Medial column fusion for degenerative pesplanovalgus deformity. Report of 9 patients.

Degenerative pesplanovalgus is a progressive disabling condition; there are more than one surgical procedure used in the treatment with varied outcomes. The aim of the current study is to highlight the benefits of the medial column fusion surgery in the treatment of this condition. Nine adult patients with rigid degenerative pesplanovalgus (without significant valgus heel deformity) underwent medial column fusion between January 2015 to December 2020. The procedure was combined with subtalar fusion in four patients and lateral column lengthening in one patient. The mean follow-up period was 19.5 months (range, 15-27). Regular clinical and radiological reviews was carried out in the postoperative period. The mean Manchester Oxford foot score was good in 7 patients, and fair in two patients. The mean Meary angle was 5.8 ± 5.4° preoperatively and improved to 0.9 ± 7.7° at final follow-up, and the mean Pitch angle also improved from 12.5 ± 3.7° preoperatively to 23.2 ± 4.1° (P < .001). In a patient, and at a different stage, talo-navicular fusion was added to the medial column fusion.The outcome of this series of cases was encouraging and medial column fusion continues to be a good option in the management of rigid pesplanovalgus deformity.

Listen while you work? The attitude of healthcare professionals to music in the operating theatre.

Although the playing of music is commonplace in the operating theatre, there is nothing in the literature examining whether staff feel this is beneficial. Questionnaires were distributed amongst a random selection of staff in practice at a district general hospital: medical staff from a range of surgical specialities, anaesthetists, and all grades of perioperative staff (nurse/operating department practitioners/healthcare assistants) were encouraged to participate. There were 121 health professionals in total working in the operating theatres. The authors compared the responses to each question amongst the respondents, to check for the tendency to correlate. Out of the 52 health professionals who responded, 36 stated that music is played in their theatre either every day, or two to three times a week. Only five respondents felt that this was too often. Fifteen percent of medical staff were of the opinion that the nursing staff controlled the choice of music. Nursing staff were almost evenly split in thinking that nursing staff, surgical staff and the whole theatre team controlled the choice of music. The majority of both nursing and medical staff felt that they enjoyed their work more and performed better when music was played in theatre. The study concluded that the majority of theatre staff found listening to music while they work a positive experience. The potential for music to have a distracting or detrimental effect on a minority of individuals should always be considered.

Cardiac hydatid disease, case report, and review of literature.

Cardiac Hydatidosis is a rare but potentially very serious complication of hydatid disease. It is a diagnostic and therapeutic challenge due to the variability of signs and symptoms at presentation. A case of disseminated hydatidosis, affecting the heart muscle, which failed to surgical evacuation and followed by spread to the brain and elsewhere in the body, is presented, discussed, together with a review of the literature. The disease, hydatididosis, remains a challenge even in our days. Systematic radical control in the Middle East is required. Alternative surgical options include heart transplantation when the disease affects the heart muscles and there is more than one cyst which fails to surgical evacuation.

Anterior thigh pain after cementless total hip arthroplasty.

We compared the incidence of anterior thigh pain retrospectively following primary uncemented total hip replacement in 70 patients (78 hips) with osteoarthritis. In one group (38 hips), an Endoplus porous-coated, canal-filling prosthesis was inserted through an anterolateral approach. In the other group (40 hips), a Furlong hydroxyapatite-coated prosthesis was inserted through a posterior approach. The latter prosthesis has a relatively longer femoral stem and does not achieve diaphyseal press-fit contact. Three patients in the Furlong group had anterior thigh pain, which eventually resolved in two patients. In the Endoplus group, two patients developed anterior thigh pain; in both cases, there was an underlying cause, which had to be treated. Idiopathic anterior thigh pain is more common in non-canal-filling prostheses. When anterior thigh pain is noticed in canal-filling prosthesis, a search for and treatment of the cause will cure the pain. The hydroxyapatite coating did not prevent thigh pain in the Furlong group.

Multidisciplinary integrated care pathway for fractured neck of femur. A prospective trial with improved outcome.

Admitting patients with fractured neck of femur using fast tracking procedure is well established in over 75% of hospitals in the United Kingdom. A retrospective study on 143 patients admitted using such procedure revealed inadequacies in the system. Although the waiting time in the Accident and Emergency Department (A&E) was reduced, it did not contribute much to the other aspects of patients outcome. We conducted a prospective trial using a multidisciplinary integrated care pathway (ICP) for the management of patients with fractured neck of femur. The objective of this study was to assess the effect of this protocol on the outcome compared to the earlier findings. The outcomes measured were admission time, time to surgery, length of in-hospital stay, cancellations, and 30-day mortality. The results showed a significant reduction in the length of hospital stay (P = 0.001). The 30-day mortality (P = 0.056) and number of patients operated within 24 h of admission were better (P = 0.048) but not significant. There was no difference in the time to admission to orthopaedic ward and other related complications between the two groups. This study has shown that a multidisciplinary care pathway for management of patients with fractured neck of femur has potential benefits.

Bilateral simultaneous combined intra- and extracapsular femoral neck fracture secondary to nutritional osteomalacia: a case report.

A case of bilateral simultaneous combined extra- and intracapsular femoral neck fractures is presented in an adult Asian male patient suffering from nutritional osteomalacia. The radiological and biochemical findings were classical for osteomalacia with Looser's zones affecting the shoulder and the pelvic girdle. Treatment consisted of bed rest and calcium and vitamin-D replacement. The fractures healed without surgery. A high index of suspicion for nutritional osteomalacia among Asian immigrants especially among the low socio-economic classes is required in the Western community. Early diagnosis and treatment prevents chronic disability and skeletal deformity.

External fixation in lumbar segmental instability.

Identification of the source of pain in patients with chronic low back pain remains a challenging subject. The non-invasive investigations lack specificity. The value of invasive tests has also been controversial. At one time discograms used to be considered as the only specific investigation identifying the source of pain prior to fusion surgery; many studies however proved that this is not true. Recently, external fixation of the spine has become a popular invasive investigation in patients with low back pain. In the current review, published articles in the field are discussed. There is unfortunately not enough data to support the use of spinal external fixation.

Gram staining in the diagnosis of acute septic arthritis.

This study aimed at determining the sensitivity and specificity of Gram staining of synovial fluid as a diagnostic tool in acute septic arthritis. A retrospective study was made of 22 patients who had arthroscopic lavage following a provisional diagnosis of acute septic arthritis of the knee joint. Gram stains and cultures of the knee aspirates were compared with the clinical and laboratory parameters, to evaluate their usefulness in diagnosing acute arthritis. All patients who had septic arthritis had pain, swelling and limitation of movement. CRP was elevated in 90% of patients. The incidence of elevated white blood cell count was higher in the group of patients with a positive Gram stain study (60%) as compared to patients with a negative Gram stain study (33%). Gram staining sensitivity was 45%. Its specificity was however 100%. Gram staining is an unreliable tool in early decision making in patients requiring urgent surgical drainage and washout.

Soft-tissue chondroma in a finger: a case report.

We present a case of soft tissue chondroma arising from the soft tissues of the index finger of the right dominant hand. Although asymptomatic, the swelling gave rise to concern both for the patient and the hand surgeon. There was a relatively large osteoblastic lesion in relation to the volar aspect of the distal interphalangeal joint. The lesion was excised, the histological findings were those of a chondroma. The site, the radiological appearance and the lack of any connection of this tumor to the underlying joint, bone and tendon is extremely rare. Despite concerns of an aggressive neoplastic disease, the lesion was benign on histology and did not recur.

Penetration injury of the hindfoot following intramedullary nail fixation of a tibial fracture.

Technical errors during intramedullary nail insertion are not uncommon. We report a case of tibial guide wire penetration into the distal tibial articular surface, the talus and the calcaneus during insertion of the nail with the ankle dorsiflexed. This has not been reported in the past. Computerized tomogram was a useful tool in the diagnosis. This complication was associated with long-standing ankle pain, which however eventually settled. We advise frequent use of biplanar C-arm image during the insertion of the guide wire, the reamer and tibial nail into the medullary canal of the tibia or other long bones. None of these instruments should be forced through. Once the knobbed guide wire is exchanged to a straight guide wire, the wire should not be forced through or reamed over, and the nail should be introduced over the guide wire with caution. Early intraoperative identification and recording of this iatrogenic accident is necessary in order to explain the situation to the patient and modify treatment accordingly.

The reliability of the pre-operative classification of open tibial fractures in children a proposal for a new classification.

The purpose of this observational study was to evaluate the accuracy of Gustilo's classification of open tibial fractures in children. Pre- and post-debridement (using the parameters of Gustilo's classification) wound gradings in 27 children with a mean age of 10 years (3 to 15 years) who had sustained an open tibial fracture were compared. Pre-operative Polaroid photographs of the wound were taken of all these patients in the accident and emergency department. In every case, the fracture was treated with prophylactic intravenous antibiotic administration, wound debridement and lavage. Following wound exploration in the operating theater, the wound was classified using Gustilo's parameters again; this was different from the initial grading. We compared post-debridement classification according to Gustilo to the new classification which we propose. The latter classification is a peroperative assessment of the extent of soft tissue damage and it addresses bone stability. According to this classification, the majority of open tibial fractures were stable, requiring no skin graft or flap and had a good outcome. Only five patients were treated by initial external fixation of the tibia; the remainder were treated by cast immobilization. Wounds were treated as appropriate. The clinical outcome study included the assessment of wound and fracture healing and the incidence of complications. The mean period for follow-up was 8 months (6 to 24 months). There were no cases of nonunion or deep wound infection and the wounds healed in all these patients. We conclude that Gustilo's classification is not specific and does not reflect the extent of soft tissue and skeletal damage. Factors such as the degree of soft tissue damage and periosteal stripping that are noticed following wound debridement and velocity of injury are far more important than the wound size. Our proposed peroperative classification covers the extent of soft tissue injury and skeletal stability, thus predicting the outcome more than the Gustilo classification.

Surgical treatment for rheumatoid neck arthritis bilateral occipitospinal fusion with plate fixation.

UNLABELLED: The results of surgical treatment of 12 patients with rheumatoid cervical spine arthritis were reviewed. The Ranawat classification was as follows: 5 with Ranawat IIIB, 1 Ranawat IIIA and 6 Ranawat II. Decompression and fusion using autogenous iliac bone graft and double occipitospinal plate fixation was carried out on 11 of these patients; the remaining patient underwent upper cervical spine fusion using screw and wire fixation. The main indication for surgery was neurological deterioration. In three cases previous surgery had been carried out on the cervical spine. The results were assessed at a mean follow-up of 26.1 months. According to Frankel's grading the neurological recovery in patients with neurological compression was one grade. There was clinical and radiological evidence of fusion in all these patients. The following complications required further surgery: acute postoperative epidural hematoma (one patient) screw loosening (one patient) CONCLUSION: Fusion of the occiput and lateral mass of the involved cervical spine using a plate on each side provides a relatively stable fixation in patients with rheumatoid arthritis of the cervical spine. Laminectomy and adequate decompression of the neural elements can be carried out without compromising spinal stability. There is a relatively high complication rate associated with surgery for rheumatoid neck and the patient needs to be informed.

Snapping iliotibial band. Report of ten cases and review of the literature.

UNLABELLED: The authors performed a retrospective study on 10 young patients (11 hips) presenting with a tight iliotibial band resistant to nonsurgical treatment. The main symptoms were pain and snapping of the hip during running and strenuous brisk walking. Diagnosis was made by the exclusion of other pathology and the elicitation of the snap. Surgical treatment was performed in all these patients to aid physiotherapy. The main principle of management however remains stretching exercises. When surgery is required, the aim is to elongate the iliotibial band. In our series, we used Z-plasty of the band followed by repair of the fascia as described by Stainsby. Our postoperative rehabilitation was different from Stainsby's, however. We allowed early progressive full weight bearing in contrast to the two weeks bed rest adopted by Stainsby. Stretching exercises were started two weeks after surgery; this was active in the first four weeks. The results were good at a mean follow-up period of 12 months (range: 8 to 24 months). Scar sensitivity was a problem in three of these patients; this responded only partially to a desensitization program. CONCLUSION: A reasonable result can be obtained following Z-plasty of a tight and symptomatic iliotibal band. Surgery is required only occasionally and there are associated complications, which must be discussed with the patients, these being recurrence of symptoms and wound problems.

Posterolateral release for idiopathic clubfoot: review of 18 patients.

The authors treated and reviewed 18 patients with 26 idiopathic clubfeet by posterolateral release and elongation of the tendo Achillis at a mean age of 14.6 months (range 7-32 months). The mean follow-up of these patients was 43 months (range 6- 100 months). Function, appearance, and pain were studied. The mean ankle dorsiflexion was 20 degrees at the time of review. In all but one case, the hindfoot equinus had been well corrected. Subtalar movement was 75% of normal in six feet, and 50% of normal in 16 feet. Revision of the posterolateral release combined with anteromedial release was carried out for six patients with residual hindfoot varus and forefoot adduction at an average of 13.5 months following the initial procedure. In one patient, the deformity was overcorrected, but the results of the rest of the revision operations were otherwise good. No skin or wound problems were observed in this series. In conclusion, of 26 feet undergoing posterolateral release for severe clubfoot, 70% had a satisfactory result. Six feet required further surgery (reoperation rate of 23.1%).

A 4- to 10-year follow-up study of the Tricon-M noncemented total knee replacement.

This study reviews the clinical and radiographic results of 207 consecutive noncemented Tricon-M (Smith & Nephew Inc, Memphis, Tenn) total knee replacements (TKRs) in 189 patients. The patella was surfaced in 119 cases, and mean follow-up was 8 years (range: 4-10 years). At final follow-up, mean Hospital for Special Surgery score improved 45 points in 187 cases. Survivorship, with failure defined as the need for revision, was 98% at 4 years, 97% at 7 years, 94% at 8 years, and 90% at 10 years. Twenty-one (11.3%) patients went on to revision. Results for overweight and obese patients did not differ significantly from normal-weight patients. The noncemented Tricon-M TKR prosthesis yields acceptable results; however, patella surfacing and the use of a tibial polyethylene insert > or = 12 mm thick are recommended.

The use of a hook-plate in the management of acromioclavicular injuries. Report of ten cases.

A hook-plate is a clavicular small fragment AO plate with a hook engaging below the acromion. It is primarily used to secure the ligament repair in the treatment of displaced acromioclavicular joint dislocations. We have used the hook-plate in conjunction with a Weaver-Dunn procedure to secure the repair in seven patients. In another three we used this plate to reduce and stabilize distal clavicular fractures. Satisfactory results were obtained in all patients; the deformity disappeared, full pain-free shoulder movement was regained with no motor weakness, with a mean follow-up of 11 months (6-25 months). Our patients returned early to work and sports activities (mean period of three months). The three clavicular fractures healed. One patient developed a superficial would infection, which responded to antibiotics and would dressing. None of our patients required removal of the implant. The hook-plate appears to be a useful device for acromioclavicular trauma.

Arthroscopic findings in the knees of preadolescent children: report of 23 cases.

PURPOSE: The aim of this review was to correlate the preoperative clinical diagnoses and the diagnostic arthroscopic findings in preadolescents with knee problems. We also studied the incidence of different types of knee pathology in this age group. TYPE OF STUDY: Consecutive case series. MATERIALS AND METHODS: Twenty-three preadolescents, 13 girls and 10 boys under the age of 13 years, presenting with mechanical knee problems underwent knee arthroscopy after clinical assessment. RESULTS: Symptomatic plica synovialis was found to be the most frequent pathology (n = 8). This pathology was far more common in girls compared with boys. Anterior cruciate ligament injuries (n = 4) followed symptomatic plica synovialis in frequency. This was an isolated injury in all cases. The arthroscopic findings were negative in 4 patients. CONCLUSION: In 61% of preadolescent patients, the clinical diagnoses and arthroscopic findings were compatible and correct. The main error tended to be misdiagnosis of meniscal pathology (4 patients) and overdiagnosis (5 cases of negative arthroscopy).