One portal simultaneous bilateral endoscopic carpal tunnel release under local anaesthesia. Do the results justify the effort?

PURPOSE: The purpose of this study was to evaluate whether simultaneous bilateral endoscopic carpal tunnel release could be effectively and safely performed under local anaesthesia. METHODS: We prospectively evaluated 85 consecutive patients (62 females) who underwent simultaneous one portal endoscopic bilateral carpal tunnel release with subcutaneous injection of 2 mL 2 % lidocaine. In case of pain after discharge, all patients were advised to take paracetamol (i.e., acetaminophen) and to record the dose of drug taken. Patients were reviewed at regular intervals until one year postoperatively. RESULTS: The mean operative time was 31.2 min. Postoperatively, only nine patients (10.6 %) received on average 611 mg of paracetamol. Significant improvement was noticed in the parameters of numbness, pain, positive Phalen and Tinel tests, pinch strength, grip strength, tip pinch strength and Quick DASH Score. Patients returned fully to work after surgery in average 2.2 weeks. Conversion to open release took place in four wrists (2.4 %). Discomfort and pain from tourniquet pressure was reported from two patients (2.4 %). Two wrists (1.2 %) required revision surgery. One patient (1.2 %) reported temporary thenar numbness and another (1.2 %) had slight scar hypersensitivity. CONCLUSIONS: Simultaneous bilateral endoscopic carpal tunnel release under local anaesthesia is well tolerated by patients. The technique may be of benefit in young, active, high-demand patients who require fast recovery, early return to work and less disability time.

Trapeziometacarpal External Fixation under Local Anesthesia for the Treatment of Comminuted Intra-Articular Thumb Metacarpal Fractures: Evaluation of Clinical Results and Long-Term Patient Satisfaction.

Background A variety of internal and external fixation techniques have been described for the treatment of Rolando fractures, but the optimal fixation method has not been clearly defined. Purpose The aim of the study was to describe the results and the long-term functional outcome of the application, under local anesthesia, of an external fixation system for the treatment of Rolando fractures. Patients and Methods In total, 22 consecutive patients (16 men) underwent surgical treatment for Rolando fractures by using two pairs of pins external fixator. All procedures were performed under local anesthesia (Xylocaine 2%) and an image intensifier. Patients were evaluated at regular intervals postoperatively and contacted by phone for long-term follow-up. Functional outcome was assessed using the validated Quick Disabilities of the Arm, Shoulder, and Hand (Quick DASH) tool. Results The mean age was 39.8 ± 14.2 years. The mean time from injury to surgery was 4.1 ± 2 days. The mean operative time was 16.3 ± 2.6 minutes. All fractures were healed and no loss of fracture reduction was observed postoperatively. One patient developed wound erythema at the proximal pins, without requiring early removal of the implant, and another one experienced temporary numbness at the distribution of the superficial radial nerve. In total, 20 out of the 22 patients who were available for long-term follow-up did not report any complaints and could perform the daily activities without restriction. The average follow-up was 6.5 ± 1.2 years, and the mean Quick DASH score was 1.8 ± 3. Conclusion The two pairs of pins external fixator is a valuable option for the treatment of Rolando fractures and can be easily, quickly, and effectively applied under local anesthesia.

Lateral trochanteric bursa repair improves early hip function after posterior approach total hip arthroplasty: a prospective randomized control trial.

BACKGROUND: The trochanteric bursa (TB) is an anatomic structure, which is dissected during posterior/lateral hip approaches in Total Hip Arthroplasty (THA). Some surgeons prefer to simply resect the bursa as they believe that it may be responsible for postoperative lateral trochanteric pain (LTP). Others advocate that this tissue acts as a buffer minimizing friction between soft tissue and bone, and therefore its repair may prevent LTP after THA. AIM: The purpose of this prospective randomized controlled trial was to compare the clinical results of either resecting or repairing the TB during posterior approach THA. METHODS: Forty-two patients with primary hip osteoarthritis undergoing THA via a posterior hip approach were randomly assigned to two groups; Group A, or TB resection group and Group B, or TB repair group. All patients in both groups were evaluated postoperatively in terms of hip function, measured by the Harris Hip Score (HHS), at 6 weeks, 3 months, 6 months, and 12 months after surgery, as well as LTP during daily routine activities and lying on the operative side. RESULTS: Forty patients completed the study. Postoperative difference in terms of leg length and femoral offset was similar among the two groups (P = 0.467 and P = 0.39, respectively). At 6 weeks, patients in Group B had higher HHS (P = 0.052) and experienced less LTP when lying on the operative side (P = 0.046) but not during activities (P = 0.759). Thereafter, all functional parameters measured had comparable values in both groups. Subgroup analysis failed to identify any correlation between high offset stems and LTP. CONCLUSION: TB repair in posterior approach THA improves hip functional recovery as well as patients' ability to lie on the operative side during the early postoperative period.

Long-term results of posterior-cruciate-retaining Genesis I total knee arthroplasty.

BACKGROUND: Long-term results of Genesis I modular total knee system are not well known. METHODS: We analyzed data from 345 patients with 393 primary total knee arthroplasties (TKA) using the Genesis I prosthesis. In all cases, the posterior cruciate ligament (PCL) was retained, and the patella was not resurfaced. The minimum follow-up was 10 (range 10-16) years. RESULTS: Preoperative range of motion improved from 89° preoperatively to 105° at the time of the most recent follow-up (p < 0.001). Mean preoperative Knee Society pain and function scores increased from 29 and 25 points to 91 and 85 points, respectively (p < 0.001). Tibiofemoral angle shifted from 2.40° of varus before to 4.8° of valgus after the operation (p < 0.001). Early postoperative complications occurred in 34 knees (8.6%). Manipulation under general anesthesia was done in six knees (1.5%). Nonprogressive radiolucent lines were seen around the femoral component in 16 knees (4%) and at the tibial bone-cement interface in 101 knees (25%). However, in only five cases (1.3%) was there significant progression leading to implant loosening and revision surgery. Eight more revisions were performed due to infection (three knees), stiffness (three knees), excessive wear and fracture of polyethylene liner (one knee), and instability (one knee). The overall survivorship of knee replacement reached 96.7%. CONCLUSIONS: In the long term (up to 16 years), PCL-retaining Genesis I total knee prosthesis is associated with good functional outcomes and low failure rates.

Primary malignant clavicular tumours: a clinicopathological analysis of six cases and evaluation of surgical management.

Primary malignant tumours of the clavicle are extremely rare and little is known regarding their clinicopathological characteristics and outcomes of surgical management. The aim of the study is to analyse the clinical, imaging, and histological features of six patients with malignant tumours of the clavicle and present the outcome of cleidectomy in four of them. A review of the literature is also provided. Six cases were included in this series: two plasmocytomas; three PNETs, one non-Hodgkin lymphoma, one high-grade chondrosarcoma and one post-irradiation fibrosarcoma. Apart from one patient with plasmocytoma and another one with non-Hodgkin lymphoma, the remaining four patients underwent partial or complete cleidectomy according to tumour location. At the time of latest follow-up all patients were alive. Neither local recurrence nor metastases were observed in patients that underwent cleidectomy. In this group, the average score was 86.6% of the expected normal function according to the Musculoskeletal Tumour Society (MSTS) evaluation form. The mean Constant-Murley score of the affected side was 80. Patients after cleidectomy were pain free, they had almost full shoulder range of motion and no significant functional deficit was reported. Primary malignant clavicular tumours may be easily undiagnosed due to their insidious clinical onset. Partial or total cleidectomy is associated with adequate shoulder mobility and mild functional deficit. Therefore, the extent of clavicle excision during tumour removal does not seem to determine the functional outcome of the affected shoulder.

Tricortical Bone Grafting with Limited Midcarpal and Carpometacarpal Fusion for the Treatment of Giant Cell Tumor of the Capitate.

Background Giant cell tumor (GCT) of capitate is a rare lesion that is challenging to treat. Case Description We present a case of a 12-year-old girl suffering from a GCT of the capitate. Wide excision combined with adjuvant treatment including hydrogen peroxide, alcohol, tricortical bone grafting, and limited midcarpal and carpometacarpal fusion achieved good functional result without evidence of tumor recurrence or radiocarpal degeneration at 8 years postoperatively. Clinical Relevance In this case with long-term follow-up, surgical treatment of capitate GCT with limited midcarpal and carpometacarpal fusion led to a satisfactory outcome despite the alteration of wrist kinematics.

The effect of transverse carpal ligament lengthening on carpal tunnel volumetry: a comparison between four techniques.

Transverse carpal ligament (TCL) reconstruction after open carpal tunnel release has been advocated to restore wrist kinematics and grip strength. This study investigates the effect of TCL reconstruction in carpal tunnel volume (CTV). Thirty-eight cadaveric wrists were volarly approached and TCL was exposed to its proximal and distal edges. Carpal tunnel contents were removed and the CTV was measured considering that carpal tunnel resembled the shape of a truncated cone. TCL was then dissected and subsequently reconstructed by using 4 different surgical lengthening techniques. Three of these techniques were retrieved from the literature. The fourth was proposed and performed by the authors. Postreconstruction calculation of CTV was done with the same method. In 6 cadavers, a magnetic resonance imaging-based measurement of CTV was performed to assess the validity and reliability of simulation method. The average increase of CTV ranged from 31% to 44% (P < 0.001 for all techniques). However, no statistical significant difference was found between the 4 techniques (P = 0.097). Magnetic resonance imaging volumetric values were equal to simulation measured values before and after reconstruction of TCL (P = 0.224 and P = 0.674, respectively). Lengthening of TCL substantially increases the carpal tunnel capacity regardless the applied surgical technique. The simulation model method seems to be an accurate, precise, and cost-effective approach for the evaluation of CTV.

Aspiration alone versus aspiration and bupivacaine injection in the treatment of undisplaced radial head fractures: a prospective randomized study.

HYPOTHESIS: Some physicians advocate that aspiration of elbow joint hematoma in radial head fractures is helpful not only for determining a mechanical block to motion from a fracture fragment but also for improving the elbow motion and pain. However, the supplementary role of intra-articular anaesthetic injection is unclear. MATERIALS AND METHODS: In this prospective randomized study, 40 patients with undisplaced radial head fractures (Mason I) were treated with elbow joint aspiration alone (20 patients) or aspiration plus intra-articular injection of 3 mL of bupivacaine 0.5% (20 patients). Active elbow exercises were immediately commenced. The patients were evaluated at 1 day, 1, 3, and 6 weeks, 3 and 6 months, and 1 year. RESULTS: No difference was found in terms of range of motion, pain and elbow function between the 2 groups in all the examined time points. The improvement in the above parameters achieved a plateau at 3 weeks in both groups. DISCUSSION: Intra-articular use of local anaesthetic after joint aspiration does not offer any benefit over aspiration alone in the treatment of undisplaced radial head fractures and its routine application is not supported by the clinical data.

Prognostic value of suction drain tip culture in determining joint infection in primary and non-infected revision total hip arthroplasty: a prospective comparative study and review of the literature.

INTRODUCTION: Closed suction drainage in joint replacement surgery has been considered to carry an obvious risk of bacteria invasion. Previous studies have shown controversial results regarding the role of suction drain culture in predicting artificial joint infection. Furthermore, the efficacy of the method has not been established in revision total hip or knee arthroplasty. MATERIALS AND METHODS: Suction drain tips from 110 patients who underwent 73 primary and 37 revision non-infected total hip arthroplasties were prospectively cultured. The drains removed at 48 h postoperatively. The patients had an average age of 64.3 years (range 25-81 years) and followed up for 2-4 years (average 2.8 years). RESULTS: Positive cultures were identified in two primary (2.74%) and six revision (16.22%) total hip replacements (p = 0.017). The most frequently isolated microorganisms were Staphylococcus aureus (3 cases) and S. epidermidis (2 cases). Resistance to perioperative antibiotics was found in three out of eight isolated pathogens. However, no infection was recorded in any of the eight patients whose cultures found positive. CONCLUSION: Although suction drains are more often contaminated in revision total hip arthroplasty, the prognostic value of the method in determining joint infection is very limited and its routine use is not supported from the clinical data.

Spinal cord compression by a solitary metastasis from a low grade leydig cell tumour: a case report and review of the literature.

BACKGROUND: Leydig tumour is rare and there are only three cases with metastatic disease reported. CASE PRESENTATION: A 52 year-old Caucasian male was admitted, on emergency basis to the Orthopaedic Department with six weeks history of increasing midthoracic back pain, change in gait, poor balance, subjective weakness and numbness of the lower trunk and legs. MRI scan showed change in the signal intensity of T4 and T5 vertebral body but their height were maintained. Urgent T4 and T5 corpectomies, decompression of the spinal cord and reconstruction of the vertebral bodies were performed followed by radiotherapy. Neurological status significantly improved with a mild residual numbness over the dorsum of the right foot. The histology of the excised tumour was identical to the primary. At 2 years follow-up visit the patient is neurologically stable and disease free without other organs metastases. CONCLUSION: This is the first case in English literature, which shows that spinal metastases could occur even in the early stage of Leydig cell tumour, without other organs involvement. Aggressive surgical management of spinal metastases combined with post operative radiotherapy can give a better chance for long survivorship.

Intercalary bone grafting for the reconstruction of phalangeal osteolysis in disappearing bone disease: case report.

Disappearing bone disease (DBD) is a rare condition of unknown etiology that may cause massive hand deformity due to severe osteolysis and soft-tissue atrophy. Bone grafting of the affected metacarpal bones or wrist has been described with moderate success in only 4 cases, but phalanx reconstruction has not been attempted. We report a case with multicentric DBD that was treated with staged intercalary iliac bone grafting of the phalanges of the dominant thumb and index finger. After 3 years, no graft resorption was noticed and the patient reported considerable functional improvement.

Exophytic growth of a neglected giant subcutaneous Leiomyosarcoma of the lower extremity. A case report.

BACKGROUND: Superficial leiomyosarcoma is an exceedingly uncommon malignant tumor which could be located either to cutaneous or subcutaneous tissues. Increased mass size and depth, advanced tumor staging and inadequate surgical excision are the main prognostic factors for poor result. CASE PRESENTATION: We report a rare case of a 71-year-old man with an extensive exophytic lesion (12 x 10 cm) in the anterior-medial side of the proximal right tibia. The lesion was painless and consistently neglected by the patient until a skin trauma caused ulceration of the affected area. Magnetic Resonance Imaging revealed a soft-tissue mass which was well defined from the surrounding bone and muscles. As initial biopsy in another hospital hadn't clarified the true nature of the lesion, new samples were taken and the diagnosis of leiomyosarcoma was established. Laboratory examination showed no distant metastasis and wide excision of the neoplasm was decided. After tumor resection, the remaining soft tissue and skin defect was covered with a gastrocnemius myocutaneous flap. The postoperative period was uneventful and wound healing was followed by local radiotherapy and systemic chemotherapy. At 3 years follow up, no recurrence or metastasis was identified and the patient was able to walk and stand without impairment of his ambulatory status. CONCLUSION: Proper surgical management of soft tissue leiomyosarcoma continues to remain the cornerstone of treatment efficacy and the most important prognostic factor for patients' survival. Reconstruction of the remaining soft tissue defect should be always performed at the same operative time when removal of giant size tumors leaves an uncovered cavity with an inadequate sleeve of muscular and skin tissues.

Modified ulnar translocation technique for the reconstruction of giant cell tumor of the distal radius.

Giant cell tumors of the distal radius have been frequently described as difficult to treat, chiefly because of their close proximity to multiple tendons, median nerve, radial artery and carpus.The aim of treatment is to remove the tumor completely and preserve the radiocarpal and radioulnar joints.However, this is not always feasible as giant cell tumors seem to behave more aggressively and have a higher recurrence rate in the distal radius, even if local adjuvant treatment with phenolmethylmethacrylate or liquid nitrogen is applied. The above incidence is increased in Campanacci grade III lesions, which are characterized by fuzzy borders, loss of cortical continuity, and extension into soft tissues. In these cases, wide excision instead of intralesional excision may be advocated, particularly when the tumor breaks through the cortex, violates the articular surface, and destroys >50% of the surrounding metaphysis. Several reconstructive options (e.g., resection arthroplasty, prosthetic replacement, arthrodesis, ulnar translocation, centralization of the carpus over the remaining ulna, use of a nonvascularized, or vascularized fibular graft [with or without arthrodesis], and allograft replacement) have been described for the treatment of either recurrent or primary grade III giant cell tumor with destruction of the bone cortex and associated soft tissue mass. Ulnar translocation has been mentioned rarely in the literature, and, according to our knowledge, only 10 cases have been previously reported. This article presents a case of a woman with a grade III giant cell tumor of the distal radius. Wide excision of the tumor followed by reconstruction of the distal forearm with a modified ulnar translocation technique and wrist arthrodesis led to optimum results and no mass recurrence at 13 years postoperatively.

Carpal tunnel syndrome due to an atypical deep soft tissue leiomyoma: The risk of misdiagnosis and mismanagement.

BACKGROUND: Leiomyomas of the deep soft tissue are quite uncommon and occur even more rarely in upper extremity. CASE PRESENTATION: A 32-year old manual laborer man presented with a two-year history of numbness, tingling and burning pain in the palmar surface of the left hand and fingers. His medical history was unremarkable and no trauma episode was reported. According to the clinical examination and the result of median nerve conduction study (NCS) the diagnosis of carpal tunnel syndrome was established. Operative release of the transverse carpal ligament was subsequently performed but the patient experienced only temporary relief of his symptoms. MRI examination revealed a deep palmary located mass with well-defined margins and ovoid shape. Intraoperatively, the tumor was in continuity with the flexor digitorum superficialis tendon of the middle finger causing substantial compression to median nerve. Histopathological findings of the resected mass were consistent with leiomyoma. After two years the patient was pain-free without signs of tumor recurrence. CONCLUSION: Despite the fact that reports on deep soft tissue leiomyoma are exceptional, this tumor had to be considered as differential diagnosis in painful non-traumatic hand syndromes especially in young patients.

Lateral parapatellar approach with tibial tubercle osteotomy for the treatment of non-correctable valgus knee osteoarthritis: a retrospective clinical study.

BACKGROUND: The aim of this retrospective study was to evaluate the efficacy of a lateral parapatellar approach combined with a tibial tubercle osteotomy (TTO) in patients undergoing total knee arthroplasty (TKA) with non-correctable valgus knee osteoarthritis. METHODS: We studied 53 consecutive patients (57 knees) who had a primary TKA via lateral parapatellar approach with a global step-cut "coffin" type TTO over a 10-year period. All patients had non-correctable grade II valgus deformity according to the Ranawat classification. The average age of patients was 71 years (45 to 77) and the mean follow-up was 39 months (20 to 98). RESULTS: Post-surgery, there was a significant improvement in knee extension (p=0.002), flexion (p=0.006), Knee Society Pain and Function Scores (p<0.001) and WOMAC Osteoarthritis Index (p<0.001). The tibiofemoral angle changed from a preoperative median value of 11 deg (10 to 17) to a postoperative value of 3.75 deg (0 to 9). Congruent patellar tracking was observed in all cases. All but one osteotomy united in a median period of 16.7 weeks (9 to 28) and no hardware removal was required. One knee developed infection treated with two-stage reconstruction. A proximal tibial stress fracture also occurred in a patient on long-term bisphosphonate therapy. CONCLUSION: Lateral parapatellar approach along with TTO is an effective technique for addressing non-correctable valgus knee deformity during TKA.

Pulsed electromagnetic fields for the treatment of tibial delayed unions and nonunions. A prospective clinical study and review of the literature.

BACKGROUND: Pulsed electromagnetic fields (PEMF) stimulation for the treatment of bone nonunion or delayed union have been in use for several years, but on a limited basis. The aim of this study was to assess the overall efficacy of the method in tibial delayed unions and nonunions and identify factors that could affect the final outcome. METHODS: We prospectively reviewed 44 patients (27 men) with a mean age of 49.6 ± 18.4 years that received PEMF therapy due to tibial shaft delayed union or nonunion. In all cases, fracture gap was less than 1 cm and infection or soft tissue defects were absent. RESULTS: Fracture union was confirmed in 34 cases (77.3%). No relationship was found between union rate and age (p = 0.819), fracture side (left or right) (p = 0.734), fracture type (simple or comminuted, open or closed) (p = 0.111), smoking (p = 0.245), diabetes (p = 0.68) and initial treatment method applied (plates, nail, plaster of paris) (p = 0.395). The time of treatment onset didn't affect the incidence of fracture healing (p = 0.841). Although statistical significance was not demonstrated, longer treatment duration showed a trend of increased probability of union (p = 0.081). CONCLUSION: PEMF stimulation is an effective non-invasive method for addressing non-infected tibial union abnormalities. Its success is not associated with specific fracture or patient related variables and it couldn't be clearly considered a time-dependent phenomenon.

Cuff width increases the serum biochemical markers of tourniquet-induced skeletal muscle ischemia in rabbits.

Tourniquet application is a widely accepted adjuvant technique in extremity surgery. The purpose of this prospective, randomized trial was to evaluate the effect of cuff width on skeletal muscle ischemia-reperfusion injury. A 2- or 4-cm wide curved tourniquet cuff was applied around the midthigh of 36 New Zealand White rabbits and inflated to a pressure of 200 or 400 mm Hg for 2 hours: group A=2 cm to 200 mm Hg; group B=2 cm to 400 mm Hg; group C=4 cm to 200 mm Hg; group D=4 cm to 400 mm Hg. Blood levels of potassium, lactic acid, urea, lactic dehydrogenase, and creatinine phosphokinase MM isoenzyme (CPK-MM) were measured as basic indicators for limb ischemia before tourniquet inflation and 1, 5, and 30 minutes after cuff release.Potassium values did not differ among the 4 groups. Lactic acid and urea concentrations were always higher in the 400 mm Hg groups (B and D) (P<.001). However, cuff width did not affect their levels (P>.16). Lactic dehydrogenase and CPK-MM values were also greater in the 400 mm Hg groups at all times (P<.001). Further subgroup analysis of 200 mm Hg pressure groups showed higher lactic dehydrogenase (P<.02) but not CPK-MM (P>.9) concentrations in group C than in group A during the 30-minute period. At 400 mm Hg, lactic dehydrogenase and CPK-MM values were higher in group D compared with group B only 30 minutes after cuff deflation (P<.001). Broad tourniquets are associated with significantly greater and prolonged elevation of serum biochemical markers of inducible skeletal muscle ischemia-reperfusion injury compared with narrow ones. This difference is more prominent when a wide cuff is inflated to a high pressure.

Giant cell tumour of tendon sheath of the digits. A systematic review.

BACKGROUND: We reviewed the literature to evaluate the demographic, clinical and histological profile of giant cell tumour of tendon sheath of the digits (GCTTSD). The overall recurrence rate and the factors affecting tumour recurrence were also assessed. METHODS: We searched for published articles regarding the GCTTSD in the English literature the last 30 years using the PubMed search engine. All retrieved papers were analysed and their reference lists were also screened if relevant. Clinical studies with less than five patients and follow-up less than 2 years were excluded from further evaluation. For each report, information was gathered related to trial characteristics and study population. Location and multicentricity of lesions, kind and severity of symptoms, type of applied treatment modality and histopathological features of the excised tumours were additionally recorded. A meta-analysis for estimating the pooled recurrence rate after surgical excision was also conducted. Statistical significance was assumed for p ≤0.05. RESULTS: We found 21 studies with histological confirmation of GCTTS. However, only 10 studies including 605 patients were reviewed according to selection criteria (average follow-up 36.7 to 79 months). The male-to-female ratio was 1:1.47 (p < 0.005) and the mean age ranged from 32 to 51 years. Pain or sensory disturbances reported only in 15.7% and 4.57% of cases, respectively. A definite history of trauma recorded in 5% of lesions. The most frequent tumour location was the index finger (29.7%). In total, 14.8% of patients had tumour recurrence. Type I tumours (single lesions) were more frequently detected (78.7%) than type II tumours (two or more distinct tumours that were not joined together) (21.3%) but the latter were associated with a higher recurrence rate (p < 0.001). Study design also affected the possibility of recurrence as it was lower in prospective studies compared to retrospective studies (p = 0.003). Even though bone erosion was detected in 28.39%, recurrence was not more common in this group. In addition, recurrence was not significantly associated with a specific finger or phalanx. CONCLUSIONS: Intrinsic biology of the tumour seems to play a more fundamental role in recurrence than tumour location or local invasiveness. More prospective well-designed studies including a large number of cases are necessary to identify tumours prone to recurrence and determine the proper treatment protocol for each individual patient.