An anatomical approach to the tarsal tunnel syndrome: what can ankle's medial side anatomy reveal to us?

BACKGROUND: The heel is a complex anatomical region and is very often the source of pain complaints. The medial heel contains a number of structures, capable of compressing the main nerves of the region and knowing its anatomical topography is mandatory. The purpose of this work is to evaluate if tibial nerve (TN) and its main branches relate to the main anatomical landmarks of the ankle's medial side and if so, do they have a regular path after emerging from TN. METHODS: The distal part of the legs, ankles and feet of 12 Thiel embalmed cadavers were dissected. The pattern of the branches of the TN was registered and the measurements were performed according to the Dellon-McKinnon malleolar-calcaneal line (DML) and the Heimkes Triangle (HT). RESULTS: The TN divided proximal to DML in 87.5%, on top of the DML in 12,5% and distal in none of the feet. The Baxter's nerve (BN) originated proximally in 50%, on top of the DML in 12,5% and distally in 37.5% of the cases. There was a strong and significant correlation between the length of DML and the distance from the center of the medial malleolus (MM) to the lateral plantar nerve (LPN), medial plantar (MPN) nerve, BN and Medial Calcaneal Nerve (MCN) (ρ: 0.910, 0.866, 0.970 and 0.762 respectively, p <  0.001). CONCLUSIONS: In our sample the TN divides distal to DML in none of the cases. We also report a strong association between ankle size and the distribution of the MPN, LPN, BN and MCN. We hypothesize that location of these branches on the medial side of the ankle could be more predictable if we take into consideration the distance between the MM and the medial process of the calcaneal tuberosity.

Treating Little Finger's Flexor Profundus Tendon Rupture after Percutaneous K-wire Fixation of a Bennet Fracture - A Case Report.

Introduction: About 20% of all fractures in the human skeleton involves the hand, affecting primarily the young and active population. A Bennett's fracture (BF) is a fracture of the base of the first metacarpal and surgical management is generally needed, with the K-wire fixation being the most preferred option. Among the most common complications with K-wires, we find infection and soft-tissues damages like tendon ruptures. Case Report: Here, we report a case of iatrogenic rupture of the Little Finger's Flexor Profundus Tendon after K-wire fixation of a BF that was diagnosed 4 weeks after the lesion. Different surgical strategies were proposed for managing chronic flexor tendon's ruptures; however, no consensus exist around what option would be the best. Here, we describe a flexor transfer from the 5th to the 4th finger that resulted in a great improvement in patient's DASH score and general quality of life. Conclusion: It is important to remember that percutaneous fixations with K wires in the hand can have disastrous complications, patients should be evaluated for possible tendon ruptures after the surgery, no matter how impossible they may seem, as even unexpected complications can have easier solutions in the acute setting.

Evaluation of the Davos self-assisted technique for reduction of anterior glenohumeral dislocations: a comparative study with the traction/countertraction technique.

Background: Few studies have compared conventional and self-assisted shoulder reduction maneuvers. The goal of this study was to evaluate the results of self-assisted Davos vs. traction/countertraction (T/Ct) techniques in the treatment of acute anterior shoulder dislocations. Methods: This was a single-center, prospective study carried out at a tertiary hospital emergency department. Patients aged 18-69 years old, with radiographic confirmation of anterior glenohumeral dislocations, were consecutively allocated to treatment groups. Recorded data included pain at admission (visual analog scale [VAS] score at admission), analgesia before reduction, maximum pain during reduction (maximum VAS score), demographic characteristics, lesion mechanism, laterality, prior dislocation, and immediate complications. The primary outcomes were reduction success rate and pain. Results: Eighty individuals were included (40/group). Regarding the success rate, no statistically significant differences were found between Davos or T/Ct (87.5% vs. 85%; P = .058). The maximum VAS score was significantly lower in Davos than that in T/Ct (4.18 ± 2.00 vs. 6.30 ± 2.13; P < .001). The effect of analgesia in the maximum VAS score was more evident among Davos patients, with significantly lower pain in the subgroup who were provided analgesia (3.63 ± 2.02 vs. 5.31 ± 2.01; P = .01). Discussion: Davos was as effective as T/Ct for reduction of acute anterior shoulder dislocations (highest reported success rate: 87.5%) and conditioned a less traumatic experience, with significantly lower pain during reduction (the maximum VAS score was more than 2 points lower in the Davos group; P < .001). Analgesia had a synergistic effect among patients submitted to the Davos technique, suggesting that T/Ct is inherently more painful. Conclusion: The Davos is a patient-controlled, atraumatic, and safe technique, allowing successful, gentle, and less painful glenohumeral reduction. These findings favor Davos as an easy-to-teach and effective first-line treatment for first-time and recurrent shoulder dislocations.

Proximal humerus fractures: epidemiology and trends in surgical management of hospital-admitted patients in Portugal.

Background: Proximal humerus fractures (PHFs) are frequent and associated with significant health care burden. National epidemiological data are limited. Our objective is to characterize the Portuguese population admitted with PHFs and analyze therapeutic management, the impact of associated lesions, and mortality rate. Methods: This was a retrospective, observational study of admissions from mainland public hospitals (2000-2015), with primary or secondary diagnosis of PHFs. Incomplete records, pathologic lesions, malunion/nonunion, and hardware removal were excluded. Age, gender, admission date, hospitalization period, associated injuries, treatment, and mortality were recorded. Results: A total of 19,290 patients were included. Through the analyzed period, an increase in the absolute number and incidence of PHFs was observed. The mean age at diagnosis was 62.6 ± 21.0 years old (57% elderly; 63.5% female). The mean length of stay was 10.0 ± 14.1 days, higher in patients submitted to arthroplasty (P < .001) and in those with associated fractures (25%; P < .001). A total of 14,482 patients were operated, most frequently with open reduction and internal fixation (28%). The inpatient mortality rate was 3.2%, significantly higher in patients with associated fractures (odds 2.77 for lower limb vs. upper limb). Conclusion: There is a trend toward an increase in surgical management of PHFs. The relative proportion of open reduction and internal fixation and arthroplasty (particularly reverse arthroplasty) increased, probably reflecting biomechanical implant properties, fracture pattern, and demand for better functionality. Associated fractures are an important comorbidity, associated with increased mortality and length of stay.

A Technique for a More Accurate Acromioclavicular Joint Reduction in Arthroscopic Coracoclavicular Stabilization of Acromioclavicular Joint Dislocation.

Loss of reduction is the most common complication following acromioclavicular dislocations treatment, with literature showing greater postoperative coracoclavicular distances associated with worse clinical results. We present a surgical gesture that aims to help surgeons achieve and secure an anatomic acromioclavicular reduction during coracoclavicular fixation. This technique has the possibility to improve radiological and functional results of acromioclavicular dislocation treatment.

Muscular Cysticercosis: An Incidental Finding in the Developed World.

CASE: We present a case of muscular cysticercosis incidentally diagnosed in a patient admitted for a femoral neck fracture and submitted to total hip arthroplasty. CONCLUSION: Human cysticercosis is a parasitic infection representing a major health concern in developing countries. The clinical features are variable and depend on the anatomic location, cyst burden, cysticerci stage, and host inflammatory response. Diagnosis is commonly incidental, and prompt pattern recognition is key to diagnosis, adequate referral, and treatment. This is one of the first reports of hip arthroplasty in a patient with a history of parasitic infection (without the need for directed pathogen treatment).

Azole-resistant Candida albicans Spondylodiscitis After Bariatric Surgery: A Case Report.

CASE: We present a case of azole and partial caspofungin-resistant Candida albicans spondylodiscitis, after bariatric surgery with bowel perforation. Treatment included debridement and several months of anidulafungin, complemented with antibacterial therapy because of relapse for bacterial superinfection. After treatment, the infection did not recur clinically or radiologically during one and half years follow-up. CONCLUSION: Although C. albicans spondylodiscitis is rare, fungi should be suspected as a causative agent. Adequate history, imaging and laboratory testing, and medical and surgical treatment should be performed to successfully eradicate the infection and resolve potential neurological deficits.

Portuguese Version of the EORTC QLQ-OES18 and QLQ-OG25 for Health-Related Quality of Life Assessment.

INTRODUCTION: Health-related quality of life assessment is increasingly important as it can help both clinical research and care for patients, particularly among oncological patients. Quality of Life Questionnaire - OES18 (esophageal module) and Quality of Life Questionnaire - OG25 (esophagogastric module) are the European Organization for Research and Treatment of Cancer modules for the evaluation of quality of life in patients with esophageal and esophagogastric cancers, respectively. The aim of our study was to translate, to culturally adapt and to perform a pilot testing to create the Portuguese version of both questionnaires. MATERIAL AND METHODS: The European Organization for Research and Treatment of Cancer guidelines were followed for translation, cultural adaptation and pilot testing of Quality of Life Questionnaire - OES18 (esophageal module) and Quality of Life Questionnaire - OG25 (esophagogastric module). The Quality of Life Questionnaire - OG25 (esophagogastric module) went through a process of forward (English → Portuguese) and backward (Portuguese → English) translation, by independent native speaker translators. After review, a preliminary version was created to be pilot tested among Portuguese patients. As a Brazilian version was already available for Quality of Life Questionnaire - OES18 (esophageal module), the questionnaire was simply culturally adapted and pilot tested. Both cancer and non-cancer patients were included. RESULTS: Overall, 30 patients completed the Portuguese version of each questionnaire. Afterwards, a structured interview was conducted to find and report any problematic items. Troublesome items and wording were changed according to the pilot testing results. The final versions were sent to the European Organisation for Research and Treatment of Cancer Quality of Life Group and approved. CONCLUSION: The Portuguese versions of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire - OES18 (esophageal module) and OG25 (esophagogastric module) questionnaires are useful, reliable and valid tools for measuring health-related quality of life in patients with esophageal and esophagogastric cancers, respectively. They can now be used in clinical setting and for scientific purposes.

Introdução: A avaliação da qualidade de vida relacionada com a saúde é cada vez mais importante, já que pode beneficiar a investigação clínica e os cuidados prestados aos doentes, particularmente entre doentes oncológicos. O Quality of Life Questionnaire ­ OES18 (esophageal module) e o Quality of Life Questionnaire ­ OG25 (esophagogastric module) são módulos da Organização Europeia para a Investigação e Tratamento do Cancro para avaliação da qualidade de vida em doentes com neoplasia esofágica e/ou esofagogástrica, respetivamente. O objetivo do nosso estudo foi traduzir, adaptar culturalmente e realizar um ensaio-piloto para criar a versão portuguesa de ambos os questionários. Material e Métodos: Foram seguidas as orientações da Organização Europeia para a Investigação e Tratamento do Cancro para tradução, adaptação cultural e ensaio-piloto do Quality of Life Questionnaire ­ OES18 (esophageal module) e Quality of Life Questionnaire ­ OG25 (esophagogastric module). O Quality of Life Questionnaire ­ OG25 (esophagogastric module) passou por um processo de tradução (inglês → português) e tradução-reversa (português → inglês), por tradutores independentes falantes nativos. Após revisão, uma versão preliminar for criada para ensaio-piloto entre doentes portugueses. Uma vez que já estava disponível uma versão brasileira do Quality of Life Questionnaire ­ OES18 (esophageal module), o questionário foi apenas adaptado culturalmente e alvo de ensaio-piloto. Foram incluídos doentes com e sem neoplasia. Resultados: No total, 30 doentes preencheram a versão portuguesa de cada questionário. No final, foi conduzida uma entrevista estruturada para detetar e documentar quaisquer tópicos problemáticos. Tópicos e enunciados problemáticos foram alterados, conforme os resultados do ensaio-piloto. As versões finais foram enviadas para o grupo de Qualidade de Vida da Organização Europeia para a Investigação e Tratamento do Cancro e foram aprovados. Conclusões: As versões portuguesas dos questionários da Organização Europeia para a Investigação e Tratamento do Cancro Quality of Life Questionnaire ­ OES18 (esophageal module) e OG25 (esophagogastric module) são instrumentos úteis, fidedignos e válidos para aferição da qualidade de vida relacionada com a saúde em doentes com neoplasia esofágica e/ou esofagogástrica, respetivamente. Podem agora ser utilizados em contexto clínico e para fins científicos.