Distribution of nerve endings in human thumb interphalangeal joint.

This study aims to quantitatively analyze the distribution of encapsulated nerve endings in the human thumb interphalangeal (IP) joint capsule. There are three types of nerve endings. Type-I nerve endings (Ruffini-like ending) sense pressure changes, Type II (Pacini-like ending) nerve endings contribute to the kinesthetic sense, and Type III (Golgi-like ending) nerve ending provides proprioceptive information. We dissected five right thumbs IP joints from freshly frozen cadavers (5 men). The mean age of the cadavers at the time of death was 63.4 years (55-73). Sections were stained with the hematoxylin-eosin and antiprotein gene product 9.5 (PGP9.5) to identify encapsulated nerve endings. Transverse sections were cut and divided into volar, dorsal, and then into two equal parts, proximal and distal. The density of encapsulated nerve endings compared to volar versus dorsal and proximal versus distal regions was examined. This study showed that type 1 nerve endings were more common in the distal parts of the IP joint (p < 0.05). Also, type 3 nerve endings were observed in the thumb IP joint. There was no difference between regions in type II and type III nerve endings. The current study demonstrates that the distribution of encapsulated nerve endings in the IP joint is different from the PIP and DIP joints. Moreover, further studies are required to understand the thumb's physiology.

Risk factors, classification, and operative choices of femur fractures at a Tertiary Hospital: first report from Somalia.

A traumatic femur fracture is a significant cause of morbidity, affecting one to three million individuals annually. The present is the first study investigated the epidemiological characteristics, risk factors, classification, mechanisms of injury, and early management of femoral fractures in Somalia. This retrospective epidemiological study included all patients with a femur fracture who were admitted for four years between November 2018 and December 2022 to the orthopedic and trauma surgery department. We reviewed patient demographic characteristics, including age and gender, the mechanism of injury, injury characteristics, and the type of fixation performed. We reviewed the radiographs and classified the fracture using the AO/OTA classification system. During the study period, a total of 402 patients were treated for femur fractures; 256 (64%) were males, and 144 (36%) were females. The mean patient age was 47.7 ± 8.5 years. Regarding the anatomical location of femur fractures, the proximal (31A, 31B) was the most common, accounting for 50% of the patients. Femur neck fracture (31B) was the most common in the proximal femur fractures. Gunshot 82 (59.42%) was the leading cause of femur shaft fractures. Most patients with femur shaft fractures were males; 150 (86.20%) and 152 (64.47%) were young patients between 19 and 40 years old. Almost half of the patients (86) with femur shaft fractures had open fractures. The distribution of the mechanism of injury significantly differed according to age (p < 0.001). Younger patients (< 40 years) were predominantly injured due to gunshot injuries compared to elderly cases (> 60 years), where falls from standing height were the primary mechanism of injuries. There was a statistically significant difference between the mechanism of injury and gender categories (p < 0.001). Male patients were injured mainly by gunshots in about 40%, while 80% of fractures in female patients were due to falls from standing height. Female fractures occurred primarily in the proximal, while the males had an equal fracture rate for proximal and shaft fractures. Femur fracture causes significant morbidity and mortality. The study findings revealed that the most common femur fracture type was femur neck fracture, and low-energy injuries were the most common mode of injury in the elderly. Proximal femur fractures occur in older age and mainly in females. Gunshots were the most common cause of femur shaft fractures in Somalia, a country that has struggled with wars for over 30 years.

Neglected bilateral geno valgum deformity managed with a dynamic compression plate and the ilizarov construct: a case report.

Deformities of the lower limb are common in childhood; however, they are mainly variations of the natural growth pattern. The rare case showed up late with a genu valgum deformity centered on both tibias and a closed physis. Case presentation: A 20-year-old male has suffered from bilateral knee pain and genu valgum deformity centered at both tibias with a closed physis. Management was challenging, requiring multiple surgeries and high patient cooperation. The patient underwent two surgeries: a right-sided osteotomy and Ilizarov fixation with gradual deformity correction. In the second operation, a proximal tibia osteotomy of the left side was executed with acute correction of the deformity and open reduction and internal fixation of the tibia with a medial tibial dynamic compression plate. Ultimately, the authors successfully corrected both leg deformities. Conclusion: This results reflect the efficacy of dynamic compression plates and Ilizarov for correcting genu valgum deformity in patients with closed epiphyseal plates.

Reverse sural flap for anteromedial ankle and dorsal foot soft-tissue defect following an injury: A case report.

Introduction and importance: Foot and ankle soft-tissue defects constitute a real challenge to reconstructive surgeons because of restricted local soft tissue availability. We report a 28 years old male with a significant soft-tissue defect on the left anteromedial ankle and dorsal foot. Case presentation: A 28 years old male with soft-tissue necrosis on the left anteromedial ankle and dorsal foot, as well as second - fourth metatarsal fractures with gangrene of the first - third phalanx, presented to our hospital 14 days after a traffic accident. He underwent debridement and amputation of the gangrenous fingers. In the second operation, a pin fixation of the metatarsal fractures and the reverse sural flap was performed. The donor site was covered with a split-thickness skin graft. The wounds began to improve significantly on the tenth day after the surgery, and his wounds were gone entirely in the third week. The pins were removed eight weeks after the surgery with the fractures healed. Clinical discussion: Skin grafts are easy and quick to cover open wounds but cannot be applied to cover bare tendons or bone. Local flaps of the distal third of the lower extremity have a limited range of motion and arc of rotation. Free flaps are an acceptable but complex reconstructive surgery that requires long operative time, special instruments, and microsurgical training and are expensive. Conclusion: The reverse sural flap was considered feasible in reconstructing patients with soft-tissue defects of the distal leg, ankle, and foot, especially in resource constraint scenarios.

Anterior Tibial Artery and Its Clinical Importance in the Posterolateral Approach to the Tibial Plateau: An Angiographic Study on 219 Lower Limbs.

The anterior tibial artery (ATA) is the most critical anatomical structure at risk at the distal border of the posterolateral approach to the tibial plateau. This study aimed to use available lower extremity digital subtraction angiography (DSA) images to determine the distal safe limit of this approach by measuring the distance from the tibial joint line to the ATA where it pierces the interosseous membrane. Tibial plateau mediolateral width (TP-ML-W) and the perpendicular distances from the ATA to the tibial joint line and fibular head were measured on DSA images in 219 lower extremities. To normalize the distances according to the tibial dimensions, each distance was divided by the TP-ML-W, and a ratio was obtained. Popliteal artery branching pattern was categorized according to the classification proposed by Kim et al. Comparative analysis between right and left extremities, genders, and anatomical variations were performed. There were 102 male and 26 female subjects with a mean age of 60.7 ± 15.7 years (range, 17-92 years). Ninety-one subjects had bilateral lower extremity DSA; thus, a total of 219 extremities were analyzed. The TP-ML-W was wider in male (78.3 ± 7.0) than female (70.5 ± 7.3) subjects (p = 0.001). The ATA coursed through the interosseous membrane at 50.9 ± 6.9 mm (range, 37.4-70.2 mm) distal to the tibial plateau joint line, and it was 66.5 ± 7.2% of the TP-ML-W. The ATA coursed through the interosseous membrane at 36.5 ± 6.0 mm (range, 21.9-53.8 mm) distal to the fibular head, and it was 47.7 ± 6.6% of the TP-ML-W. All measured variables were similar between the regular branching pattern of the popliteal artery (type 1A) and other observed variations among male subjects. The safe length of dissection in the posterolateral approach is average 66.5% (range, 45.7-86.7%) of the TP-ML-W. This ratio is valid for both genders. The use of a ratio instead of a distance, which is subject to personal variations, seems to be more logical and practical for planning this surgery, but the wide range should still not be ignored.

Beneficial effects of levothyroxine replacement therapy on leptin adiponectin ratio in patients with idiopathic primary hypothyroidism.

OBJECTIVE: To assess the metabolic effects of primary hypothyroidism (PHT) on the leptin (LP), adiponectin (ADP) level and leptin adiponectin ratio (LAR), with identification of the beneficial effects of L-thyroxine (LT4) therapy on these parameters. METHODS: This case-control study was conducted at the Department of Pharmacology, College of Medicine, Mustansiriyah University, Baghdad, Iraq, from July to October 2019. This study included 62 PHT patients, of whom 27 were newly diagnosed and 35 were on LT4 therapy. There were 28 healthy controls. Anthropometric, lipid and pressure profiles were evaluated along with estimation of TSH, T3, T4, LP and ADP serum levels. SPSS version 20.00 was used for data analysis. RESULTS: LP serum level did not significantly differ among the three groups (P=0.23), however, ADP serum level was higher in patients with PHT on LT4 therapy (77.48±9.97ng/dL) as compared to the newly diagnosed patients without LT4 (66.21±7.67ng/dL), and controls (71.40±10.72), (P=0.01). Moreover, LAR was higher in non-treated PHT (1.29±0.18) as compared to the controls (1.13±0.14), (95%CI=0.0568 to 0.2632, P=0.001) and treated PHT (1.04±0.16), (95%CI=-0.3480 to -0.1520, P=0.001). On the other hand, no significant difference was detected between healthy controls and treated PHT patients (95%CI=-0.1871 to 0.0071, P=0.07). CONCLUSIONS: PHT is associated with poor cardio-metabolic profile and high LAR. ADP but not LP, mainly affected in patients with PHT. However LAR is better than ADP and LP in reflecting the underlying PHT-induced cardio-metabolic derangements. LT4 replacement therapy improves cardio-metabolic profile, ADP and LP serum levels with significant amelioration of LAR in PHT patients.

Is There a Role of Meniscal Morphology in the Risk of Noncontact Anterior Cruciate Ligament Rupture? A Case-Control Study.

The purpose of this study was to identify the anatomical risk factors and determine the role of meniscal morphology in noncontact anterior cruciate ligament (ACL) rupture. A total of 126 patients (63 with noncontact ACL rupture and 63 age- and sex-matched controls) with intact menisci were included in this retrospective case-control study. On knee magnetic resonance imaging (MRI), meniscal morphometry (anterior, corpus, and posterior heights and widths of each meniscus), tibial slope (medial and lateral separately), notch width index, roof inclination angle, anteromedial bony ridge, tibial eminence area, and Q-angle measurements were assessed. The data were analyzed using multiple regression analyses to identify independent risk factors associated with ACL rupture. Using a univariate analysis, medial and lateral menisci anterior horn heights (p < 0.001; p < 0.003), medial and lateral menisci posterior horn heights (p < 0.001; p < 0.001), lateral meniscus corpus width (p < 0.004), and notch width index (p < 0.001) were significantly higher in the control group. Lateral tibial slope (p < 0.001) and anteromedial bony ridge thickness (p < 0.001) were significantly higher in the ACL rupture group. Multivariate analysis revealed that decreased medial meniscus posterior horn height (odds ratio [OR]: 0.242; p < 0.001), increased lateral meniscus corpus width (OR: 2.118; p < 0.002), increased lateral tibial slope (OR: 1.95; p < 0.001), and decreased notch width index (OR: 0.071; p = 0.046) were independent risk factors for ACL rupture. Notch stenosis, increased lateral tibial slope, decreased medial meniscus posterior horn height, and increased lateral meniscus corpus width are independent anatomical risk factors for ACL rupture. Meniscal morphological variations also play a role in ACL injury. This is a Level III, retrospective case-control study.

Extension pin block technique versus extension orthosis for acute bony mallet finger; a retrospective comparison.

PURPOSE: This study aimed to compare the clinical, radiological, aesthetic and economic outcomes of extension pin block technique and extension orthosis in closed mallet fractures with more than 1/3 of articular surface involvement without subluxation (Wehbe and Schneider classification type IB and IC). MATERIALS AND METHODS: Thirty-nine patients (11 women and 28 men; mean age: 40.9±11.5 years) who had mallet fractures were retrospectively reviewed. Twenty-one patients were treated with the extension pin block technique, and the remaining 18 were treated with the extension orthosis. Fracture classification, measurement of articular surface involvement, presence of subluxation, and the fragment displacement were performed according to the Wehbe and Schneider classification. Crawford's criteria, extension lag, distal interphalangeal joint (DIPJ) range of motion, dorsal bump, and visual analog scale were evaluated. Fracture union, articular incongruity, and all other complications were followed and analyzed. The Michigan Hand Questionnaire (MHQ) was used to evaluate the aesthetic perception of the patient's finger. Direct and indirect costs were calculated for each treatment method. RESULTS: At the final follow-up (mean: 18.4±6.2 months), there was no significant difference with respect to clinical outcomes between groups (p=0.335) and pain (p=0.131). Fracture union was achieved in all cases. Both extension lag (p=0.150) and DIPJ flexion (p=0.261) were not different between groups. Dorsal bump was more frequent in the conservative treatment group (p=0.048). Aesthetic scores were similar between groups (p=0.477), but female patients rated significantly lower aesthetic scores than males (p=0.003) regardless of the treatment method. The direct medical (p=0.001), indirect (p=0.009) and cumulative costs (p=0.001) were significantly higher in surgical treatment group. One pin tract infection, one nail dystrophy, and one joint space narrowing were seen in the surgical treatment group versus none in the conservative treatment group (p=0.698). CONCLUSIONS: Conservative treatment does not result in inferior clinical, radiographic and aesthetic outcomes compared to surgical fixation in closed mallet fractures with more than 1/3 of articular surface involvement without subluxation. Extension orthosis which is non-invasive, and cheap, maybe the treatment of choice in closed mallet fractures. LEVEL OF EVIDENCE: IV; Retrospective cohort.

Is there a safe place for posterior malleolar screw fixation? An anatomic study on dry bones.

OBJECTIVES: This study aims to determine the secure location and angle of the most distal screw during posterior malleolar (PM) fracture fixation. MATERIALS AND METHODS: This prospective study was performed on September 15, 2019. Distal tibial concave articular depth and PM inclination angle were measured on 100 (50 male and 50 female) dry tibia bones using a digital caliper. A comparative analysis between male and female tibias was performed. RESULTS: Anteroposterior width of male tibia (38.3±3.1 mm) was wider than female tibia (35.3±3.2 mm) (p:<0.001). Mediolateral length of the male tibia (44.8±3.5 mm) was longer than female tibia (42.7±3.4 mm) (p:0.003). Male tibial joint (5.4±0.7 mm) was deeper than that of female (4.7±0.3 mm) (p:<0.001). The PM inclination angle was higher in male tibia (18.0±1.5°) than female tibia (15.4±1.3°) (p:<0.001). CONCLUSION: If a screw placement parallel to the joint surface is desired, the screw insertion should be located 6 mm and 5 mm superior to the distal edge of the PM rim in males and females, respectively. If a more distal screw is required, the screw should be inserted in at least 18° and 15° anterosuperior direction for males and females, respectively.

Bioabsorbable magnesium screw versus conventional titanium screw fixation for medial malleolar fractures.

BACKGROUND: It is still unknown whether bioabsorbable magnesium (Mg) screws provide an advantage over titanium screws in the treatment of medial malleolar (MM) fractures. The purpose of this retrospective study is to compare the clinical and radiological outcomes of MM fractures fixed with either bioabsorbable Mg screws or conventional titanium screws. MATERIALS AND METHODS: A cohort of 48 patients with MM fractures who underwent compression screw fixation was retrospectively reviewed. Twenty-three patients (16 male, 7 female; mean age: 37.9 ± 17.7 years) were treated with bioabsorbable Mg screws, and 25 patients (14 male, 11 female; mean age: 45.0 ± 15.7 years) were treated with conventional titanium screw fixation. All patients were followed up for at least 1 year, with a mean time of 24.6 ± 10.5 months (12-53 months). The American Orthopedic Foot and Ankle Society (AOFAS) scale was used to evaluate the clinical results. The Kellgren-Lawrence (KL) osteoarthritis grading was used to evaluate posttraumatic osteoarthritis on final ankle radiographs. Fracture union, rate of implant removal, and complications were recorded. Comparative analysis of two independent groups was performed using the chi-squared test and the Mann-Whitney U-test. RESULTS: The two groups were comparable concerning demographic and clinical characteristics. Age (p = 0.146), sex (p = 0.252), side (p = 0.190), MM fracture type (p = 0.500), associated fractures (p = 0.470), and follow-up period (p = 0.903) were similar between the groups. At final follow-up examination, AOFAS score (p = 0.191) was similar between groups. Fracture union was achieved in all cases. Grade of posttraumatic osteoarthritis, according to KL, was equally distributed in both groups (p = 0.074). No deep infection or osteomyelitis was seen. Five patients in the titanium screw group underwent implant removal, due to pain in three of them and difficulty in wearing shoes in the other two (p = 0.031). Implant removal was performed after a mean of 14.2 ± 3.1 months (12-19 months). CONCLUSIONS: Bioabsorbable Mg and titanium screws had similar therapeutic efficacy in MM fracture fixation regarding functional and radiological outcomes. However, the rate of implant removal was higher with titanium screws. Bioabsorbable Mg screws may be a favorable fixation option since secondary implant removal procedures can be prevented. LEVEL OF EVIDENCE: Level IV, Retrospective case series.

Avulsion fracture of anterior talofibular ligament from talus: A case report.

Anterior talofibular ligament (ATFL) injuries can occur in three different distinct patterns; rupture of the ligament as a pure soft tissue injury, an avulsion fracture at the ATFL's attachment to either the fibula or the talus. Although fibular avulsion fractures are common, avulsion fracture of ATFL from talus is extremely rare with a single previously reported case in the current literature. A 34-year-old female with ATFL talar avulsion fracture associated with medial malleolar fracture was presented to the emergency department. Fixation of the fragment resulted with excellent functional outcome without a residual instability. Besides more common injury patterns such as mid-substance ATFL rupture and ATFL fibular avulsion fracture, talar avulsion fracture pattern should also be kept in mind in a patient presented with lateral ankle sprain. When a fragment is seen on the ankle radiographs at the tip of fibula, previously described special oblique views should be performed to reveal the correct origin of the fragment.

Symptomatic os talus secundarius: a case report and review of the literature.

Os talus secundarius is an extremely rare accessory ossicle located at the lateral aspect of the talus just anterior to the fibula. Although rarely seen, it may cause lateral-sided chronic ankle pain. Only a few cases of symptomatic os talus secundarius have been reported to date. Herein, a 42-year-old male patient with symptomatic os talus secundarius is presented, and its imaging findings, differential diagnosis, and treatment are discussed. LEVEL OF EVIDENCE: Level IV.

Removal of a bent intramedullary nail in lower extremity: report of two cases and review of removal techniques.

Removal of a bent intramedullary nail (IMN) is a rare but challenging orthopedic problem. Several removal techniques have been described up to date; however, there is no extensive review and no algorithm to manage these cases in current literature. The purpose of this paper is to present two cases that presented with bent IMN and provide an algorithm for management of this rare complication.

Acromioclavicular Dislocation Associated with Coracoid Process Fracture: Report of Two Cases and Review of the Literature.

Acromioclavicular dislocation associated with coracoid process fracture is a rare injury. Herein we reported two further cases with such combination of injuries and reviewed all previously published cases in current literature. In this review, we discussed the demographic characteristics, mechanism of injury, diagnosis, and treatment options extensively.