Combination of lumbar erector spinae plane block and transmuscular quadratus lumborum block for surgical anaesthesia in hemiarthroplasty for femoral neck fracture.

Femur neck fractures may occur in elderly patients with multiple co-morbidities. Spinal or general anaesthesia may not be safe in such patients, leading to a search for other safer alternatives. Herein, we report a case in which a never previously reported combination of quadratus lumborum block (QLB) and erector spinae plane block (ESPB) was successfully used as the main anaesthetic method for hemiarthroplasty. An 86-year-old female patient with severe aortic stenosis was scheduled for internal fixation or hemiarthroplasty due to right femoral neck fracture. Following sedoanalgesia, the patient was placed in lateral decubitis position and ESPB and transmuscular QLB were performed from the fourth lumbar vertebra level. Adequate and effective surgical anaesthesia was achieved and hemiarthroplasty was performed. The combination of lumbar ESPB and QLB can be used for the anaesthesia management in high-risk patients undergoing hemiarthroplasty.

Comparison of Ultrasound-Guided Lumbar Erector Spinae Plane Block and Transmuscular Quadratus Lumborum Block for Postoperative Analgesia in Hip and Proximal Femur Surgery: A Prospective Randomized Feasibility Study.

STUDY OBJECTIVE: Lumbar Erector spinae Plane block (L-ESPB) is a modification of a recently described block. Both L-ESPB and Transmuscular Quadratus Lumborum block (QLB-T) have been reported to provide effective postoperative analgesia in hip and proximal femur surgery. Herein, we compare the effectiveness of L-ESPB and QLB-T in providing postoperative analgesia in patients undergoing hip and femur operations. DESIGN: Double-blinded, prospective, randomized, feasibility study. SETTING: Tertiary university hospital, postoperative recovery room and ward. METHODOLOGY: A total of 72 patients (American Society of Anesthesiology physical status classification II-III) were recruited. After exclusion, 60 patients were allocated to three equal groups (control, L-ESB and QLB-t). INTERVENTIONS: Standard multimodal analgesia was performed in the control group while L-ESPB or QLB-T was performed in the block groups. MEASUREMENTS: Pain intensity between groups was compared using Numeric Rating Scores. Furthermore, tramadol consumption and additional rescue analgesic requirement was measured. RESULTS: There was no difference between demographic data or type of surgery. While there was no difference in Numeric Rating Scale (NRS) score at any hour between the block groups; NRS scores at the 1st, 3rd and 6th h, tramadol consumption during the first 12 h and total tramadol consumption, the number of patient required rescue analgesic in 24 h were significantly higher in the control group compared to both block groups. CONCLUSION: While L-ESPB and QLB-T have similar effect, they improve analgesia quality in patients undergoing hip and proximal femoral surgery when compared to standard intravenous analgesia regimen.

Distal humeral coronal plane fractures: management, complications and outcome.

BACKGROUND: Coronal plane fractures of the distal humerus have special characteristics in classification, imaging, surgical approaches, materials used, treatment modalities, and complications. The purpose of this study is to comment on these topics. MATERIALS AND METHODS: A retrospective analysis was done for patients with distal humeral coronal plane fractures. They were classified according to Dubberley and functionally evaluated by Mayo Elbow Performance Index (MEPI). The long-term complications were evaluated. RESULTS: There were 15 patients, with type 1 fractures in 2, type 2 in 6, and type 3 in 7. All patients were treated by open reduction and internal fixation either by lateral or posterior approach. The average MEPI score was 83.3 (range, 60-100) points with 7 excellent, 2 good, and 6 fair results. The MEPI scores of type 3 fractures were significantly lower than those of types 1 and 2 fractures (P = .037 and P = .002, respectively). The complications were avascular necrosis in 4 (27%) patients, degenerative arthritis in 6 (40%), joint step-off in 6 (40%), heterotopic ossification in 7 (47%), nonunion in 1 (7%), and implant failure in 1 (7%). The presence of avascular necrosis and joint step-off were significantly associated with degenerative arthritis (P = .004 and P = .005, respectively). Heterotopic ossification was significantly associated with presence of lateral epicondyle fracture (P = .004). CONCLUSION: Type 1A and 2A coronal plane fractures typically had an excellent outcome. However, type 3 and subtype B fractures are prone to developing complications which are primarily avascular necrosis, degenerative arthritis and heterotopic ossification.

Measurement of lateral plateau depression and lateral plateau widening in a Schatzker type II fracture can predict a lateral meniscal injury.

PURPOSE: The purpose of this study is to determine the plain radiographic signs that can be indicative of meniscal injuries in Schatzker type II tibial plateau fractures. METHODS: The lateral plateau depression and lateral plateau widening were measured on anteroposterior knee radiographs in 20 patients with Schatzker type II tibial plateau fracture. Meniscal injury was present in 12 patients (three, meniscal tears; nine, peripheral meniscal detachments). The lateral plateau depression and lateral plateau widening measurements were compared between those who had meniscal injury (Group 1) and those who did not (Group 2). RESULTS: In Group 1, the median lateral plateau depression was 20 mm (IQR: 14-25) and the median lateral plateau widening was 12 mm (IQR: 10-14). In Group 2, the respective values were 10 mm (IQR: 5-17) and 6 mm (IQR: 2-10). There was a statistically significant difference in both parameters when the two groups were compared (p = 0.001). CONCLUSIONS: A plain anteroposterior radiograph depicting a lateral plateau depression ≥14 mm and/or a lateral plateau widening ≥10 mm is associated with a significantly increased risk of meniscal injury in Schatzker type II tibial plateau fractures. These parameters can be used to predict the probable presence of lateral meniscal injury in such patients in routine clinical practice. LEVEL OF EVIDENCE: Retrospective comparative study, level III.

Snapping scapula syndrome caused by subscapular osteochondroma.

OBJECTIVES: This study aims to evaluate the results of surgical excisions of subscapular exostoses which caused snapping scapula syndrome. PATIENTS AND METHODS: Between September 1980 and January 2010 30 patients with scapular osteochondromas which caused snapping, were treated surgically in our clinic. Fifteen patients (9 males, 6 females; mean age 15.6 years; range 6 to 29 years) in whom we were able to contact following treatment were clinically evaluated. The mean follow-up was 13.7 years (range 1 to 31 years). The initial examination included radiographs and computed tomography. The clinical results were evaluated with a simple shoulder test at their last follow-up. RESULTS: The preoperatively most common complaint was winging of the scapula in all patients (100%), followed by pain in 12 patients (80%), and crepitus with scapulothoracic motion in 10 patients (66.6%). None of the patients had any clue in favor of snapping after surgical treatment. According to the responses to the simple shoulder test, none of the patients had any restriction of motion on their operated shoulders. They didn't give us a history about recurrence of the lesion. CONCLUSION: Excision is an appropriate treatment for osteochondromas. In this retrospective analysis, complete relief following excision of the exostosis was achieved in all patients. No patient had any complaint or recurrence.

Irreducible open posterolateral knee dislocation due to medial meniscus interposition.

Posterolateral knee dislocations are generally irreducible due to the interposition of the medial capsule and retinaculum. These injuries have a 'dimple sign' which shows the invagination of the tissues in the medial joint line. We present an unusual case of an open posterolateral traumatic knee dislocation (KD-4 [ACL/PCL/MCL/LCL-PLC torn] open knee dislocation) without a 'dimple sign'. Closed reduction attempts were unsuccessful. In surgery, it was found that the medial meniscus was detached from the meniscocapsular junction and entrapped in the joint. The medial meniscus was extracted from the joint, and the joint was reduced. The medial meniscus was sutured to the meniscocapsular junction with anchors. This is the first study reporting medial meniscus interposition in an open posterolateral knee dislocation. Moreover, the presented case is peculiar because although it was a posterolateral knee dislocation, the posterolateral ligament complex was also torn.

Medial superior cluneal nerve entrapment neuropathy in military personnel; diagnosis and etiologic factors.

BACKGROUND AND OBJECTIVES: Pain caused by medial superior cluneal nerve entrapment (MSCNE) is an infrequent cause of unilateral low back pain. There is limited information about this neuropathy in the literature. In this study, the etiologic factors leading to this clinical entity were evaluated and also the clinical and imaging findings were examined. MATERIAL AND METHOD: The study was conducted in 3 groups. The study group included 25 patients with MSCNE, the hernia group included 25 patients with herniated nucleosus pulposus and the control group included 25 healthy subjects. The initial evaluation included lumbar computerized tomography (CT) and magnetic resonance imaging (MRI) in the study and the hernia groups. The comparisons between these two groups were made by using clinical assessment questionnaires (SF-36 mental and physical health scores and Oswestry scale). Additionally, all three groups were compared by lumbosacral radiographies and low back superficial ultrasonographies. As treatment, 1 ml of prilocaine combined with 1 ml of steroid injection was used in the study group. RESULTS: In the study group, there was no disc herniation, facet joint problems, spinal stenosis or spondylolisthesis detected by CT or MRI. The SF-36 mental health score before treatment was lower in the study group than in the hernia group. The ultrasonographic examination detected a paravertebral hypoechogenic globular-shaped muscle disorganization associated with lipomatous degeneration exclusively localized to the trigger point in the study group. Both the mean soft tissue and the periiliac band thickness were significantly higher in the study group than in the other two groups. The lumbosacral radiographies did not show any significant difference in either the degree of lumbar spinal lordosis or the intercristal line levels among the three groups. CONCLUSION: This prospective study depicts the etiologic factors, ultrasonographic features and treatment protocol of MSCNE which is usually an underestimated cause of the low-back pain. LEVEL OF EVIDENCE: Diagnostic study, Level I-1 (prospective study).

Ponseti management of clubfoot after walking age.

BACKGROUND: With an incidence of 1-2 per 1000 live births, clubfoot is one of the commonest congenital deformities. Deformity has four components: equinus, hindfoot varus, forefoot adductus, and cavus. The Ponseti method for the treatment of clubfoot has been shown to be effective in children up to one year of age. Even with this effective method, late-presenting cases are still challenging. The aim of this study is to evaluate the corrective effect of the Ponseti method on different components of clubfoot after walking age and to find how the patient's age relates to this correction. METHODS: From 2003 to 2005 we treated 31 feet of 27 patients with clubfoot with a mean age of 21 months (12-72 months) with the Ponseti method. Average follow up was 42 months. All of the patients were evaluated before and after treatment for Dimeglio scores. Patients in the first group, aged less than 20 months, were compared with those in the second group, who were older than 20 months. The corrections for each component of the deformity were analyzed separately. RESULTS: All deformities showed significant correction. Improvements for each separate component were found to be statistically significant. Patients older than 20 months improved less for the components of varus, medial rotation of calcaneopedal block and adductus compared to younger patients. CONCLUSIONS: The Ponseti method is effective in correcting deformities of clubfoot, even after walking age, but affectivity may decrease with age.

Intermediate-term results after uncemented total hip arthroplasty for the treatment of developmental dysplasia of the hip.

OBJECTIVES: We aim to evaluate the restoration of the hip and limb length in patients with osteoarthritis secondary to developmental dysplasia of the hip (DDH) using total hip arthroplasty (THA). PATIENTS AND METHODS: Between February 1996 and September 2001, 65 hips in 55 patients (2 males, 53 females; mean age 48.6 years; range 37 to 60 years) with advanced osteoarthritis secondary to DDH underwent uncemented THA. According to the Hartofilakidis classification, 20, 27, and 18 hips were evaluated types I (dysplasia), II (subluxation), and III (dislocation), respectively. All of the acetabular cups were reconstructed in the original anatomic location. Structural autografts were used in seven hips to supplement the acetabular coverage. We evaluated all patients clinically and radiographically. RESULTS: All of the patients were followed up for 7-12 years. Preoperatively, the Harris score averaged 52.5, 48.41, and 45.28 in types I to III, respectively. At the final follow-up, the Harris score averaged 89.65, 87.44, and 83.28, respectively. The difference between the pre- and postoperative scores was significant (p=0.0001). Preoperatively, 26 patients (47.27%) had slight limps (length difference <1 cm), eight (14.55%) had moderate limps (length difference 1-3 cm), and 21 (38.18%) had severe limps (length difference >3 cm). At their final follow-up, four (7.27%) had severe limps. The limps of all of the patients improved significantly (McNemar's test p=0.0001). We observed aseptic loosening and subsidence in six hips. In seven hips, we used a femoral head autograft for the superior acetabular defect. We performed femoral shortening osteotomies only for two (3.07%) type III hips. CONCLUSION: In addition to the standard procedure, structural bone autografting, medialization of the cup, and placing the acetabular component in the true acetabulum are important factors for successful intermediate-term results.

Irreducible fracture dislocation of the ankle caused by tibialis posterior tendon interposition.

A patient with severe irreducible open fracture dislocation of the ankle was admitted to our emergency department. After wound irrigation and debridement, skeletal traction was applied to the calcaneus to minimize soft tissue injury and swelling. The patient was followed in traction for 1 week, after which reduction and fixation of the fibula was attempted but not achieved. We extended the incision distally, visualized the ankle, and located the tibialis posterior tendon between the distal tibia and fibula, thereby inhibiting the reduction. The tendon coursed into the tibiotalar joint anteriorly and pushed the talus anterolaterally. After manipulation of the tendon to its anatomically correct location, the ankle was easily reduced. The wound at the medial side was closed with a fasciocutaneous rotational flap. The ankle was then immobilized for 6 weeks postoperatively. The patient regained her full range of motion, and there were no problems with the tibialis posterior tendon, such as rupture or insufficiency. Isolated tibialis posterior tendon interposition between the distal tibiofibular and tibiotalar joints has rarely been reported, and can inhibit anatomical reduction of the fractured ankle.