Subclavian vein injury and massive hemothorax requiring thoracotomy following insertion of tunneled dialysis catheter. A case report and review of literature

Tunneled dialysis catheters are widely used for hemodialysis. Large caliber dilator is used for insertion of such catheter which can result in serious vascular injury leading to haemothorax. Here we report such an inadvertent central venous injury requiring thoracotomy following blind dilator advancement along with review of literature and recommendation to prevent such complication

Total hip arthroplasty for management of neglected fracture neck femur in old patients

The aim of this study was to evaluate functional and radiological findings of patients after primary total hip arthroplasty for neglected intracapsular fracture of the femoral neck in old patients. Between January 2007 and February 2009, we treated 19 consecutive cases of neglected intracapsular fracture of the femoral neck in old patients by total hip arthroplasty; there were 11 males and 8 females with a mean age 55 [range, 50-65] years. The right hip was involved in 9 patients and left hip in 10 patients. Six patients had been injured in road traffic accidents and 13 patients had fallen from considerable height. The interval between injury and surgery has ranged from 8 months to 2 years with an average 11 months. Avascular necrosis of the femoral head was presented in 15 patients with neck resorption and non union with neck resorption in 4 patients. Total hip arthroplasty was done for all patients; cemented total hip arthroplasty was done for 11 patients, cementless total hip arthroplasty for 3 patients and hybrid total hip arthroplasty for 5 patients. The mean duration of follow up was 23 [range, 17-30] months. The patients were evaluated both clinically and radiologically, 15 patients out of the nineteen had no pain and 4 patients had mild pain. Radiologically, there were no signs of loosening

role of arthroscopy in the treatment of ankle fractures

Anatomic surgical realignment of ankle fractures may still be associated with poor clinical outcomes, possibly as a result of occult intra-articular injury. Malleolar fractures have been reported to be associated with a poor prognosis even when the anatomic reduction is complete. Soft tissue injuries such as damage to the cartilage and ligaments, soft tissue impingement, and the existence of free bodies within the intra-articular space account for this poor outcome. In treating acute malleolar fractures, an arthroscope is used to confirm anatomic reduction on the articular surface and treat intra-articular injuries [Leontaritis et al, 2009]. The aim of this study was to evaluate the arthroscopic findings and the surgical outcome for arthroscopy-assisted minimally invasive internal fixation of acute medial malleolar fractures. From January 2005 to December 2008, thirty two patients who had experienced medial malleolar fractures [17 males, 15 females; mean age, 35 years; range, 11-54 years] were operated on using minimally invasive surgical fixation assisted with arthroscope in the Department of Orthopedics Surgery, Al-Azhar University. Arthroscope was used to confirm the fracture line, cartilaginous damage, presence of detached cartilaginous fragments in the articular space, ligament damage, and diastasis of the distal tibiofibular joint. The cartilaginous damage was treated using shaving, and the free cartilaginous fragments were excised. Diastasis of the distal tibiofibular joint was treated using distal tibiofibular joint fixation, using a cortical screw 3.5mm Phi. Fracture fixation was conducted after anatomic reduction had been confirmed using fluoroscopy and arthroscopy. Cartilaginous damage was noted in 15 [46.8%] patients, among whoml0 patients were treated by shaving and 5 underwent cartilaginous fragment removal. From a postoperative radiographic evaluation, a good result in 28 [87.5%] patients and a fair outcome in 4 [12.5%] were confirmed. The clinical results were good in all and no postoperative complications or pseudoarthrosis was noted. The results were scored according to Freiburg Ankle Scoring System [BULGUN et al, 2004] containing the criteria pain, function, swelling, range of motion and athletic activity. The overall score significantly increased from 52.1 preoperatively to 74.8 postoperatively. Comparing the different criteria, the score parameters pain and function improved significantly, whereas the other parameters did not show significant improvements. We concluded that the arthroscopy of the ankle joint can be used in case of arthroscopic guided percutaneous fracture reduction and fixation, the procedure that shorten the recovery time, minimize the postoperative discomfort, and producing and early mobilization of the joint

Shoulder arthroscopy: part I Is it justifiable after acute first-time anterior shoulder dislocation?

We reported on 34 young labor men, mean age 31.4 years with high physical demands who sustained first-time anterior dislocation of the shoulder. All were treated initially with closed reduction and immobilization, followed by shoulder therapy programs. Despite this, patients still suffered episodes of pain, discomfort and/or insecurity and feelings of joint being out on performing a particular activity. MRI was done for all cases, then, arrangement was made for arthroscopic evaluation some weeks to few months after primary treatment. The pathologic findings at arthroscopy divided the cases into 5 groups: capsular tears only in 5 patients; 4 [11.8%] of them [G1] the tear was defined at the glenoid attachment - in the rest one [2.9%] it was at the humeral insertion [G2]. Capsular tears associated with partial labral detachment [G3] in 9 [26.5%], capsular tears and complete labral detachment [G4] in 17 [50.0%], and complex injury [G5] in the remaining [8.8%] shoulders that demonstrated full labral detachment from the glenoid, frank tearing and fraying of the capsular structure which was seen as well avulsed from the labrum. No bony Bankart lesions, or mid-capsular tears were defined. The decision, based on the literature review [1-4-5-8-12-13-14-15-17-18-32] was to continue conservative treatment and observation for the 5 patients suffered capsular tears, but, an arthroscopic repair was an option in our mind for the 4 shoulders with glenoid capsular detachment, and an open surgery for the humeral avulsion of the glenohumeral ligament. While the option for the fifth group of cases was open shoulder stabilization procedures. The third, and fourth groups of cases including 26 shoulders were considered as an ideal candidates for arthroscopic treatment. This study emphasizes that a systemic arthroscopic examination of the glenohumeral joint is not only more confirmatory, defining the exact pathologic anatomy associated with first-time anterior shoulder dislocation, but as well how best in patient selection, and decision making

Shoulder arthroscopy: part II arthroscopic Bankart repair for anterior shoulder instability using suture anchor reconstruction technique

Suture anchor reconstruction technique was used in 19 shoulders over the last 2.7 years in 19 patients in an attempt to restore anterior stability. All the patients had traumatic anterior instability diagnosed on physical examination and at arthroscopy. Discrete Bankart lesion and well formed glenohumeral ligaments, with or without capsular laxity was the evidence consistent with instability in all patients, and each underwent a standardized procedure, however, the number of anchors were different for every patient, range 1-to-3 according to the size of the lesion. Additional capsulorraphy procedures were done to reduce excess capsular volume including; plication sutures in 8 shoulders, and thermal shrinkage in 7. All patients were young active men with high physical demands, the average age at the time of operation was 25.2 years. All were right handed, the dominant side was affected in 11 patients. None of the patients had prior instability operations. The follow-up averaging 18 months, range 9-to-3 1 months. None of the patients developed redislocation, subluxation, or positive apprehension during the follow-up period. No major intra-operative, or pen-operative complications were reported during this study. 75%-to-full range of motion of the shoulder joint as compared with the opposite asymptomatic side was preserved 21 in most patients. Using the shoulder evaluation scale advocated by Rowe; and Zarins, 1981 1421, the patients had excellent-to-good results with an overall average score of 85.82 points; but 5 patients had episodes of moderate pain with activity, and 7 had moderate limitation in overhead work. It would appear that arthroscopic repair of pathologic Bankart lesion in a carefully selected patients using suture anchor technique is a favorable answer restoring stability to the shoulder better than non-operative treatment of first-time dislocation and to surgical treatment of recurrent shoulder dislocation

Shoulder arthroscopy: part III arthroscopic versus open anterior shoulder stabilization

To evaluate the efficacy of a particular line of treatment, criteria based on functional basis and complication rate must be considered. This work was carried out because of the authors' conviction that any new operative procedure must be critically assessed, on this basis, comparison with other procedures must be included. Forty one shoulders were allocated to an arthroscopic repair group [19 shoulders], and an open repair group [22 shoulders]. The two groups were generally comparable in terms of age [a mean of 25.2 years in the arthroscopic group and 27.3 years in the open group], gender [all patients in either group were males], mechanism of injury and etiology of instability [all patients related a history of a traumatic event], dominant extremity [the right and the dominant side was the most vulnerable], duration of symptoms [a mean of 13 months and 19 months for the arthroscopic and open groups respectively], level of daily activities and effort demand [all were young active with high physical demand]. Three variations were existed: [1] pre-selection and pre-conditioning was the strategy in the arthroscopic repair group, so that, procedural option was determined on the basis of the pathological findings, only at the time of surgery, modification of treatment was possible. [2] the arthroscopic procedure involved an anatomic repair of the avulsed anterior capsule and labrum to the glenoid lip using standardized suture anchor technique and an incorporation of capsulorraphy in most shoulders. While in the open repair group, different operative modalities were employed using familiar techniques including: 2 soft tissue reconstructions; Magnuson - Stack [4 shoulders] and Putti-Platt [6 shoulders]. In addition, coracoid tip with its attached muscles transfer [Bristow operation in 9 shoulders] and rerouting [Boytchev operation in 3 shoulders]. [3] the duration of the follow-up, which considered short-to-mid term [averaging 18 months] and long-term [averaging 71 months] in the arthroscopic and open groups respectively. The treatment outcomes for each group were determined according to the recurrence rate, the presence or absence of -pain, the range of motion, the strength and the return to pre-injury activity. Analysis of the measured parameters for both approaches; open and arthroscopic showed no significant differences, both yielded comparable results

Shoulder arthroscopy: part IV idiopathic frozen shoulder: arthroscopic distension, release, and debridment

Twenty three carefully selected patients with frozen shoulder with variable degrees of complaint and severity constituted the material of the present study. All failed to response to the conventional lines of conservative treatment as an initial measures, and then, arthroscopic management was undertaken followed by a well designated physical therapy program and stretching mobilization. The indication for surgery was persistent pain, stiffness, and limited function. There were 15 [65.2%] males, and 8 [34.8%] females with an average age of 49.6 years. All were right handed, and all but 2 were unilateral dominant-side presentation - for bilateral affection, arthroscopy was done in one shoulder, the one with the severe symptoms. Before operation, all the patients had shoulder pain and motion restriction for at least 6 months despite conservative treatment. At operation, synovectomy, rotator interval capsulotomy, and glenohumeral joint and subacromial space debridment and clean-up were done for all cases, additionally, selective release procedures were performed in a controlled manner according to the findings, varied from limited freeing-up to a more aggressive or a complete release of the contracted anterior capsulo-ligamentotendinous structures. The range of external rotation at the side and in abduction was examined intermittently to check improved laxity and motion arc. The functional mobility, the range of motion in the different planes, the power, and pain were assessed and recorded before and after surgery according to the Constant scoring system [9]. Functional assessment was carried out at 3 post-operative intervals during the course of follow-up; immediate postoperative, at 10 th week, and finally at 20 th week. Final re-assessment at the end of the treatment showed appreciable improvement with no significant recorded complications. On conclusion, the combination strategy; arthroscopic management with shoulder exercises can offer effective treatment for frozen shoulder

Shoulder arthroscopy: part V post-arthroscopic immediate pain control, and then, early mobilization

Any evolution in surgical procedure must seek to improve established results, minimize previous complications, and maximize applicability to the general patient population. Arthroscopic examination and treatment of selected shoulder disorders have undoubtedly earned a permanent role in the practice of orthopaedic surgery, with an exciting and expanding future. The current study was designed to evaluate the clinical value of a post-arthroscopic local analgesic method using a single intra-articular injected dose of a mixture of 20mg [4 ml] tenoxicam, 20mg [0.5 ml] triamcinolone acetonide, 0.2% [10 ml] ropivacaine, and 0.5 ml of a 1: 1000 epinephrine solution, in an attempt to achieve a pain-free post-operative period to allow for early rehabilitation. The study was conducted in 76 patients, mostly were young active men, all underwent shoulder arthroscopic surgery for diagnostic and therapeutic purposes. Visual analogue scale [VAS] scores as regards pain intensity and relief were taken before surgery and then, at recovery, 1, 2, 4, 8, 24 hours postoperatively. In addition, patients were assessed for quality of sleep and for daily living. The physiotherapist's opinions about the analgesia provided were also recorded as indicated by the patient's ability to participate in the immediate post-operative mobilization programs. The results revealed a significant benefit as it offered an immediate post-operative pain relief, high therapist compliance, and good patient satisfaction. In addition, the incidence of adverse actions was negligible

Occupational health hazards among nurses exposed to glutaraldeliyde

This study was curried out to describe the occurrence of work-related symptoms, lung function changes among nurses exposed to glutaraldehyde [GA] and DNA damage in human leukocytes incubated with GA [in-vitro study]

Methods: a cross-sectional study was carried out on 65 nurses exposed to GA from operating theaters and endoscopy units in Liver institute and University Hospital of Menufiya, Egypt. Pre and post-ship spirometry to measure forced expiratory flow rate in first second [FEVI] and peak expiratory flow rate [PEER] were performed on 26 nurses who had multiple lower respiratory work related symptoms and comet assay was used for detection of DNA damage in human leukocytec incubated with GA at different concentrations

Results: work-related symptoms reported by nurses were nausea [26.2%], headache [58.5%], skin allergy [86.2%], eye irritation [72.3%], and watering of eyes [35.4%]. Upper respiratory symptoms included nose irritation [84.6%], running nose [18.5%], throat irritation [81.5%]. Lower respiratory symptoms included sneezing [23.1%], cough [30.8%], difficult breathing [30.8%], and chest tightness [23.1%]. Their knowledge and practice turned to be very deficient regarding personal protection. Statistically significant reductions in post-ship PEER and FEVI were revealed, with 8 nurses [30.8%] having reductions >15%. Negative statistically significant correlations were detected between practice scores and post-ship reductions in PEER and FEVI. Human leukocytes incubated with GA at concentrations of 0.05 and 0.1 mg/ml had 13% and 8% DNA damage [DNA migration], respectively, compared to control [4%], p<0.05. Higher concentrations led to less damage

Conclusion: GA is associated with many work-related symptoms and reduction in lung functions among exposed nurses, and might increase DNA damage in in-vitro study. Training of nurses about safe handling and storage of GA, proper use of protective measures, periodical health care and surveillance, with reduction of exposure time, use of automated washing units, and effective ventilation methods are recommended to reduce the hazards of exposure to GA. Further studies involving environment assessment are needed

Fractures of the ulnar styloid in young adults: to fix or not?

In this study, 44 cases of fracture base of the ulnar styloid were treated by open reduction and internal fixation using tension band wiring. 68% of the cases were associated with unstable distal radius fracture. In 10% of the cases, the ulnar styloid fracture was isolated; in 11% of the cases, it was associated with carpal injuries, fractures and or dislocation as well as 11% were associated with Galeazzi fracture. The assessment of stability of the distal radio-ulnar joint was tested after fixation, during surgery. An additional percutaneous fixation of distal radio ulnar joint [DRUJ] by KW was done in four cases. The results were encouraging, 85% of the patients had painless free range of supination-pronation. A residual prominence of the ulnar head was observed in two cases

Comparative study between intrauterine insemination and timed intercourse as a treatment for male infertility

Objective: the objective of this study was to evaluate the role of intrauterine insemination [IUI] in treatment of male factor of infertility and also to compare it with timed natural intercourse

Setting: infertility clinic, King Abdul Aziz Specialist Hospital, Taif, Saudi Arabia

Patients and methods: forty couples with primary infertility due to moderate semen defects and a period of infertility of at least two years were selected and randomly divided into 2 groups. The first group comprised 20 couples, who underwent IUI using prepared semen by swim up technique, while the second group comprised 20 couples who underwent timed intercourse

Results: the results of the current study showed that there was no statistical significant difference between both groups as regard female age, male age, duration of subfertility, sperm count, motility and normal morphology of the sperms. Pregnancy rate [PR], PR/couple and PR/cycle, were significantly higher in group A when compared to group B, [P<0.05 and<0.001] respectively. There was no statistical significant difference between the occurrence of pregnancy and different semen parameters. Only, the mean duration of subfertility was significantly lower in the pregnant versus non pregnant cases P<0.05

Conclusion: it could be concluded that IUI is more effective than timed intercourse in treatment of malefactor infertility, but further studies are needed to clearly define the impact of various semen parameters on the prediction of pregnancy outcome

Compression triple fusion using screws fixation

Fourteen patients complaining of painful and/or deformed foot resistant to conservative management treated by using triple fusion were included in this study aiming to evaluate the results of the efficiency of double approach exposure and compression internal fixation in improving the results of triple fusion. Ten feet had peroneal spastic foot, three had post traumatic arthritis and one had unstable paralytic foot. All were treated using medial and lateral exposure and rigid internal fixation. After a mean follow up period of 19 months, pain, gait, walking ability of the patients were improved in all but one patients. Triple fusion is a good salvage option for the treatment of resistant painful foot, if proper surgical technique is followed