Delayed Presentation of Non-traumatic Bilateral Leg Pseudoaneurysms Mimicking Soft-Tissue Sarcoma - A Case Report.

Introduction: Non-traumatic pseudoaneurysms are very rare but should be considered as a differential diagnosis on patients presenting with a thigh mass. Case Report: We present an extremely unusual case of a 70-year-old patient who presented with clinical features of a soft-tissue sarcoma of the thigh that instead was proven to be a non-traumatic pseudoaneurysm. There was also incidental finding of bilateral leg non-traumatic pseudoaneurysms. Conclusion: Medical practitioners must consider the possibility of non-traumatic pseudoaneurysm in patients that present with a thigh mass.

Leiomyosarcoma of the Lower Limb Presenting as a Benign Mass: A Case Report.

INTRODUCTION: Soft tissue sarcomas are rare tumors that often present with pain, increasing size and a location deep to the fascia. If they do not present with the aforementioned symptoms and signs, delayed diagnosis can occur. CASE REPORT: We present an unusual case of a 51-year-old patient who presented with clinical features of a benign mass of the lower limb that turned out to be a soft tissue sarcoma - a leiomyosarcoma. CONCLUSION: Medical practitioners must consider the possibility of soft tissue sarcoma in patients that present with a benign looking mass. Diagnostic imaging can be inconclusive on these cases and definite diagnosis is made on histological examination. Treatment includes surgery and radiotherapy.

Management of proximal humerus fractures in adults.

The majority of proximal humerus fractures are low-energy osteoporotic injuries in the elderly and their incidence is increasing in the light of an ageing population. The diversity of fracture patterns encountered renders objective classification of prognostic value challenging. Non-operative management has been associated with good functional outcomes in stable, minimally displaced and certain types of displaced fractures. Absolute indications for surgery are infrequent and comprise compound, pathological, multi-fragmentary head-splitting fractures and fracture dislocations, as well as those associated with neurovascular injury. A constantly expanding range of reconstructive and replacement options however has been extending the indications for surgical management of complex proximal humerus fractures. As a result, management decisions are becoming increasingly complicated, in an attempt to provide the best possible treatment for each individual patient, that will successfully address their specific fracture configuration, comorbidities and functional expectations. Our aim was to review the management options available for the full range of proximal humerus fractures in adults, along with their specific advantages, disadvantages and outcomes.

High failure rate of the R3 metal-on-metal total hip arthroplasty.

We report our failures with the use of the R3 metal-on-metal bearing. Forty six patients had an R3 acetabular system metal-on-metal THR in our centre between March 2007 and March 2009. All operations were performed using femoral components and appropriately matched femoral heads manufactured by Smith and Nephew. Twelve patients underwent revision surgery for adverse reaction to metal debris (ARMD). The median acetabular inclination was 40 degrees (range 21.1-49.1) and the median acetabular anteversion was 7.5 degrees (range 3.3-10.4). The median serum Cobalt was 9.9 µg/L (range 3.1-45) and the median serum Chromium was 5.8 µg/L (range 1.8-19.3). The time to revision was 39.2 months (range 13-53). Our current failure rate is 24%.

Manipulation for stiffness following total knee arthroplasty: when and how often to do it?

Stiffness following total knee arthroplasty is a disabling complication. One of the management options of stiffness includes manipulation under anaesthesia, but no real consensus exist on appropriate timing of intervention, and the timing and results of the manipulation under anaesthesia (MUA) are under debate in the literature. Our aim was to determine the efficacy of single and multiple manipulations under anaesthesia following total knee arthroplasty and to determine the most appropriate timing for manipulation. We retrospectively reviewed 86 patients who underwent manipulation for stiffness following primary total knee replacement with at least 1-year follow-up. Range of motion before surgery, at the time of the MUA, immediately after MUA and at 6 weeks and 1 year post-MUA were recorded. At the end of 1 year post-manipulation, manipulations performed at less than 20 weeks, following primary total knee arthroplasty, showed 31° of flexion gain as compared to only 1.5° of flexion gain when manipulation was undertaken after 20 weeks. Of the 86 patients, 21 had multiple manipulations with no significant difference in flexion gain after the second manipulation. Patients on warfarin (26%) had an increased incidence of stiffness and poor flexion gain. This study showed that better results were achieved when manipulation was performed at less than 20 weeks (particularly between 12 and 14 weeks) from primary surgery with no added benefit from re-manipulations.

Leg length discrepancy after total hip arthroplasty: a review of literature.

Discrepancy of leg length is often considered to be a problem after total hip replacement and can adversely affect an otherwise excellent outcome. Furthermore, it has been associated with patient dissatisfaction and remains one of the most common reasons for litigation against the orthopedic community. As a consequence of the need to equalize leg length, several authors have sought to validate methods of minimizing limb length discrepancy based on preoperative planning with preoperative radiological templates or intraoperative methods of measurement. In this article, we present a review of the limb length discrepancy in total hip arthroplasty, its implications and several techniques to avoid it. We recommend that a combination of the above mentioned methods will give the best chance for the surgeon to minimise the risk of leg length discrepancy following total hip replacement.

Acetabular revision surgery with the uncemented oblong BOFOR Cup--early to midterm results.

INTRODUCTION: Failure of acetabular components frequently leads to bone loss with extensive elongated defects in the surrounding bone. In these cases the use of an oblong cup has been described as an option for acetabular reconstruction. We report the longest follow up results obtained with this implant to date. MATERIALS AND METHODS: A prospective study was conducted to evaluate the results of the BOFOR oblong revision cup. Between 2001 and 2006, 15 acetabular revisions were performed for aseptic loosening of the acetabular cup. The acetabular defects were classified as type 2A to 3A, according to Paprosky's criteria. No allografts were used in any of the cases. The mean follow-up was 90 months (range 60-120 months). RESULTS: Clinical assessment at follow-up showed a significantly improved mean Harris Hip Score from 39 points preoperatively to 84 points postoperatively and a mean Oxford Hip Score from 55 points preoperatively to 22 points postoperatively. Only one case underwent re-revision due to aseptic loosening in a patient with severe ankylosing spondylitis. There were no cases of dislocation or infection. One patient had a sciatic nerve neurapraxia. After an average follow up of 7.5 years, 93% of the investigated implants remained in-situ without further revision. CONCLUSION: This study shows that the BOFOR cup provided good clinical results and showed satisfactory stability at early to midterm follow-up.

Critical review of the current practice for computer-assisted navigation in total knee replacement surgery: cost-effectiveness and clinical outcome.

In this article, we present a review of the current practice regarding computer-assisted navigation in total knee replacement together with the bearing on cost-effectiveness and clinical outcome.

Stewart-Treves syndrome and the use of positron emission tomographic scanning.

In this article, we provide an account of two rare cases of Stewart-Treves syndrome, that is, cutaneous angiosarcoma secondary to lymphedema, treated at our center. Unusually, both occurred in the lower extremity. The first case was treated initially with a wide local excision, followed by a further re-excision, and eventually an above-the-knee amputation because of recurrence. In the second case, a hindquarter amputation was undertaken after a positron emission tomographic scan, which revealed the extent and spread of the lesions. In cases of cutaneous angiosarcoma, a positron emission tomographic scan can be extremely helpful in demonstrating the extent of subcutaneous spread and planning surgical management.

A simple technique to position patients with bilateral above-knee amputations for operative fixation of intertrochanteric fractures of the femur: a case report.

INTRODUCTION: Intertrochanteric fractures of the femur are common fractures in the elderly, and management includes operative fixation after patient positioning on the fracture table. Patients with bilateral above-knee amputations are challenging in terms of positioning on the table. We describe a simple technique to overcome this special problem. CASE PRESENTATION: A 75-year-old wheelchair-bound Caucasian man with bilateral above-knee amputations presented to our hospital after a fall. Plain radiographs showed an intertrochanteric fracture of the femur, and operative fixation with a dynamic hip screw was planned. His positioning on the table posed a particular problem, and therefore we developed a technique to overcome this problem. CONCLUSION: Positioning of patients for fixation of intertrochanteric fractures of the femur poses a particular problem that can be solved by using our simple technique.

Critical appraisal of subjective outcome measures used in the assessment of shoulder disability.

INTRODUCTION: Objective measures can be impractical in some settings, because they are time consuming and require face-to-face contact. More recently, there is an increasing trend towards the use of subjective outcome measures. Hence, in this article, five common subjective shoulder outcome measures are critically appraised in terms of their development, validity, reliability, responsiveness and clinical application. MATERIALS AND METHODS: Following an extensive literature search, five common shoulder patient-based scores were identified: Disability of Arm, Shoulder and Hand (DASH), Oxford Shoulder Score (OSS), Shoulder Disability Questionnaire (SDQ-UK), Shoulder Pain and Disability Index (SPADI), and the Shoulder Rating Questionnaire (SRQ). These questionnaires were then critically appraised in terms of their development process, validity, reliability, responsiveness, and clinical application. RESULTS: The SDQ-UK has shown good construct validity but there is no data available regarding internal consistency, reliability and responsiveness. The SPADI has good internal consistency, fair reliability with adequate criterion and construct validity. The DASH has shown to have good construct validity, excellent test-re-test reliability and responsiveness to change. The OSS has good sensitivity, validity and responsiveness. Though SRQ has good internal consistency, its reproducibility and responsiveness are poor. CONCLUSIONS: Based on this critical appraisal, the DASH received the best ratings for its clinimetric properties followed by the OSS.

Discharging pin sites following K-wire fixation of distal radial fractures: a case for pin removal?

The aim of this study was to find out whether discharging pin sites following Kirschner-wire fixation of distal radial fractures warrant early wire removal. In a prospective study of 50 patients with a closed distal radial fracture treated by manipulation and either percutaneous or mini-incision Kirschner-wiring, we identified 14 patients (28%) with discharging pin sites. All of the cases were observed within the first two weeks following surgery. Of the 14 cases, only 2 patients had a positive swab culture and were treated with systemic antibiotics. In all cases the Kirschner wires were left in situ until serial radiographs demonstrated satisfactory union. Three patients (8.6%) in the percutaneous group had superficial radial nerve irritation, which settled following wire removal. Deep soft tissue infection, pyoarthrosis, osteomyelitis, and extensor tendon rupture were not encountered. We conclude that pin site discharge, whether sterile or infected, is in general not an indication for early wire removal.

Cemented total hip arthroplasty in a patient with alpha-mannosidosis: a case report.

Mannosidosis is an extremely rare genetic disease occurring due to deficiency of the lysosomal enzyme, alpha-mannosidase. Patients with this disorder often suffer from musculoskeletal abnormalities and muscular weakness leading to joint destruction and severe morbidity along with other major systems involvement. We present here such a case of a 27-year-old male that highlights the challenges in management of hip joint destruction secondary to Mannosidosis.

Periprosthetic osteolysis due to metastatic renal cell carcinoma: a case report.

Failure of total hip arthroplasty through septic or aseptic loosening, periprosthetic fracture, or recurrent dislocation is well recognized and understood. We present an unusual cause of failure of total hip replacement which occurred on a 79 year old gentleman: that of prosthetic loosening secondary to malignant infiltration around components. Our aim is to highlight the fact that malignant infiltration should be considered as part of the differential diagnosis in aseptic and septic loosening of prosthetic implants.

Autologous blood transfusion after primary unilateral total knee replacement surgery.

A prospective study was undertaken to assess the efficacy and financial cost of the use of an autologous blood transfusion device in the reduction of allogeneic blood requirements of patients undergoing primary unilateral total knee arthroplasty. Forty-nine consecutive patients received either the CellTrans blood salvage device (group A of 32 patients) or the Redivac high vacuum drainage system (group B of 17 patients). The preoperative and postoperative haemoglobin levels were recorded at 72 or 96 hours. Nine percent of group A patients received an allogeneic blood transfusion compared to 59% in group B. There was an average saving of 1.1 unit of allogeneic blood per patient in group A (p<0.001). The total cost per patient was about Euro 111 less for the group A patients. Autologous re-infusion was found in this study to be an effective method of reducing allogeneic blood requirements and to afford significant cost savings in primary unilateral knee arthroplasty.

Angioleiomyoma: a rare cause of fixed flexion contracture of the elbow.

We describe an unusual case of a patient presented with a painless fixed flexion contracture of the elbow due to an angioleiomyoma. This benign smooth muscle tumour should be considered in the differential diagnosis of flexion contractures of the elbow.

Suprascapular neuropathy in volleyball players.

Entrapment neuropathy of the suprascapular nerve (SNE), although a recognised clinical entity, is a relatively rare cause of shoulder pain and subjective weakness in the athlete involved in overhead sports like volleyball and badminton. This study deals with the presentation and management of four unusual cases of suprascapular nerve entrapment in volleyball players. Four male volleyball players presented to our department with intractable shoulder pain and subjective sensation of shoulder weakness. They all had visible wasting of both supraspinatus and infraspinatus muscles, together with weakness of abduction and external rotation of the arm. They all responded temporarily to a diagnostic injection of local anaesthetic. MR imaging was useful in diagnosing space occupying lesions in three cases and the presence of a hypertrophic suprascapular ligament in one case. Due to failure of non- operative treatment, which included activity modification, rest, analgesics and rehabilitation programme over 6 months, surgery was then required to decompress the suprascapular nerve. All patients were symptom free at 6 months postoperatively and after an intensive rehabilitation programme, they were able to return to their normal level of activity including sport.