retrocalcaneal bursitis (3 patients, 7%), lipoma (1 patient, 2%), and foreign bodies (2 patients, 5%). The mean diameter of the pathological tendons was 10.4 +/- 2.7 mm, while normal tendons measured 5.2 +/- 0.8 mm (P < 0.001). CONCLUSION: As in many other soft tissue lesions, ultrasonography is a useful tool in the evaluation of the underlying pathology in patients presenting with achillodynia.

Composite grafts in the treatment of osteosarcoma of the proximal humerus.

Treatment of osteosarcoma (OSA) of the proximal humerus poses many difficulties and challenges to the treating team. Between 1993 and 2000, we treated 11 patients (three women, eight men; age range, 17-74 years) suffering from OSA of the proximal humerus by 'composite': massive allografts and long humeral prosthesis. At presentation, 10 patients were at stage 2-B and one at stage 3-B of OSA. One patient presented with a pathologic fracture. All patients except patient No. 6, received preoperative chemotherapy followed by limb salvage surgery and postoperative chemotherapy.Surgical margins were graded as wide in all patients. Postoperative complications included non-union at the allograft/host junction (which united after auto grafting) and superficial wound infections that resolved after antibiotic therapy. All surgical procedures were performed by a team headed by an orthopedic oncologist and shoulder surgeon. At latest follow-up (December 2001) all patients, with the exception of one (who was at stage 3-B at presentation) were alive, and had good function of the upper limb. It is our opinion that the team approach comprising an orthopedic oncologist and shoulder surgeon greatly contributed to the good surgical outcome, and hence the good survival and functional results of the patients. Bone allograft offers a modular malleable durable solution to the resected bone segment.

Bone allograft in revision total knee replacement.

Revision total knee replacement (TKR) is often associated with the necessity to reconstruct a certain amount of bone loss. In a retrospective study we reviewed the records of 137 patients who had undergone revision TKR in our department between 1990 and 1996, due to loosening or inflection. Bone allografts were used in 91 patients (67%) to accomplish stable, new prostheses. Three types of bone loss were identified in this group: Type I - minor, Type II - moderate, and Type III - large bone defects, located on either side of the knee joint - A, or both sides - B.The treatment results of these 91 patients, according to the type of bone loss, are presented, showing good functional outcome when utilizing bone allografts in revision TKR. However, careful preoperative planning, identification of bone loss type, and a well-equipped bone bank are mandatory to the success of the operation.

Subtalar arthritis as a presenting symptom of Familial Mediterranean fever: case report and literature review.

Familial Mediterranean fever (FMF) is an autosomal, recessive disease affecting mainly people of Mediterranean origin. The primary pattern of FMF is acute, self-resolving periodic attacks of high-grade fever, accompanied by either peritonitis, pleuritis, or arthritis and sometimes typical ankle rash that simulates erysipelas. Rare manifestations, such as pericarditis or massive knee effusion, have been reported in the literature as a presenting symptom of FMF. The final diagnosis has recently become more accurate by identification of the gene for FMF. We describe a unique presenting symptom of subtalar arthritis with no former personal or family history of FMF. A genetic evaluation revealed a 694/726 genetic variant that confirmed the diagnosis of FMF. Treatment with daily colchicine, 1 mg/day, resulted in complete resolution of all complaints.

[Concept management in penetration of unusually shaped foreign bodies into extremities].

During routine emergency room work penetration by foreign objects is frequently encountered, some of which may be very irregular in shape. These may cause further damage if inappropriately removed. It is important to perform a proper X-ray survey.

Lengthening of the shortened first metatarsal after Wilson's osteotomy for hallux valgus.

Metatarsalgia is a recognised complication following iatrogenic shortening of the first metatarsal in the management of hallux valgus. The traditional surgical treatment is by shortening osteotomies of the lesser metatarsals. We describe the results of lengthening of iatrogenic first brachymetatarsia in 16 females. A Scarf-type osteotomy was used in the first four cases and a step-cut of equal thicknesses along the axis of the first metatarsal was performed in the others. The mean follow-up was 21 months (19 to 26). Relief of metatarsalgia was obtained in the six patients in whom 10 mm of lengthening had been achieved, compared to only 50% relief in those where less than 8 mm of lengthening had been gained. One-stage step-cut lengthening osteotomy of the first metatarsal may be preferable to shortening osteotomies of the lesser metatarsals in the treatment of metatarsalgia following surgical shortening of the first metatarsal.

Fixation of an Akin osteotomy with a tension suture: our results.

An Akin osteotomy is a closing wedge varus osteotomy of the proximal phalanx, usually performed as part of a hallux valgus correction surgery to complement the metatarsal correction. Numerous fixation techniques have been described; most provide good and stable fixation, but involve permanent and sometimes protruding hardware. A retrospective cohort study has been carried out of 115 feet in 109 patients using a technique with an absorbable suture fixation of the medial cortex of the proximal phalanx while preserving the lateral cortex. All the osteotomies united completely with no loss of position. HV angles and IM angles were within acceptable parameters. In comparison to others methods, the technique presented in this study is technically simple, provides good results, requires no specialized instrumentation, is cost effective and has a very low complication rate.

Prenatal diagnosis of distal arthrogryposis type 1.

A 23-year-old woman, gravida 1 parity 0, was referred for routine ultrasound examination at 23 weeks gestation. Fetal anatomy was normal. However, both hands demonstrated clasped thumbs without extension. Repeated ultrasound examination verified the bilateral hands posture. The position of the hands did not change following sound stimulation. The child was diagnosed as distal arthrogryposis type 1. Prenatal counselling by the pediatric orthopedic surgeon, geneticist and gynecologist, was provided, to inform the parents on the probable outcome of the fetus and the hands. The parents were advised to continue with the pregnancy. A 1,975-g healthy boy was delivered by spontaneous vaginal delivery. Neonatal examination confirmed the prenatal diagnosis of arthrogryposis type 1. Following reconstructive surgery the child functions well with both his hands.

Hydatid cyst presenting as a soft-tissue thigh mass in a child.

We report a rare case of intramuscular hydatid cyst in a boy who presented clinically as having a soft-tissue thigh mass. A high level of awareness concerning the occurrence of these cysts is important, especially in regions where Echinococcus is endemic. Surgical treatment follows the principles of malignant tumour, namely, wide surgical resection.

A young athlete with myositis ossificans of the neck presenting as a soft-tissue tumour.

Myositis ossificans is usually the result of direct injury to a muscle and is a self-limiting disease. It may present as a soft-tissue mass with a broad differential diagnosis, including highly malignant tumours, such as soft-tissue sarcomas. Many theories can be found concerning the aetiology of myositis ossificans, but minor or major traumas are considered to be the most common cause. A unique case of myositis ossificans of the neck in a 17-year-old professional, female, ground gymnast, who presented initially with a soft-tissue tumour, was treated successfully. The main differential diagnosis is presented along with typical radiographic features on conventional radiography, computerised tomography and magnetic resonance imaging, and typical pathological appearance, such as the pathognomonic "zoning phenomenon". Myositis ossificans should be added to the differential diagnosis of every young patient who engages in sport presents with a soft-tissue mass. Careful padding of the area and teaching the rolling technique to avoid repeated injuries to the neck can prevent recurrence.

Total hip arthroplasty after childhood septic hip in patients younger than 25 years of age.

Childhood septic hip should usually be treated immediately by arthrotomy and antibiotic. Even if treated correctly, the affected hip may become osteoarthritic and functionally disabling. Usually the literature is not in favor of total hip arthroplasty in young patients, and the reports are on patients older than 32 years of age. We present here a unique group of very young patients with early coxarthrosis caused by septic hip in childhood, with an average age of 19.14 years (range, 14-25) at the time of the arthroplasty. The Harris hip score improved from a preoperative mean of 58.43 to a postoperative mean of 94.14. The follow-up period ranged between 2 and 24 years, with an average of 8.14 years. We conclude that total hip arthroplasty in young people with early coxarthrosis caused by septic hip in childhood provides good functional results.

Fishing penetration injuries.

BACKGROUND: Fishing involves millions of people throughout the world and is considered a pleasant and harmless sport. However, many kinds of injury can occur. Penetrating injuries to the extremities by fishing equipment such as hooks and harpoons, and even by scales, or infection from penetration of scales etc are relatively common although hardly ever reported in the literature. METHODS: Illustrative cases of penetrating fishing injuries are presented and discussed, with suggestions for the recommended management of these types of injury. RESULTS: Most of these objects are designed to catch and hold resisting fish, so are usually sharp and narrow in the front and wider in the rear with or without spurs. Because of their very irregular shape, simple extraction by pulling is not recommended, because further damage may occur. CONCLUSIONS: The use of the appropriate imaging modalities, a full knowledge of the contours of the object, and careful preplanning of the method of treatment are very important.

Magnetic resonance imaging of hydatid cyst in skeletal muscle.

The typical MRI features of hydatid cyst in soft tissue/muscle are presented and discussed.

Total hip arthroplasty in patients younger than 30 years of age following developmental dysplasia of hip (DDH) in infancy.

Total hip arthroplasty (THA) in young patients is a controversial subject, due to the high failure rates reported in the literature, and even more so in patients with a history of developmental dysplasia of the hip (DDH). A group of 11 patients, all under the age of 30 years at the time of surgery, underwent THA due to congenital dislocation of the hip. Mean age at the time of operation was 23.3 years (range 16-30 years). The mean follow-up period was 9 years (range 3-14 years). The mean preoperative Harris' hip score (HHS) was 56.9 compared with the postoperative HHS of 90.6. Due to aseptic loosening of the cup, 4 patients underwent successful revision arthroplasty. These encouraging medium-term results in our patients suggest that THA may be a good solution for young patients suffering from coxarthrosis due to DDH, at least temporarily, especially when other alternatives, such as arthrodesis or resection arthroplasty, are considered.