Arthroscopic debridement for knee osteoarthritis.

BACKGROUND: Knee osteoarthritis (OA) is a progressive disease that initially affects the articular cartilage. Observational studies have shown benefits for arthroscopic debridement (AD) on the osteoarthritic knee, but other recent studies have yielded conflicting results that suggest AD may not be effective. OBJECTIVES: To identify the effectiveness of AD in knee OA on pain and function. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2006); MEDLINE (1966 to August, 2006); CINAHL (1982 to 2006); EMBASE (1988 to 2006) and Web of Science (1900 to 2006) and screened the bibliographies, reference lists and cited web sites of papers. SELECTION CRITERIA: We included randomised controlled trials (RCT) or controlled clinical trials (CCT) assessing effectiveness of AD compared to another surgical procedure, including sham or placebo surgery and other non-surgical interventions, in patients with a diagnosis of primary or secondary OA of the knees, who did not have other joint involvement or conditions requiring long term use of non-steroidal anti-inflammatory drugs (NSAIDs). The main outcomes were pain relief and improved function of the knee. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials for inclusion, assessed trial quality and extracted the data. Results are presented using weighted mean difference (WMD) for continuous data and relative risk (RR) for dichotomous data, and the number needed to treat to benefit (NNTB) or harm (NNTH). MAIN RESULTS: Three RCTs were included with a total of 271 patients. They had different comparison groups and a moderate risk of bias. One study compared AD with lavage and with sham surgery. Compared to lavage the study found no significant difference. Compared to sham surgery placebo, the study found worse outcomes for AD at two weeks (WMD for pain 8.7, 95% CI 1.7 to 15.8, and function 7.7, 95% CI 1.1 to 14.3; NNTH=5) and no significant difference at two years. The second trial, at higher risk of bias, compared AD and arthroscopic washout, and found that AD significantly reduced knee pain compared to washout at five years (RR 5.5, 95% CI 1.7 to 15.5; NNTB=3). The third trial, also at higher risk of bias, compared AD to closed-needle lavage, and found no significant difference. AUTHORS' CONCLUSIONS: There is 'gold' level evidence that AD has no benefit for undiscriminated OA (mechanical or inflammatory causes).

Osteotomy for cubitus varus: a simple technique in 10 children.

10 children with cubitus varus deformity after supracondylar fractures were operated on with a supracondylar lateral closing wedge osteotomy. The medial cortical periosteal hinge was left intact and the osteotomy stabilized with two Kirschner wires and a tension-band wire loop. The osteotomies healed within 2 months, without any complications or recurrence of the deformity. The outcome was satisfactory as regards both cosmesis and mobility.

Late open nailing for neglected femoral shaft fractures.

The results of open nailing in 14 cases of neglected closed femoral shaft fractures were reviewed. The mean patient's age was 28 years (range, 17-50). The mean delay to definitive treatment was 4.6 months (range 2-10). All fractures were malaligned with an average shortening of 4.9 cm (range 2.5-6.5). All cases underwent one-stage open nailing using the Küntscher nail fixation. The femur was shortened at the fractured end of one or both fragments to accomplish reduction in nine cases. The mean length of the bone resected was 9 mm (range 5-15). Only local callus was used for bone grafting in all cases. There were no neurovascular complications. All fractures healed an average of 3 months (range 2-4) after operation. Six cases had regained full knee flexion at the time of the latest follow up. Eight cases had decreased knee flexion with an average arc of knee flexion of 119 degrees (range, 100-125). The mean length of hospital stay was 7 days (range, 5-12). The method was found to be safe and effective with acceptable shortening and knee motion.

Charcoal bamboo as a bone substitute: an animal study.

UNLABELLED: Charcoal bamboo (Bambusae glaucescens) was placed in the resected tibial diaphysis of sixteen New Zealand White rabbits. At two, four and six weeks and again at six months after the operations, four rabbits in each period were killed and all specimens were examined under a light microscope and a scanning electron microscope. The six-week specimens showed that there was neobone invasion into the pores of the charcoal bamboo. There was no evidence of fibroencapsulation or inflammatory response. Due to its structure as a uniform porous material with interconnecting pores and carbon composition, the charcoal bamboo has been proved to be an osteotropic material. CLINICAL RELEVANCE: Charcoal bamboo should be an alternative bone substitute which may be used in humans in the near future. This material is available and easy to produce and prepare in developing countries.

Iliotibial band for anterior cruciate ligament reconstruction: a new technique for graft augmentation, placement and fixation.

A simple surgical technique to reconstruct the ACL deficient knee was described. A strip of ITB and fascia lata augmented by degradable suture materials was used as the substitute. The strip was introduced into the isometric area of the original ACL attachment through a drill hole made in the lateral femoral condyle. Drilling was guided by the anatomical landmarks without using special device. The graft was then rigidly fixed to the tibia by intraosseous compression, the method previously described by the author. Clinical results were assessed by both subjective symptoms and physical examinations. In 33 patients followed-up for an average of 34.1 months, thirty of them who were chronic cases had few or no symptoms concerning pain, swelling, laxity and stiffness at the last visit. Lachman test, anterior drawer and Slocum test were negative in 87.92, 81.87 and 100 per cent respectively. This technique requires only basic instruments and skill, and is thus generalizable to institutions having limited surgical facilities.

Rotational deformity of the distal humerus in cubitus varus.

The medial rotation deformity of the distal humerus usually exists in the cubitus varus deformity but has received little attention. Study of this deformity in 29 cases of cubitus varus was carried out using the osteotomized bony specimens that were removed during closed wedge osteotomy in order to determine the actual bone deformity. The average duration of the varus deformity was 5.6 yrs (range 1 to 11). The medial rotation deformity of the distal humerus averaged 27 degrees (range 15 to 45). There was no correlation between the degree of rotation and that of the varus deformity (correlation coefficient r = 0.15). The affected-side shoulder compensated well in both internal and external rotation, and had a greater arc of rotation than that of the normal side. The affected-side shoulder exhibited an internal rotation deformity with an average of 16 degrees (range 5 to 25), with restriction of external rotation of only 13 degrees (range 0 to 20) in comparison to normal side shoulder.

Musculoskeletal melioidosis.

During a four-year period, twenty-one patients were found to have melioidosis of the musculoskeletal system caused by Pseudomonas pseudomallei. The melioidotic patients were matched with thirty-nine patients who had a musculoskeletal infection due to some other organism, and the two groups were compared with regard to the presence of concurrent disease. The indirect hemagglutination test for melioidosis was positive for all of the melioidotic patients; in thirteen, cultures also were positive. For the patients who did not have melioidosis, the diagnosis was made on the basis of positive cultures of other organisms or histological sections. In most of the non-melioidotic patients, the infection was due to Staphylococcus aureus (twenty-four patients) or to Mycobacterium tuberculosis (twelve patients). The most common concurrent diseases in the melioidotic patients were diabetes and thalassemia. The odds that melioidosis was the cause of the infection in a patient who had a concurrent disease were twelve to one. All melioidotic patients were managed with operative débridement and a combination of drugs--usually, trimethoprim and sulfamethoxazole, doxycycline, and kanamycin or chloramphenicol--for six months. The mean duration of follow-up was one and one-half years. Of the twenty-one patients, eighteen had an excellent or good result in terms of motion of the joint and absence of relapse.

Supracondylar fracture of the humerus: malrotation versus cubitus varus deformity.

A study correlating the degree of medial rotational deformity of the distal humerus and the degree of cubitus varus deformity secondary to supracondylar fracture was performed in 23 patients who underwent corrective supracondylar osteotomy. The mean age of the patients at the time of operation was 10.9 years (range 5-14 years). The time interval from injury to operation averaged 3.2 years (range 1-6 years). A medial rotational deformity occurred in 20 cases. The degree of medial rotational deformity (MRD) averaged 16.2 degrees (range 0-34 degrees). Mean carrying angles (CA) of the deformed and normal sides were -19.6 degrees and 6.5 degrees, respectively. Mean humero-elbow-wrist (HEW) angles, measured from radiographs, of the deformed and normal sides, were -18.8 degrees and 7.7 degrees, respectively. There was no correlation between the degree of MRD and the degree of varus deformity, using as a comparison either the CA or the HEW angle of the deformed elbow or their differences from the normal side.

Ultrasonography of pulled elbow.

We used ultrasonography in ten children with pulled elbow to compare measurements of the radiocapitellar distance (RCD) on the affected and the unaffected sides. Similar measurements were made in a group of ten age-matched normal children. The mean RCD in pronation of the affected and normal sides in the patients with pulled elbows was 7.2 mm +/- 0.7 and 3.8 mm +/- 0.5, respectively (p < 0.0001). In the normal children the mean RCD in pronation was 4.5 mm +/- 0.5. We conclude that ultrasonography is of value for documenting pulled elbow in children.

Late reduction of dislocated elbow. Need triceps be lengthened?

We compared the results in two groups of patients with late reduction of posterior elbow dislocations, one of which had lengthening of the triceps (group A, n = 36) and the other did not (group B, n = 34). The elbows had all been dislocated for more than one month and less than three months. The patients in group B had better clinical results and significantly less postoperative flexion contracture (p < 0.05).

Ultrasound or image intensifier for closed femoral nailing.

We describe a method of closed, unlocked nailing for femoral fractures using ultrasound instead of an image intensifier. Radiography was used only to confirm that the guide wire had been passed into the intramedullary canal of both fragments. The method succeeded in 26 of 30 cases. The failures all occurred in fractures which could not be reduced within 20 minutes. The operating time in those nailed successfully with ultrasound control was not different from the time for 30 control cases using conventional methods with an image intensifier.

Osseous adenocarcinoma of unknown primary site: study of survival and prognostic factors.

A prospective study of 149 patients suffering from adenocarcinoma of unknown primary site (ACUPS) of bone was carried out. The tumors are classified as 63 extraspinal, 67 spinal and 19 mixed involvement. Upon meticulous physical examination, Virchow's node was detected in 15 cases, rectal shelf in 11 cases and hepatomegaly in 44 cases. Blood chemistry showed elevation of alkaline phosphatase (> 3 sigma units) in 98 cases and chest roentgenogram showed pulmonary lesions in 23 cases. Treatment was surgery and radiotherapy in 64 and two cases respectively. In all of these patients histological findings of the biopsy or resection specimen had confirmed the diagnosis of adenocarcinoma. Among 124 evaluable patients, overall survival was analysed using Kaplan-Meier life table analysis. Survival rates at one, two and four months after diagnosis were 80.7, 60.5 and 25 per cent with a mean and median survival times of 90 and 77 days respectively. Statistical analysis was also performed to ascertain the prognostic importance of the following variables: age, gender, Virchow's node, rectal shelf, hepatomegaly, serum alkaline phosphatase, pulmonary lesion, and multiplicity and site of the osseous lesions. The presence of pulmonary lesion or hepatomegaly significantly produced unfavorable impact on the duration of survival (p = 0.0004 and 0.0150, respectively) while other remaining factors had not.

An aiming device for distal locking in closed locked femoral nailing.

A method of constructing an aiming device for insertion of distal locking screws is described. The device helps facilitate the free-hand technique, lessens the difficulty of drilling and insertion and allows the surgeon to perform at a distance, away from the radiation beam.

Subtrochanteric fracture: fixation using the AO tibial nail.

We describe an alternative fixation for the pure uncomminuted subtrochanteric fracture by using the AO tibial nail. There were no intraoperative complications in 24 fractures with this method. The fractures healed within 4 months postoperatively in 18 non-pathological fractures that could be followed up. There were minor complications, including 10 degrees external malrotation in one case and varus angulation after nail breakage in another. The nails were removed in seven healed fractures without problems. Two pathological fractures which were stabilized by the AO tibial nail, combined with the use of bone cement to fill the bone defect, were able to have early postoperative ambulation without any problems with the fixing device.

Ultrasound for closed femoral nailing.

A new application of operative ultrasound to help assess the fracture alignment for closed reduction and passing the guide wire in closed femoral nailing is described. This method can be used instead of fluoroscopic monitoring in certain important steps which can markedly reduce the exposure time of fluoroscopic monitoring. Nine of ten cases were successful using this technique for closed unlocked nailing with an average ultrasound monitoring time of 8 minutes. The time required for fluoroscopic assessment was reduced to less than 1 minute for each successful case.

Isolated articular melioidosis.

Melioidosis is an infection caused by a gram-negative bacilli, Pseudomonas pseudomallei. This organism can cause fatal infection in domestic animals and are probably transmitted to humans by soil contamination of skin abrasions, ingestion, and inhalation. Melioidosis is being increasingly diagnosed in Western countries in other than its endemic areas of tropical and subtropical zones. In the past, only a few single case reports of articular melioidosis were published in English journals, and almost all were secondary to melioidosis of another organ. Accurate diagnosis of this infection is important because a high mortality rate is usually associated with the septicemic form. Nine cases of isolated articular involvement were diagnosed between 1984 and 1988 in Northeast Thailand. Symptoms were subtle and diagnosis required a high degree of suspicion. Diagnosis depended on bacteriologic methods including Gram's stain, pus and blood cultures, and on an indirect hemagglutination titer of over 1:40. In addition to general measures for septic arthritis, antibiotic therapy using a combination of intravenous cotrimoxazole, doxycycline, and chloramphenicol was generally satisfactory. Second line drugs (i.e., more effective but also more expensive drugs that the authors administered when patients failed to respond to the first line drugs cotrimoxazole, doxycycline, and chloramphenicol) comprising intravenous ceftazidime and cotrimoxazole were administered in cases with an underlying disease. Comparison of the disease course before and during hospitalization as well as the total days of treatment between two small groups of patients with and without underlying disease revealed no statistically significant difference.

Clinical diagnosis for metastatic adenocarcinoma of spine of unknown origin. A comparative study.

The diagnostic values of the presence of Virchow's node (VN) or rectal shelf (RS) in spinal metastasis from adenocarcinoma of unknown origin were studied prospectively in 60 patients during 1986-1988. These were compared with 14 cases with other malignancies of the spine and 37 controls with nonneoplastic spinal lesions. The diagnosis was confirmed by histologic study in all malignant cases. The results were analyzed by diagnostic test analysis and McNemar chi 2 testing. This yields 18.3-21.6%, 97.2-100%, and 92.8-100% sensitivity, specificity, and predictive value, respectively, for a positive test for VN and RS to differentiate significantly adenocarcinoma from other malignancies and control patients (P less than 0.005). These findings may thus be considered as a simple and economic guide for physicians to determine the proper approach to patients with a spinal lesion suspected to be malignant.

Simplified method for closed femoral nailing.

We describe the method to simplify the procedure and shorten the operating time during closed femoral nailing. This includes early surgery, using a special reduction device, a marker to help interpretation of fracture alignment, limiting the surgical field to the trochanteric area with the thigh undraped to facilitate mobilization of the undraped C-arm, avoiding unnecessary intermediate reamers, less cortical reaming and a second team for distal locking when required. For 60 simple unlocked nailings and 15 locked nailings, the operation times were 40.4 and 58.7 min, respectively. These are much shorter than in previous reports.