Reduction of acute anterior shoulder dislocation under a narcotic saves more service time in an emergency room than combined narcotic and sedation.

Objective: To compare the post-reduction service time between using a narcotic and combination of a narcotic with sedative drugs for reduction of acute anterior shoulder dislocation. Methods: Between 2004-2010, medical records and radiographs of patients who sustained acute anterior shoulder dislocation and obtained the successful reduction under sedation were reviewed. The patients were divided into 2 groups. Group 1, reduction was done under either intravenous morphine or pethidine and group 2, under either intravenous morphine or pethidine combined with diazepam. Post-reduction service times were recorded. The statistically significant difference was considered at p ≤ 0.05. Results: 42 patients were divided to 2 groups (21 patients in each group). The mean post-reduction service time of group 1 was 62.10 (SD = 31.42) and group 2 was 87.57 (SD = 32.07) minutes. The statistical analysis showed that group 1 significantly spent 25.47 minutes less post-reduction service time than group 2 (p = 0.013). Conclusion: Reduction of acute anterior shoulder dislocation under a narcotic significantly uses shorter post-reduction service time than under a combination of a narcotic with sedative drug in the emergency room.

Intracapsular hip fractures have poorer nutritional status and more complications than trochanteric fractures: A retrospective study of 255 Thai patients.

Poor nutritional status which is found in many hip fracture patients may be one explanation for their increased morbidity and mortality. A retrospective study was performed to study the nutritional profile in Thai patients with hip fracture who had been admitted to Siriraj Hospital from January 2005 to March 2006. The parameter that was used to determine the nutritional profile was the level of albumin. The nutritional differences in hip fractures were assessed. The incidence of protein depletion was significantly higher in patients with trochanteric hip fractures than patients with intracapsular hip fractures. However, the average serum albumin level was significantly lower in patients with the intracapsular fractures than patients with trochanteric fractures. In addition, we found that a moderate level of malnutrition was related to post-operative complications in patients with the intracapsular hip fractures. Therefore, the higher complication rates in patients with intracapsular fractures than in patients with trochanteric fractures may be caused by the poorer nutritional status.

Open total talus dislocation: A case report.

Total dislocation of the talus is a rare and severe injury. We report a case of 18-year-old man who sustained a Gustilo type IIIA open total talus dislocation when he had a car accident. Immediate surgical debridement and putting the dislocated talus into an ankle mortise were accomplished under antibiotic coverage. The ankle was immobilized for 12 weeks, and weight-bearing was restricted for 3 months. At the 6-month follow-up, the patient had both ankle septic arthritis and avascular necrosis of the talus. After treatment with antibiotics for 8 months, the septic arthritis was resolved. Finally, at 12 month follow-up, the patient had a good plantigraded foot even though avascular necrosis of talus was presented.

A comparison of acetabular diameter using direct and indirect measurement.

Background: In total hip arthroplasty, it is necessary to evaluate the diameter of the acetabulum as a part of the preoperative planning. However, usually the measurement of the acetabular diameter in the anteroposterior view of the pelvic radiograph gives an inaccurate value. Objective: To determine the accuracy of acetabular diameter measurement from various pelvic radiographs when compared to direct measurement. Methods: The study was performed in 10 cadavers; 5 males and 5 females with a mean age of 69.7 years. 20 hips were studied by taking radiographs at 3 positions: anteroposterior, 45° iliac oblique and 45° obturator oblique views. The acetabular diameters were directly measured from the cadaver and in all views of pelvic radiographs. Intraobserver and interobserver reliability of all the methods were evaluated by measuring 3 times by 3 doctors. Results: The mean diameter of the acetabulum measured directly from the cadaver was 46.13± 3.05 mm., while when measured from the pelvic radiographs in anteroposterior, iliac oblique and obturator oblique view was 54.29 ± 3.67, 47.63 ± 2.85, and 57.29 ± 4.34 mm. respectively. The iliac oblique view gave the most accurate value with a magnification of 3.36%, while the magnification in the anteroposterior and the obturator oblique view was 17.81% and 24.30%, respectively. The diameter measured from the iliac oblique view was not statistically different from the direct measurement, while the diameter measured from the anteroposterior and obturator oblique view was statistically different (p < 0.001).The intraobserver and interobserver reliability of the 3 observers showed excellent correlations (p < 0.0001). Conclusion: The iliac oblique view of the pelvic radiograph provided the most accurate value compared with the direct measurement. The iliac oblique view is the best view of the pelvic radiograph used to measure the acetabular diameter for operative planning for hip arthroplasty as a guide to choosing the proper prosthetic size.

Results of necrotic bone removal and replacement with Iliac bone in the treatment of nontraumatic avascular necrosis of the femoral head ficat Stage IIb and III.

This prospective study reported a one year follow up of seven patients (8 hips) with avascular necrosis of the femoral head, Ficat stage Ilb and III. All necrotic bone at the avascular areas were removed and repleaced with iliac bone graft. The average age of the patients was 39.3 years (range 31-35). The mean modified Harris Hip Score was 52.4 (range 35-73) preoperatively, 81 (range 67-95) at six months and 59.6 (range 38-91) at one year follow up. The mean visual analogue scale was 5.8 (range 3.0-10.0) preoperatively, 3.1 (range 0.7-5.2) at six months and 5.4 (0.6-7.9) at one year follow up. Four patients (4 hips) and successful results. Three patients (4 hips) had clinical and radiographic progression. One of them required bipolar hemiarthroplasty at 11 months postoperatively. The others (3 hips) have been planned for arthroplasty. Removing and replacing necrotic bone with iliac bone graft is an alternative method to preserving the femoral head in the treatment of nontraumatic avascular necrosis, Ficat stage IIb and III. Initial pain relief and clinical improvement were obtained by most patients. Patient selection is considered to be one of the important factor in predicting long term outcomes.

Local compressive strength of the superolateral and sueromedial aspects of the anterior half of the talar dome: A biomechanical and histological study.

One cause of osteochondritis dissecans of the talar dome is related to trauma. The lesion occurs at the anterior half of the talar dome. The lateral osteochondritis dissecans is located at the superolateral aspect, while the medial lesion is located at the superomedial aspect. The lateral lesion is more common and its crater is shallower than that of the medial lesion. This study was therefore carried out to determine the local compressive strength of the superolateral and superomedial aspects of the anterior half of the talar dome. Ten pairs of fresh normal cadaveric tali were obtained. Using a universal testing machine, a compressive load was applied through a metal indenter at the superolateral and superomedial aspects of the talar dome until the maximal load was obtained. The maximal load and depth of depression were recorded. Histological studies of the compressive lesion was done using decalcified hematoxylin eosin stain. The results of the study showed that the superolateral aspect of the talar dome could withstand 1.27 times less compression load than could the superomedial aspect without a significant difference in stiffnesses. Moreover, the depth of depression of the superolateral compressive lesion was shallower than that of superomedial. Histological studies showed that the compressive lesion was a depression fracture. The depression fracture was a free osteochondral fragment surrounded by normal osteochondral tissue. The free fragment included articular cartilage, subchondral plate, and subchondral cancellous bone. The result of this study may explain why the prevalence of the lateral traumatic osteochondritis dissecans is higher, and its lesion crater shallower, than that of the medial aspect of the talar dome.

Bleeding in open-book type pelvic fracture.

Hypovolemic shock in severe pelvic injury, such as open-book pelvic injury is a life-threatening condilion. Increased intrapelvic volume causes loss of temponade effect for bleeding control. Most of the bleeding is confine in the false pelvis and lower abdomen. Therefore, this study is carried out to measure intrapelvic volume from the pelvic floor to the level of the pelvic brim and to the horizontal level of the iliac crest. Ten embalmed cadaver pelvic ring in which the pelvic floor, pubic symphysis and sacroiliac joints were preserved, were dissected. Open-book pelvic ring disruption was created by separation of the pubic symphysis and left sacroiliac joints at 2.5,3,5 and 8 cm separation. Intrapelvic volume was measured at two levels. Level 1 was measured from the pelvic floor to the level of pelvic brim (V1) and level 2 from the pelvic floor to the horizontal level of the iliac crest with reconstruction of anterior lower abdominal wall. V1 and V2 before separation of pubic symphysis were 701.00 ml (SD 69.72) and 1,591.40 ml (Sd215.23) respectively. Percentage of increment of V1 at 2.5,3,5 and 8 cm separation were 3.68 ml (SD 1.29), 6.69 ml (SD 2.08), 9.25 ml (SD 2.63) and 31.28 ml (SD 6.47 respectively and of V2 were 26.08 ml (SD 11.19), 31.36 ml (SD 9.51), 37.06 ml (SD 9.31) and 74.08 ml (SD 18.51) respectively. The increment of V1 at less than 5 cm pelvic ring disruption is minimal when compared with V2 The increment of both V1 and V2 is large when the pelvic ring is disrupted over 5 cm. Obviously, V2 increases much more than V1. The increment of intrapelvic volume in open-book pelvic ring disruption is much greater at the level of the false pelvis and lower abdomen especially when the disruption is more than 5 cm, so that there is loss of the temponade effect of the intrapelvic cavity for the control of bleeding, one of the possible causes of hemodynamic instabiliy.

Failure mode of depressive osteochondral fracture under maximum compressive load: Studies of normal, osteoporotic, and osteosclerotic subchondral bones.

Objective: To determine the failure mode of depressive osteochondral fracture under the maximum compressive load. Design: An experimental cadaveric study. A compressive load was applied through an indenter on a femoral condyle to create a depressive osteochondral fracture until the maximum load was reached. Background: Most depressive osteochondral fractures occur without a gross articular cartilage injury because a large amount of load is reabsorbed by the surrounding tissues, especially the subchondral bone under the cartilage. We asked what the mode of depressive osteochondral fracture is. It might function as a load adsorber from the articular cartilage. Methods: Three groups of depressive osteochondral fractures were studied. Croup 1 consisted of 12 pieces of middle third of normal median and lateral femoral condyles. Groups 2 and 3 consisted of 12 pieces of osteoporotic and osteosclerotic middle of both femoral condyles. Using a universal testing machine, a depressive osteochondral fracture was created by applying a uniaxial compressive load through an indenter until the load rose to the maximum level. At that point, the load applied was stopped in order to minimize the extent of subchondral trabeculae fracture. Maximum load was recorded. Pressure and stiffness were calculated. The pattern of depressive fracture was studied histologically. Results: The failure mode of depressive osteochondral fracture wan such that the bone under the articular cartilage had a subchondral plate fracture, an interlacing of bone trabeculae under the plate, and a few fractures of the bone trabeculae. The interlacing of subchondral bone trabeculae was most evident in the normal bone as compared with the osteoporotic and osteosclerotic bones. The osteosclerotic bone failed at the highest load, while the osteoporotic bone failed at the lowest. Conclusion: The subchondral plate fracture and the interlacing of subchondral bone trabeculae under the plate are the characteristics of the failure mode of depressive ostechondral fracture. This failure mode occurs before there is a discernible fracture of the subchondral bone trabeculae. The amount of load causing fracture depends on the quality of the bone. Relevance: The failure mode, especially the interlacing of subchondral bone trabeculae, night function as a load absorber from the articular cartilage. Therefore, the quality of subchondral bone is important for protection of the articular cartilage from compressive load injury.

Local compressive strength at the middle of the weight-bearing surface of the femoral head and talar dome: A biomechanical study.

Objective: To compare the local compressive strength at the middle of the weight bearing surface of the femoral head and talar dome. Design: Cadaveric and comparative experimental study. The compressive strength of the talar dome and the femoral head were measured and compared. Background: The prevalence of late collapse of femoral head from avascular osteonecrosis is higher than that of the talar dome. The femoral head and acetabulum form a hip joint with monoarticulation whereas the talus itself has several articulations with several bones, so the talar dome distributes load more effectively from it the surroundings than does the femoral head. Compressive strength of the weight bearing surface of the femoral head and talar dome, however, may play a role in late collapse. Methods: Ten fresh cadaveric normal adult femoral heads and tali were obtained. A compressive load was applied through an indenter at the middle of the superior quadrant of the femoral head and talar dome by using a universal testing machine until a maximum load was obtained. The maximum load and depth of depression at maximum load were recorded. Results: The middle of the weight bearing surface of the femoral head could withstand an average maximum pressure of 30.42 MPa. Its stillness was 929.04 N/mm and its depth of depression was 1.11 mm. The corresponding figures for the talar dome were 49.64 Mpa, 1631.65 N/mm, and 0.96 mm respectively. Conclusion : This study showed that local compressive strength at the middle of the weight bearing surface of the talar dome was 1.63 times greater than that of the femoral head. Relevance : This finding may explain the higher prevalence of late collapsing avascular necrosis of the femoral head than that of the talar dome.

A simple procedure for reducing anterior shoulder dislocation without anesthesia: Traction, abduction and external rotation.

General anaesthesia is normally used for facilitating reduction of anterior dislocation of the shoulder. To avoid anaesthesia or other medication, a simple technique of reduction of the shoulder dislocation by applying gentle traction along the extremity in elbow extension and continuing abduction with external rotation of the shoulder has been used. Since 1975, this simple procedure has been used in 32 patients who sustained anterior dislocation of the shoulder. The dislocation was a recurrence in 11 of the patients and a primary in 21 patients. The mechanism of reduction was studied by observing the relationship of the humeral head and glenoid using portable X-ray in anteroposterior and transaxillary views of the shoulder in nine patients. The results showed that there was no need for anaesthesia. All shoulder joints were successfully reduced without the need for assistance or the use of instruments. The mechanism of reduction showed that when the shoulder was 0-90 degree abducted during applying the traction, the humeral head rose upwards and closed outwards to the centre of the glenoid fossa, but remained anterior to the glenoid . When the shoulder was externally rotated during continuing abduction from 90 to 110 degrees, there was disengagement of the posterolateral aspect of the humeral head from the anterior aspect of the glenoid rim. Under those conditions, successful reduction of the shoulder was achieved.

Extraspinal canal lumbar disectomy: Via transverse pediculotransverse process approach technique.

This study reviews the developed technique of pediculoteansverse process approach for extraspinal lumbar disectomy which performs at lateral aspect near the posterior of lumbar disc space. This technique specifies only the soft tissue operation. Thus, it is different from the conventional disectomy. The technique can avoid epidural fibrosis, that compresses nerve roots, excision of the bone at the posterior part of lumbar spine and also surgical trauma to the lumbar nerves in the spinal canal. During November 1992- October 1993, the pediculoransverse process approach technique of lumbar disectomy was performed in 33 patients who suffered lumbar disc herniation, consisted of 10 females and 23 males, with age ranged 22-59 years old. The lesions were comfirmed by MRI as contained lumbar disc herniation and no extrusion of disc material into the spinal canal. The level of the lesions were two L 3-4, twenty – four L4-5 and seven L5 S1 levels. The results were that the hossptalization were only 2-3 days. The radicular pain to the leg disappeared immediately one day postoperation. Back pain improved about 80-90 percentage at the first day after operation and no residual back pain at two week later. The sensory deficit recovered about 80-90 percentage in one day and completely recovered in 1-2 weeks. The motor power and reflex changes recovered about 2 months. No complications were found in this series except only two patients had reoperation. The first one was operated at L4-5 disc space ans had symptoms free for 3 weeks. Afterwards he suffered low back pain and radicular pain to the fight leg again. The same operative technique was performed and it was found that the retained disc material compressed the same fifth lumbar nerve root. The other one suffered again low back pain and radicular pain, after symptoms free for six months. The diagnosis was spinal stenosis at L4-5 level and decompressive total laminectomy at L4-5 was done and radicular pain was improved except the back pain still persisted. The x-ray of lumbar spine showd postlaminectomy L4-5 spondylodisthesis and his back pain could be relieved by lumbosacral support. During 8 months to 1 year and 4 months follow up, the clinical evaluation found that all of 33 patients were graded in the good results.

The use of the simple designed bone awl to facilitate the bankart operation.

This study reviews the results of using the simply designed bone awl to simplify the Bankart operation. The awl is characterized by a handle connected to the curved part in a bayonet position. The curve is 2.5 cm. In diameter, 2-3 mm. thick, with a sharp tip, as in a trocar point. During 1987-1989, this instrument was used to perform the Bankart operation in 13 patients with recument dislocation of the shoulder. The patient’s ages ranged from 18-31 years, twelve were males and one was female. Eleven patients suffered dislocation of the right shoulder and two of suffered dislocation of the left. In the operation, the awl could perform 3 holes at the edge of the glenoid. Three millimeters from the glenoid edge was the proper area to make the inlet hole. The canal was curve and 2 mm. in diameter. The outlet hole through the articular suface was 2 mm. below the glenoid edge. The time spent boring one hole was about 2 minutes and the hole could provide adequate strength to suture the anterior capsule to the glenoid edge without breakage of the hole. The use of the awl minimizes the duration of the operation and decreases the surgical trauma. The clinical results of five year follow-up showed that the patients could move the shoulder joint in full range of motion in two and a half months, and could do heavy duty work and play the sport in about three and a half months with no re-dislocation.

The stable upper tibial osteotomy for treatment of osteoarthritic knee (part III): The simplified medial opening step wedge technique.

This study reviews the simplified medial opening step wedge technique for upper tibial osteotomy by performing the operation without osteotomy of fibula and using narrow straight plate instead of T-plate fixation of the tibia. During 1991-1993, this simplified osteotomy technique was used in 19 patients 2 males and 19 females with age ranged 51-69 years old, whose 21 knees had degenerative varus osteoarthritic, 15 right and 6 left knees. Among these 19 patients, both joint debridement of the knees and the osteotomy were done in 2 patients suffered from osteoarthritic knees with excessive osteophytes near the joint surface. The result of 1-2 year follow up showed that the technique provided increased stability of osteotomy site, decreased postoperative swelling and pain during exercise and ragne of motion of the knees. Moreover, it could reduce the operative time. For the union of osteotomy, radiologic changing appearance of the knees and used the knees in daily activities were similar to the results of the treatment of osteoarthritic knees by technique of medial opening and lateral closing step wedge upper tibial soteotomy.

The stable upper tibial osteotomy for the treatment of osteoarthritic knee: Madial opening step wedge technique (part II).

This study reviews the results of the osteotomy technique of the upper tibia as medial opening step wedge using two iliac bone grafts fixed with a T-plate for the treatment of degenerative varus osteoarthritic knee. The technique was used in 32 patients twenty six females and six males with ages ranging from 50-65 years. During the two to four years postoperative follow up, we found that postoperative casting was nit necessary. The patients could move their knees after 3-5 days and a full range of motion was noted in one-and-a half months. However in 8 cases who had coincidentally suffered joint debridement, the full range of motion was obtained in about two and half months. The union of the graft osteotomy took one and a half months. Most importantly there was no alteration in the angle the corrected joint. Roentgeon appearances of the knees after one year showed the widening of the medial joint space, the decrease of subchondral bone sclerosis and the size of osteophytes and the knee joints were stable.

The stable upper tibial osteotomy for the treatment of osteoarthritis knee: Lateral closing step wedge osteotomy (part I).

This study reviews the results of the lateral closing step wedge technique for upper tibial osteotomy and fixation with an osteotomy plate for the treatment of degenerative various osteoarthritic knee. This technique of osteotomy was used in 10 patients, two males and eight females whose ages ranged from 52-66 years. During the five years postoperative follow up, we found that postoperative casting was not necessary and the patients could move the knees after 3-5 days and full range of motion was noted in one and a half months. Among these 10 patients, both joint debridement and osteotomy were done in 4 patients suffered from osteoarthritis knees with excessive osteophytes and loose bodies in the joint cavity, the full range of motion was obtained in about two and a half months. The union of the osteotomy took two months in all 10 patients and between 2-8 months they could return to their daily activities with some intermittent knee pain which relieved by analgesic drugs or using a cane. After 8 months – 5 years, nine of ten patients had no knee pain, only one patent persisted mild knee pain. Roentgen appearances of the knees after one year showed a decrease of subchondrol bone sclerosis, and the widening of the medial joint space as well as stable knee joints.