Retrograde Percutaneous Release of Trigger Finger or Thumb Using Sono-Instruments®: Detailed Technique, Pearls, and Pitfalls.

Percutaneous release is a common treatment option for trigger finger stenosing tenosynovitis. While surgical and conservative treatments are available, percutaneous techniques offer several advantages, including faster recovery time, reduced complications, and simultaneous treatment of multiple trigger fingers. The sono-instrument is a minimally invasive device designed for surgical release of the A1 pulley in adults. The device is efficient and safe, and in addition, several design features enhance the visibility of the instrument under ultrasound imaging. The technique is truly percutaneous, as the whole operation is done through a single needle puncture. This minimizes postoperative discomfort and allows an immediate return to daily living and professional activities. The technique can be performed in an outpatient clinic under local anesthesia. The learning curve is quick; however, surgeons must acquire experience in hand sonography to master this new form of surgery. The aim of this article is to provide an in-depth exposition of the technical nuances, pearls, and pitfalls of this novel retrograde percutaneous release method. To our knowledge, this is the first retrograde truly percutaneous release technique yet described, facilitated by the novel Sono-Instruments®.

Chronic Rupture of Pectoralis Major Muscle Repair: A Surgical Case Report.

Introduction: Pectoralis major injury is a rare injury. Its incidence increases with sports related activities. Early diagnosis is essential to obtain a satisfactory functional outcome. We present in this paper a case of 39-year-old male patient presenting with missed chronic the right pectoralis major muscle injury treated with anatomic surgical reinsertion of the muscle tendon to the humerus. Case Report: A 39-year-old male bodybuilder patient felt a snap in his right dominant shoulder while performing bench press. Diagnosis was missed by two physicians and right shoulder MRI confirmed the diagnosis of pectoralis major muscle injury. Reinsertion of the PM muscle tendon using suture anchor was done through deltopectoral approach. Shoulder immobilization for 1 month followed by passive and active range of motion exercises results in satisfactory cosmetic and functional outcome. Conclusion: PM muscle rupture affects mainly young male weightlifters. Loss of the anterior axillary fold is pathognomonic for PM injury. Magnetic resonance imaging of the chest wall is the gold standard examination for the diagnosis. Acute surgical repair (<6 weeks) is recommended to obtain good or excellent cosmetic and functional outcomes. Reconstruction showed lower strength and patient satisfaction; however, results were still significantly better than non-operative treatment reserved for patients with partial tears, muscle belly irreparable damage, and elderly patients with medical comorbidities whom operative treatment is not indicated.

Septic Metallosis after Unicompartmental Knee Replacement: A Case Report and Literature Review.

Introduction: Metallosis following prosthetic hip and knee replacement is a well-known complication. However, unicompartmental knee arthroplasty (UKA) metallosis is rare. In this paper, we report a case of septic metallosis after unicompartmental knee replacement and we review the literature for the available treatment options. Case Report: A 83-year-old female patient presented with left periprosthetic knee infection on the top of unicompartmental knee prosthesis three months after septic endocarditis that was treated with anti-biotherapy. Surgical exploration showed severe infected metallosis due to chronic polyethylene wear reaction; hence, management consisted of total synovectomy and debridement of all metallic debris and two stage revision. Conclusion: Metallosis is a well-known complication after prosthetic hip and knee replacements. However, in UKA, it remains a rare complication where only few cases were reported in the literature.

Intraneural Lipoma: A Rare Cause of Median Nerve Compression.

Intraneural lipomatous tumors are rare lesions that mostly affect the upper extremities. These slowly growing tumors can have a serious neurological and functional impact when they reach a significantly large size. We report herein a case of a 53-year-old female who presented with a large median nerve intraneural lipomatous tumor causing compression-related signs. She was treated with monoblock excision of the tumor that was completely residing between the median nerve fibers. At her last follow-up, no median nerve deficits were recorded, and the patient went to full resolution.

Isolated Trapeziometacarpal Joint Dislocation With Five Years of Follow-up: A Case Report and Review of the Literature.

Isolated trapezio-metacarpal joint dislocation is a rare injury. Despite being simple to reduce, there is not yet a consensus regarding how to secure the reduction, the type of immobilization, and the postoperative protocol. Herein, we present a rare case of pure trapezio-metacarpal joint dislocation without any associated fractures that was treated with closed reduction and intermetacarpal fixation, six weeks of immobilization, and an early rehabilitation protocol.

Acute Osteochondral Fracture of the Metatarsal Head: A Report of Two Cases and Review Of Literature.

Traumatic osteochondral fractures of metatarsal heads are rare injuries and are scarcely reported in the literature. Their classification and modalities of treatment remain unclear. Herein, we report two cases of traumatic fractures of the articular surfaces of the metatarsal heads in two young patients in which two different modalities of surgical treatment were used to achieve anatomic reduction and congruity of the metatarsophalangeal joints. The postoperative period was uneventful, and good functional and radiological outcomes were achieved in both patients. In this report, we review the literature for similar cases and discuss the available treatment options and their associated complications.

Floating-Variant Medial Elbow Dislocation: A New Classification System.

Floating-variant elbow dislocation is a newly updated term used to describe several associations of fractures around the elbow and elbow dislocation that are still not adequately classified due to their rarity. Being extremely rare, only a handful of case reports are found in the literature describing this condition. Most of these papers described cases associated with the posterior or posterolateral direction of elbow dislocation, wherein each author has treated the fracture differently. The decision of surgical treatment, the order of fixation, the material used, and the need for ligamentous repair are all questions that are yet to be answered. We present herein a unique new variant of floating medial elbow dislocation in a 13-year-old female that was successfully treated by closed reduction of the elbow, open reduction of the distal humerus fracture, and orthopedic treatment of the radial shaft fracture.

Minimally Invasive Osteosynthesis of Intraarticular Calcaneus Fracture Augmented by Femoral Head Allograft: A Retrospective Study.

AIM: The aim of this retrospective study is to report the results of minimally invasive osteosynthesis when used for the treatment of intraarticular calcaneus fracture. This old technique is regaining popularity recently with the multiple advances added by different institutes when it is used in the management of intraarticular calcaneus fracture. METHODS: Twenty-four patients who suffered from intraarticular calcaneus fractures between 2014 and 2019 were included. Twelve of them had Sanders II fractures (group A) and 12 had Sanders III + IV fractures (group B). The mean follow-up duration was 37.5 months. The mean age at presentation was 54.23 ± 12.48 years. The skin condition at presentation was poor (blood-filled blisters) in 25% of patients equally distributed between the two groups. The mean time to surgery was 5.6 days where patients with poor skin conditions were treated lately. The technique involved percutaneous ascending proximal-to-distal pinning of the calcaneus after reduction using a 2 cm mini-incision below the lateral malleolus and augmenting the fixation with femoral head cancellous allograft. The primary outcomes variables analyzed in this study are post-operative Bohler angle, post-operative Gissane angle, American Orthopedic Foot and Ankle Society (AOFAS) ankle/hindfoot score at long-term follow-up (Excellent>95, Good 75-94, Fair 51-74, poor 0-50), and the delta angle benefit score. The secondary outcomes included post-operative complications such as infection and osteoarthritis. RESULTS: The radiological results showed significant improvement of Bohler angle from 6.09° ± 21.6 pre-operatively, to 31.79° ± 14.1 postoperatively with a p-value <0.001. An adequate reduction was achieved in 54.16% to 70.8% of patients. There is a trend to normalization of overcorrected fracture especially Sanders II with a mean reduction of 12,71° ± 11,88 at one year post-operatively (p=0.05). AOFAS score at the last follow-up shows 20.83% poor results (AOFAS<50), 50% fair results (AOFAS between 51-74), 16.67% good results (AOFAS 75-94), and 12.5% excellent results (AOFAS>95. The satisfaction rate was 83.3% (45.8% partially satisfied, and 37.5% fully satisfied). The incidence of superficial infection (wound inflammation and pin tract infection) was more prevalent in higher group B (40%) compared to group A (0%) with p=0.014. Other complications including osteoarthritis and varus deformity were found in 95.8% and 58.3% of patients respectively at three-year follow-up. CONCLUSION: The combination of minimally invasive osteosynthesis and femoral head allograft for the treatment of intraarticular calcaneus fractures seems to give fair to good functional results. Radiological data demonstrated that when the Bohler angle is over-reduced >40°, there was a tendency to autocorrection over time. This may be due to progressive depression of the angle over time as weight bearing is authorized; however, this must be analyzed carefully due to the low number of patients who were overreduced (seven patients). Our study demonstrates that this technique has a low early complication rate (especially low infection and soft tissue problems) but carries high long-term complications such as osteoarthritis and hindfoot varus.

An Uncommon Finding of Posterior Cruciate Ligament Intrasubstance Cyst: A Case Report and Review of Literature.

Introduction: Ganglion cyst of the cruciate ligaments is a rare entity. These cysts are usually found as incidental finding during knee arthroscopy, even though they can be the cause of knee discomfort or dull pain without a clear etiology. Case Presentation: We present herein a case of 35-year-old male who presented with unexplained dull knee pain. Magnetic resonance imaging (MRI) was performed and it showed a cystic-like lesion measuring 14 mm localized within the fibers of the posterior cruciate ligament (PCL) with no other significant pathology identified. A diagnosis of symptomatic PCL intrasubstance cyst was made. Patients were treated by arthroscopic debridement with good long-term outcomes. Conclusion: Ganglion cysts of the PCL are uncommon and especially if they were localized within the PCL fibers. MRI studies are inevitable to make the diagnosis, and arthroscopic debridement remains a reasonable surgical option with low recurrence rate.

Management of Chronic Transtibial Articulocutaneous Fistula After All-Inside ACL Reconstruction: A Case Report.

CASE: A 29-year-old man presented 2 years after anterior cruciate ligament (ACL) reconstruction by autologous semitendinosus graft and suspensory fixation on both tibial and femoral sides for chronic drainage of clear fluid from an anteromedial wound at the site of the tibial tunnel with a visible sinus tract. Magnetic resonance imaging showed a transtibial articulocutaneous fistula. The patient was treated by tunnel debridement, impaction bone grafting, bioresorbable interference screw, and cement to fully seal the tunnel. The surgery was successful with good clinical outcomes for recurrence and knee stability. CONCLUSION: Communicating transtibial articulocutaneous fistulas are rare complications after ACL reconstruction. Tunnel debridement and filling with graft material affected by an interference screw seem to be an effective method for dealing with such a clinical scenario.

Belt and suspender technique for bipolar bone loss in shoulder instability.

Bipolar glenohumeral bone loss is a challenging condition to address in patients with recurrent anterior shoulder instability. In this category of patients, most isolated soft-tissue procedures such as remplissage or infraspinatus capsulotenodesis are associated with high risk of failure and instability recurrence. Even bony procedures such as Latarjet may fail to provide absolute stability, and instability may eventually recur. For a better understanding of the cause of failure in this particular type of patient, we may refer to the glenoid track concept which has been described as a useful tool for surgical planning. In fact, Latarjet procedure alone may leave a place for engagement of the Hill-Sachs defect on the anterior glenoid resulting in an off-track situation and secondary glenohumeral instability. In this technical note, we present the combination of arthroscopic remplissage and an open Latarjet procedure to treat patients with bipolar glenohumeral bone loss with good results at 31-month follow-up. Our aim is to propose these techniques as a possible rescue procedure for highly unstable shoulders combining engaged Hill-Sachs lesion and glenoid bone loss of more than 25%. We believe this technique would be a good option for patients who present other risk factors of recurrence such as past medical history of epilepsy, laxity, and psychiatric illnesses.

Osteoid Osteoma of the Distal Phalanx: A Rare Condition.

Osteoid osteoma of the distal phalanges in the hand is rare and difficult to diagnose. We report a case of a 37-year-old Caucasian female patient who presented with a mass on the distal phalanx of the index finger. The patient was suffering from intermittent nocturnal pain for more than 18 months along with thickening, localized swelling, and clubbing of the distal phalanx of the right index finger. Radiographs revealed a lytic lesion of the distal phalanx of the right index finger with surrounding sclerosis. An MRI showed an intramedullary lesion with infiltration of the bone marrow, cortex, and surrounding tissue with focal sclerosis and elements of enhancements. A presumptive diagnosis of osteoid osteoma was made and surgical removal of the lesion by curettage and bone grafting was the treatment of choice. The curetted specimen was sent to pathology and the diagnosis of osteoid osteoma was confirmed. The patient was asymptomatic at six months postoperatively. Osteoid osteoma should be included in every differential diagnosis for patients presenting with atypical features of the distal phalanx of the hand.

Post-traumatic Late Presentation of Morel-Lavallée: Case Report and Review of Literature.

INTRODUCTION: Morel-Lavallée (MLL) is an uncommon entity that is missed by many physicians, it is the result of a shearing force that leads to degloving of the subcutaneous fat from the underlying deep fascia. CASE REPORT: We present a case of a 15-year-old male patient who presented 3 months after the initial crush injury with a large MLL lesion at the lateral aspect of the right proximal thigh. He was treated with incision and drainage with compressive dressing and a negative pressure drain. CONCLUSION: Diagnosis of MLL is usually clinical and can be aided with radiological tools like MRI that is the gold standard of imaging in this lesion. Several treatment options are available, ranging from conservative treatment with compressive bandages to percutaneous drainage, injection of sclerotic agents, and surgical treatment with incision, drainage, and debridement. Diagnosis and treatment should be familiar to all caregivers to prevent further complications that could be life or organ-threatening.

Breakage of sliding hip screw after fixation of pertrochanteric hip fracture: A rare complication.

INTRODUCTION: The authors report a rare case of lag screw breakage in a patient treated using locking DHS with home-made trochanteric stabilizing plate (TSP) for pertrochanteric hip fracture. CASE PRESENTATION: A 67 year-old female was operated for pertrochanteric hip fracture with incompetent lateral wall using locking DHS with home-made TSP. At seven months postoperative, there was radiographic nonunion with breakage of the sliding lag screw. Patient was consequently scheduled for total hip replacement. DISCUSSION: Breakage of DHS lag screw has been attributed to multiple-cycle, low-stress fatigue failure associated with nonunion. Predisposing factors are: situation of the medial edge of the barrel at the level of the fracture site prohibiting fracture compression, and mechanical obstacle to the lag screw back sliding into the barrel. In our case, the use of handmade TSP interdicted lag screw back sliding and prevented fracture impaction which was already impaired by the location of the medial edge of the barrel at the fracture level. Additionally our fixation construct was very rigid because of the use of locking screws in the DHS side plate. CONCLUSION: When DHS fixation is planned for unstable or potentially unstable trochanteric hip fracture the surgeon should be prepared by making available a TSP from the manufacturer in the operative room rather than improvising intra-operatively with handmade TSP; this augmentation device shouldn't interfere with lag screw back sliding. Furthermore the DHS barrel should ideally not impinge with the fracture site, and the use of locking screws in the DHS plate should be cautious.

Osteoid Osteoma of the Scapular Neck: A Cause of Long-lasting Unexplained Pain.

INTRODUCTION: Osteoid osteoma (OO) is a common tumor of the diaphysis of long bone, where the reported incidence is up 10% of all benign bone tumors. Its presence in flat bone is seldom mentioned in literature and can be misleading when the bone involved is in proximity to a zone of wide variety of possible pathology. We report a case of a young patient with OO in a very rare location of the body -the scapular neck - that was misdiagnosed for a long period of time before receiving adequate therapy. CASE REPORT: A 20-year-old female patient presented to the clinic with chronic left shoulder pain. During the past 2 years, she received medical and physical therapy, to deal with different diagnosis such as cervical spine pathology, muscular spasm, and rotator cuff disease. However, she did not improve. At time of presentation to our clinic, radiographs of the shoulder were done and turned to be inconclusively normal. After negative magnetic resonance imaging of the cervical spine, a computed tomography scan of the shoulder was done and showed a round well-defined lesion localized in the scapular neck with a focal lucent nidus within surrounding sclerotic reactive bone measuring 8.5 mm in largest diameter, compatible with OO. Bone scan showed increased uptake. The patient was given aspirin in an intention to test and treat. The patient had dramatic pain relieve at first, which confirmed the diagnosis of OO. But then, pain became unremitting, so a decision was made for radiofrequency ablation of the lesion which gave excellent results. CONCLUSION: OO is a common benign neoplasm with high variable clinical picture and anatomic localization. Despite being more common in long bone, flat bone OO localization should be always kept in mind. Careful history and physical examination should be done for each patient presenting with unexplained pain; night pain should always raise suspicion of this condition. Radiographs are not always conclusive, and the patient with high suspicion of this condition should undergo more investigation to make the diagnosis.

Prevalence and Predictors of Vitamin D Inadequacy: A Sample of 2,547 Patients in a Mediterranean Country.

Background The aim of this retrospective study was to identify prevalence and risk factors for vitamin D inadequacy in a sunny Mediterranean country. Methods Results of 2,547 patients aged 19 to >60 years were included in this study. Data were derived from the laboratory database at Rafik Hariri University Hospital, Beirut, Lebanon, over a period of two years (2016-2017). Data included patient's age, gender, date of test, and vitamin D level. Females were questioned through phone call for marital status, parity, and veiling. Results The prevalence of vitamin D inadequacy was 83.5% overall, 86.4% in males, and 82.3% in females. At a cut-off of 20 ng/mL, vitamin D deficiency affected 63% of the studied population. A significant association was observed between vitamin D and age. The highest prevalence (71.2%) was found in females in the age group of 19-39 years, while no significant correlation with age was observed in males. Vitamin D levels were lower in veiled women (mean 25(OH)D = 17.9 ng/mL) compared to non-veiled women, although this difference was not significant. In addition, vitamin D inadequacy does not show a significant association with gender, parity, marital status, and season of the year. Conclusion The high prevalence of vitamin D inadequacy in our study in both males and females of all age groups calls for urgent actions at the national level to increase awareness in the population and to prevent the serious complications of vitamin D deficiency in all patients, especially those who are at a high risk.

Calcaneal fracture with a concomitant unstable subtalar dislocation: A case report.

BACKGROUND: Traumatic dislocation of the subtalar joint is an infrequently occurring injury, first described by DuFaurest in 1811. They were later on classified by Broca as medial, lateral, posterior and anterior dislocations based on the direction of the dislocation. CASE REPORT: We present a case of a 30 year old male who presented after a 5 m height fall and direct right foot trauma. Investigations done in the emergency department revealed a right subtalar lateral dislocation with associated calcaneal intraarticular displaced fracture. Open reduction internal fixation of the calcaneal fracture was decided alongside with reduction of the subtalar joint. Intraoperatively the subtalar reduction was totally unstable due to the deficiency of the lateral collateral ligament. A decision of reconstruction of the calcaneofibular ligament using a synthetic ligament was taken. This reconstruction resulted in an adequate intraoperative stability of the subtalar joint. On a 2 year follow up the patient was asymptomatic with no residual subtalar instability. DISCUSSION: These injuries must be suspected after high energy trauma or twisting forces in the foot. They occur more frequently in men than in women and predominately affect people in their mid-30 s. Our case is unique in that the reconstruction of the calcaneofibular ligament was done using a synthetic graft to stabilize an acute unstable subtalar joint dislocation. CONCLUSION: Subtalar dislocation is a rare injury with post reduction instability being even rarer. Care has to be taken not to overlook the frequently associated bony injuries, due to their impact on treatment decision and prognosis.

The adjunct use of lateral hinged external fixator in the treatment of traumatic destabilizing elbow injuries.

PURPOSE: The purpose of this study is to evaluate the results of using a lateral hinged external fixator as an adjunct stabilizer in the treatment of a variety of acute destabilizing elbow injuries. METHODS: A retrospective review was performed on the medical records of patients in whom a lateral monolateral elbow hinged external fixator was applied by the senior author. The indication to apply the fixator corresponded to a variety of acute injury patterns ranging from simple elbow trauma or dislocation to complex fracture-dislocation, and the decision was based on either the presence of recurrent or persistent instability in any direction and/or to secure a vulnerable or weak bony fixation or soft tissue repair as intra-operatively judged by the surgeon. The fixator was inserted in the same setting after the repair of the associated ligamentous and/or bony structures. Patients operated after one month of the trauma and those presented with open elbow injury or associated humeral or ulnar shaft fracture were excluded. Rehabilitation was immediately started and the fixator removed at six to eight weeks with elbow testing and gentle manipulation under general anaesthesia, and resuming of rehabilitation after removal. Clinical assessment was performed for all patients according to the Mayo Elbow Performance Score (MEPS) with evaluation of range of motion at regular intervals till the end of the post-operative first year, then at final follow-up for the purpose of the study with radiographic assessment for evaluation of elbow reduction and concentricity. RESULTS: There were 13 patients with a mean age of 42 years. Two patients had instability secondary to LCL rupture; one patient had redislocation because of associated coronoid process fracture; one patient had radial head fracture with rupture of both collateral ligaments; five patients had terrible triad injury with variable association of collateral ligaments lesions; and four patients had posterior Monteggia fracture-dislocation. The mean MEPS was 90 at a mean follow-up of seven years with six excellent, six good, and one fair result. All patients had a concentrically reduced and stable elbow as assessed clinically and radiologically with a mean functional arc of motion of 132° for extension-flexion and 178° for pronation-supination. CONCLUSION: The hinged elbow external fixator represents a valuable adjunct in the therapeutic arsenal for the treatment of unstable elbows after bony and soft tissue repair. It provides satisfactory results in terms of stability and function and should be available in the operating room when a surgeon treats a complex elbow dislocation or fracture-dislocation.

Marjolin's ulcer of the forearm from 30-year-neglection of external fixator.

BACKGROUND: Marjolin's ulcers are a rare form of malignancy that present at regions exposed to chronic infection. They present with a clinical triad of nodularity, induration, and ulceration greater than 3 months. CASE REPORT: We present herein, an extremely rare case of Marjolin's ulcer of the forearm, secondary to osteomyelitis, resulting from a 30-year neglection of external fixator used to treat a war injury of the forearm. DISCUSSION: Marjolin's ulcers are classically encountered in lower extremities at sites of burns, trauma or complicated wounds. In the upper extremity however, they are seldom mentioned in literature. The presence of risk factors raise the suspicion of the disease. CONCLUSION: Marjolin's ulcer is rare sequelae of chronic wound infection. Patients often present after a latency period with exacerbated pain, discharge, and exophytic mass. This disease should be suspected in every case of chronic ulcer, where histological studies of the lesion must be conducted to exclude or confirm the diagnosis.