Atraumatic Sacral Fracture in Late Pregnancy: A Case Report.

Study Design Case report. Objective Sacral fractures, traumatic or atraumatic, are a rather rare cause of low back pain. The majority of the cases of pregnancy-related sacral fractures are reported as a postpartum complication, and only few cases of sacral atraumatic fractures have been reported in the last trimester of the pregnancy. The aim of this study is to report a rare case of atraumatic sacral fracture in the third trimester of pregnancy. Methods We report the case of a 30-year-old Caucasian European woman during her 37th week (36 weeks and 4 days) of gestation, who complained during her scheduled obstetric examination of continuous low back pain with no associated history of trauma. The patient performed activities of daily living with a normal level of fatigue and reported no running or walking long distances. She was examined in our department, and a magnetic resonance imaging scan was performed that showed a vertical nondisplaced fracture in her left sacrum. Results The patient was treated conservatively, and analgesics were administrated according to the consensus of the orthopedic and the anesthesiology departments. No further complications were recognized in the remaining period of her pregnancy, and a healthy child was born by caesarean section. Conclusions Atraumatic fractures of the sacrum should be included in the differentiated diagnosis of pregnant patients with low back pain.

Proximal screws placement in intertrochanteric fractures treated with external fixation: comparison of two different techniques.

BACKGROUND: To compare two different techniques of proximal pin placement for the treatment of intertrochanteric fractures in elderly patients utilizing the Orthofix Pertrochanteric Fixator. METHODS: Seventy elderly high-risk patients with an average age of 81 years were treated surgically for intertrochanteric fracture, resulting from a low energy trauma. Patients were randomly divided in two groups regarding to the proximal pin placement technique. In Group A the proximal pins were inserted in a convergent way, while in Group B were inserted in parallel. RESULTS: All fractures healed uneventfully after a mean time of 98 days. The fixator was well accepted and no patient had significant difficulties while sitting or lying. The mean VAS score was 5.4 in group A and 5.7 in group B. At 12 months after surgery, in group A the average Harris Hip Score and the Palmer and Parker mobility score was 67 and 5.8, respectively. In group B, the average Harris Hip Score and the Palmer and Parker mobility score was 62 and 5.6, respectively. No statistically significant difference was found regarding the functional outcome. The mean radiographic exposure during pin insertion in Group A and Group B was 15 and 6 seconds, respectively. The difference between the two groups, regarding the radiographic exposure, was found to be significant. CONCLUSION: Proximal screw placement in a parallel way is simple, with significant less radiation exposure and shorter intraoperative duration. In addition, fixation stability is equal compared to convergent pin placement.

Snakebites of fingers or toes by viperidae family members: an orthopaedic approach.

The purpose of this study was to review current principles of therapy for affected patients and determine whether an emergent surgical approach or expectant management should be selected in cases of snakebites of fingers or toes by Viperidae family members. Over the past five years (January 2004 to December 2009), 12 patients bitten by Vipera ammodytes were admitted in our department. We retrospectively reviewed their demographic and epidemiological characteristics as well as their symptoms, laboratory findings, and complications. All snake bites occurred at the extremities (fingers and toes). The main complications were oedema, disseminated intravascular coagulation, and decrease in haematocrit. None of the patients developed compartment syndrome or required surgical debridement. The majority of the patients with snakebites of fingers or toes by Vipera ammodytes can be treated conservatively. Surgery is indicated only in case of compartment syndrome, where fasciotomies should be performed without delay after diagnosis.

Ilizarov treatment of humeral shaft nonunion in an antiepileptic drug patient with uncontrolled generalized tonic-clonic seizure activity.

Nonunion of the humeral shaft in patients with antiepileptic drug associated metabolic bone disorder constitute a challenging surgical problem difficult to treat due to seizure activity, osteoporosis, and poor stabilization options. We report a case of nonunion of the humeral shaft in an antiepileptic drug patient with uncontrolled generalized tonic-clonic seizure activity successfully treated with Ilizarov external fixator and a follow-up of 4 years.

Femoral periprosthetic fracture in osteoporotic bone after a total knee replacement: treatment with Ilizarov external fixation.

We report 3 cases of periprosthetic fractures after total knee replacement treated with Ilizarov external fixator (Smith and Nephew plc, Memphis, Tenn) and a follow-up of at least 3 years. We used 2 rings in the supracondylar area distal to the fracture and 3 half pins proximally in all our cases leaving the knee free to move. In one patient apart from the 2-ring frame placed distal to the fracture site the fixator included another ring frame placed proximally just below the 3 half pins. Uncomplicated fracture healing with lower extremity excellent alignment was achieved in 12 weeks after surgery. In periprosthetic femoral fractures, especially in elderly patients, Ilizarov external fixator is a treatment option which provides stable fixation, prompt postoperative mobilization, and has no major complications.

Application of the Endomodel rotating hinge knee prosthesis for knee osteoarthritis.

One hundred thirty-six knees were treated with the Endomodel rotating hinge knee prosthesis as primary total knee arthroplasty (TKA). The indications for surgery included osteoarthritis (110 knees), rheumatoid arthritis (18 knees), and osteonecrosis (8 knees). Patients were divided into four study groups according to follow-up duration. Group A was followed up from 10 to 15 years, group B from 8 to 10 years, group C from 5 to 8 years, and group D from 2 to 5 years. The Hospital for Special Surgery knee score, as well as each parameter individually, showed statistically significant improvement in all groups postoperatively. A total of 88.23% were rated as excellent, 3.67% as good, and 8.08% as fair. The results suggest that the Endomodel rotating hinge prosthesis can be considered a good alternative for primary TKA in cases of serious axial deformity and collateral ligament deficiency and in rheumatoid arthritis patients.

Turret exostosis of the hallux.

A 22-year-old woman presented with pain on the dorsum of her left big toe. The patient had had an accident 1 year previously, when a heavy object fell on her left big toe. She experienced no pain in the hallux before the injury. Radiographic evaluation revealed a well-circumscribed osseous mass, in close relationship to the underlying dorsal cortex of the proximal phalanx. A 2 x 1.5 x 0.7 cm mass was resected. No communication was found between the undersurface of the bony mass and the medullar space of the phalanx. The histology report confirmed diagnosis of acquired osteochondroma. Removal of the bony mass resulted in disappearance of symptoms without any sign of recurrence 10 months later.

Bilateral absence of the patella in nail-patella syndrome: delayed presentation with anterior knee instability.

A 27-year-old man, while serving in the armed forces, presented with complaints of right knee pain of 3 months duration. The patient reported pain localized on the lateral side of the right knee, especially during long-distance walking and stair climbing, and a feeling of giving way. There was no history of recent or remote trauma to the knee joint. At that time, he presented with knee pain and instability consistent with anterior cruciate ligament (ACL) insufficiency. During physical examination, the diagnosis of nail-patella syndrome (NPS) was made, but magnetic resonance imaging (MRI) of both knees revealed intact ACLs. The reported case presents NPS as a potential nontraumatic cause of anterior knee instability. In our patient, a discrepancy between the clinical and imaging findings was present. The initial clinical examination was consistent with ACL rupture or aplasia and this led to MRI evaluation of the knee, which showed an intact ACL, contrary to the initial diagnosis. It should be noted that anterior instability has been described after patellectomy and could be attributed to complete absence of the patella, which is rare in NPS.

Low-intensity transosseous ultrasound accelerates osteotomy healing in a sheep fracture model.

BACKGROUND: Low-intensity transcutaneous ultrasound can accelerate and augment the fracture-healing process. The aim of this study was to investigate the effect of transosseous application of low-intensity ultrasound on fracture-healing in an animal model. METHODS: A midshaft osteotomy of the left tibia was performed in forty sheep. An external fixator was used to stabilize the osteotomy site. A thin stainless-steel pin was inserted into the bone, 1.0 cm proximal to the osteotomy site. Ultrasound was transmitted through the free end of this pin, with a PZT-4D transducer. In twenty animals, the treated limb received a 200-microsec burst of 1-MHz sine waves repeated at 1 kHz with an average intensity of 30 mW/cm(2) for twenty minutes daily. Twenty other animals underwent the same surgery but did not receive the ultrasound (controls). Animals were killed at seventy-five and 120 days postoperatively. Radiographic evaluation was performed every fifteen days. Mechanical testing and quantitative computed tomography were performed after death. RESULTS: Fractures treated with ultrasound healed significantly more rapidly, as assessed radiographically, than did the controls (seventy-nine compared with 103 days, p = 0.027). On day 75, the mean cortical bone mineral density (and standard deviation) was 781 +/- 52 mg/mL in the treated limbs compared with 543 +/- 44 mg/mL in the control group (p = 0.014), and the average ultimate strength (as assessed with a lateral bending test) was 1928 +/- 167 N in the treated limbs compared with 1493 +/- 112 N in the control group (p = 0.012). No significant differences were noted on day 120. CONCLUSIONS: This study demonstrated that low-intensity transosseous ultrasound can significantly accelerate the fracture-healing process, increase the cortical bone mineral density, and improve lateral bending strength of the healing fracture in a sheep osteotomy model.

Non-union of femoral neck fractures with osteonecrosis of the femoral head: treatment with combined free vascularized fibular grafting and subtrochanteric valgus osteotomy.

Femoral neck fractures, frequently complicated by non-union and femoral head osteonecrosis,present a difficult clinical situation, especially when young patients are concerned. Existing treatment options are valgus osteotomy to address the biomechanical factors or bone grafting to address the biologic factor. The authors describe the operative technique and results of combined subtrochanteric valgus osteotomy and free vascularized fibular grafting in management of five young patients with both non-union and avascular necrosis.

Posterior tibial subluxation and short-term arthritis resulting from failed posterior cruciate ligament reconstruction.

Posterior tibial subluxations because of combined or isolated posterior cruciate ligament (PCL) injuries require detailed evaluation. PCL reconstructions are difficult procedures because of the low rate of such injuries and the complex anatomy of the ligament. We report on 2 cases of failed PCL reconstruction because of malpositioned femoral tunnels. These 2 cases support the existing biomechanical evidence that the correct placement of the tunnels, especially in the femur, is a major factor in defining the outcome. It seems that the drilling of the tunnels, especially in the femur, during PCL reconstruction must be performed with accuracy and always be evaluated in cases of graft failure. In addition, failed PCL reconstructions are usually accompanied by a short-term excessive arthritis that results in poor functional outcome.