Radial nerve palsy associated with humeral shaft fracture. Is the energy of trauma a prognostic factor?

BACKGROUND: Radial nerve palsy associated with humeral shaft fractures is the most common nerve lesion complicating fractures of long bones. The purpose of the study was to review the outcome of surgical management in patients with low energy and high energy radial nerve palsy after humeral shaft fractures. METHODS: Eighteen patients were treated operatively for a humeral shaft fracture with radial nerve palsy. The mean age was 32.2 years and the mean follow up time was 66.1 months (range: 30-104). The surgical management included fracture fixation with early nerve exploration and repair if needed. The patients were divided in two groups based on the energy of trauma (low vs. high trauma energy). The prevalence of injured and unrecovered nerves and time to nerve recovery were analysed. RESULTS: Five patients sustained low and 13 high energy trauma. All patients with low energy trauma had an intact (4) or entrapped (1) radial nerve and recovered completely. Full nerve recovery was also achieved in five of 13 patients with high energy trauma where the nerve was found intact or entrapped. Signs of initial recovery were present in a mean of 3.2 weeks (range: 1-8) for the low energy group and 12 weeks (range: 3-23) for the high energy group (p=0.036). In these patients, the average time to full recovery was 14 and 26 weeks for the low and high energy trauma group respectively. Eight patients with high energy trauma had severely damaged nerves and failed to recover, although microsurgical nerve reconstruction was performed in 4 cases. Patients with high energy trauma had a prolonged fracture healing time (18.7 weeks on average) compared to those with low energy fractures (10.4 weeks), (p=0.003). CONCLUSIONS: The outcome of the radial nerve palsy following humeral fractures is associated to the initial trauma. Palsies that are part of a low energy fracture uniformly recover and therefore primary surgical exploration seems unnecessary. In high energy fractures, neurotmesis or severe contusion must be expected. In this case nerve recovery is unfavourable and the patients should be informed of the poor prognosis and the need of tendon transfers.

Ankle and foot osteomyelitis: treatment protocol and clinical results.

INTRODUCTION: A management protocol for ankle and foot osteomyelitis and the outcome in 84 patients treated in a unit with special interest in musculoskeletal infection, is presented. PATIENTS AND METHODS: Patients' mean age was 50.7+/-16.5 years and mean follow-up 31.5+/-18.2 months. Systemic antibiotics were administered initially empirically, and later according to cultures. Surgical treatment included surgical debridement and bead-pouch technique, minor amputation (ray or toe), below knee amputation, and joint fusion. "Second-look" procedures were performed after 48-7h. Vascularised grafts or Ilizarov's technique were used for bone defect reconstruction. Soft tissues were managed according the 'reconstructive ladder' concept. RESULTS: Host-type (Cierny's classification) was A in 25, B in 53 and C in 6 patients. Seventy-six infections were chronic. Causes were: open trauma without fracture (45/84), open fractures (9/84), ORIF of closed fractures (25/84) and elective surgery (5/84). Patients underwent 3.0+/-1.5 (range 1-10) operative procedures and spent 14.8+/-12.2 (range 3-60) days in hospital. Two (host-C) patients died. Complications requiring reoperations occurred in 20/84 (2/25 host-A, 16/53 host-B, 2/6 host-C; significant difference between host-A versus host-B and -C patients, p<0.001). Infection recurrence occurred in 12 (none host-A; significant difference between host-A versus host-B and -C patients, p<0.001). Multiple organisms were isolated in 39/84. Ankle arthrodesis using external fixation was performed in 9 (fusion rate 8/9). The free vascularised fibula graft was used in 2 and distraction osteogenesis in 8 patients with a mean bone defect of 5.4 cm (range 3-13). Below knee amputations were performed in 5/84 (3/53 host-B, 2/6 host-C) and foot ray amputations in 8/84 (6/53 host-B, 2/6 host-C). Soft tissue coverage required: free muscle flap transfer in 6/84, reverse soleus flap in 1/84, local fasciocutaneous flaps in 7/84, split thickness skin grafts in 5/84, and vacuum assisted closure in 5/84 patients. Eighty-two surviving patients, including amputees, were able to mobilise independently and were satisfied with the result of treatment. CONCLUSIONS: Host-B and -C patients had more complications and infection recurrences and occasionally required amputations. Reconstructive procedures were performed for limb salvage in patients with soft tissue and bone defects and restoration of a functional limb was achieved.

Epidural bleeding after ACL reconstruction under regional anaesthesia: a case report.

INTRODUCTION: Epidural bleeding as a complication of catheterization or epidural catheter removal is often associated with perioperative thromboprophylaxis especially in adult reconstructive surgery. CASE PRESENTATION: We report on a case of a 19 years old male athlete that underwent anterior cruciate ligament reconstruction, receiving low molecular weight heparin for thromboprophylaxis and developed an epidural hematoma and subsequent cauda equina syndrome two days after removal of the epidural catheter. An urgent magnetic resonance imaging scan revealed an epidural hematoma from the level of L3 to L4. Emergent decompression and hematoma evacuation resulted in patient's significant neurological improvement immediately postoperatively. CONCLUSION: A high index of clinical suspicion and surgical intervention are necessary to prevent such potentially disabling complications especially after procedures on a day-case basis and early patient's discharge.

History and evolution in total ankle arthroplasty.

INTRODUCTION: The current study provides an overview of history and evolution in total ankle arthroplasty. METHODS: We conducted a comprehensive literature search without limitations to language. Information from any source, providing evidence of the use ankle of prostheses (e.g. biomechanical testing, cadaveric implantations or clinical use) was evaluated. Data regarding biomechanical concepts, design considerations, published results (patient numbers, surgical method, follow-up, complications and survival rates) were collected. RESULTS: Only level IV studies were found. Mobile-bearing prostheses are mainly used in Europe, and fixed-bearing implants are mainly used in the USA. The current designs' failure rate is 10-12% at approximately 5 years. Survival rates vary among different institutions. Increased surgeons' experience is associated with better outcomes. DISCUSSION: Biomechanical studies and review of previous implant failures has led to the development of a new generation of implants. CONCLUSIONS: Results show that ankle arthroplasty is a viable alternative for the management of ankle arthritis in selected patients.

Relapsed clubfoot correction with soft-tissue release and selective application of Ilizarov technique.

The Ilizarov technique is an alternative for the treatment of complex foot deformities in children. The authors retrospectively reviewed children with relapsed clubfoot deformity, treated with soft tissue procedures and additional correction with an Ilizarov frame. Twelve consecutive patients (13 feet) with relapsed clubfoot deformity after previous surgical correction were reviewed. Treatment included open releases. An Ilizarov frame was applied as an adjunct in seven patients (mean age of 7.8 years) with severe deformity where complete intraoperative correction was not achieved. Clinical and radiographic assessment was undertaken. The mean Laaveg-Ponseti score, for the 7 feet treated with the Ilizarov frame, was 85.1 after minimum 4 years follow-up. One recurrence of forefoot deformity required metatarsal osteotomies. Postoperative radiographic measurements revealed values that can be considered as normal. Complications included pin tract infections (12% of inserted wires). Flat-topped talus was observed in 3 feet. Deformity correction was possible when soft tissue procedures were combined with the use of Ilizarov technique, in order to support and gradually improve surgical correction.

Distal ulnar implant arthroplasty as a definitive treatment of a recurrent giant-cell tumor.

Giant-cell tumors of the distal ulna are frequently recurrent and difficult to treat. A Darrach-type resection can lead to functional impairments of the wrist and hand. A case of a 42-year-old man, who underwent a distal ulna arthroplasty for recurrent giant-cell tumor of the distal ulna, is presented. The patient had two previous operations in an attempt to curette the cavity, either alone or filled with allograft bone chips. En bloc resection and distal ulnar implant arthroplasty provided a good functional outcome without any evidence of tumor recurrence at a 2-year follow-up evaluation.

Arthroscopic ankle arthrodesis.

BACKGROUND: Arthroscopic arthrodesis has been used mainly for in situ fusion of arthritic ankles without deformity. This paper presents the application of arthroscopic arthrodesis of ankles with marked deformity. METHODS: The results of 78 consecutive cases of arthroscopic ankle arthrodeses, performed in 74 patients, were retrospectively evaluated. Forty-eight ankles had minor deformity (group A), whereas 30 ankles had a varus or valgus deformity of more than 15 degrees (maximum 45 degrees) (group B). The average hospital stay was 3.8 and 3.4 days in groups A and B, respectively (p = 0.74). Postoperative treatment included ankle immobilization for 3 months. Progressive weightbearing was initiated at 2 weeks. Mean followup was 21.1 months. RESULTS: Fusion occurred in 47 of 48 (97.9%) ankles in group A at an average time of 13.1 +/- 5.8 weeks and in 29 of 30 (96.7%) ankles at 11.6 +/- 2.4 weeks in group B (p = 0.19). Unplanned operative procedures were required in 11 ankles (14.1%). One superficial wound infection occurred. Symptomatic arthritis from the adjacent joints developed in six ankles (7.7%). Postoperative ankle alignment in the frontal plane averaged 0.7 and 0.4 degrees of valgus (p = 0.41), whereas the sagittal plane angle averaged 106 +/- 4 degrees and 104.5 +/- 7 degrees in groups A and B, respectively (p = 0.22). The outcome was graded as very good in 79.2% (38 feet) in group A and 80% (24 feet) in group B, fair in 18.8% (9 feet) in group A and 16.7% (5 feet) in group B and poor in one ankle in each group (p = 0.68). CONCLUSIONS: The arthroscopic technique offered high fusion rates and low morbidity. Deformity correction was achieved with good results.