Platypnoea-orthodeoxia after left total knee replacement.

Platypnoea-orthodeoxia syndrome (POS) is a rare disorder characterised by both dyspnoea (platypnoea) and arterial desaturation (orthodeoxia) in the upright position, with improvement in the supine position. We report an unusual case in which an 82-year-old woman developed severe hypoxaemia with POS after left total knee replacement. A significant difference in alveolar-arterial blood gas oxygen tension was demonstrated, and hypoxaemia failed to respond to 100% oxygen supply. A patent foramen ovale with a right-to-left shunt was evident on transoesophageal echocardiogram employing colour Doppler and agitated normal saline studies. Interestingly, the patient's symptoms resolved within 6 months with ongoing chest physiotherapy, without surgical or medical intervention.

Ruptured hepatocellular carcinoma disguising as heterotopic pregnancy.

The incidence of hepatocellular carcinoma (HCC) in pregnancy is rare but is typically aggressive, with a 1-year survival rate of 23%. One of the complications of HCC is spontaneous rupture, resulting in haemoperitoneum. A 36-year-old pregnant Chinese immigrant who was positive for hepatitis B virus and in her first trimester presented to the emergency department of Wyong Hospital, Hamlyn Terrace, New South Wales, Australia, with severe epigastric and right upper quadrant pain and haemodynamic instability. Spontaneous rupture of a heterotopic pregnancy was initially suspected. However, histopathological staining of the lesions excised during surgery revealed HCC. To our knowledge, this is the first case of spontaneous rupture of HCC with haemoperitoneum during pregnancy in Australia. As developed countries receive global migrants, similar cases may be seen in the future. Epidemiological studies suggest that immigrants from China and Vietnam have the highest incidence of chronic hepatitis B virus carrier status.

Foot Pressure Changes Before and After Ankle Fusion: A Pedobarograph Study.

We performed a case-control study with the purpose of establishing the pressure patterns in the soles of the feet of patients with ankle osteoarthritis, determining whether the pattern changed after treating the arthritis with ankle joint fusion (arthrodesis), and whether the change is significant. We also studied the benefits of ankle fusion with respect to the Short-Form 36-item Health Survey and the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale. The study included 18 participants (9 in the study group and 9 in the control group) to reach statistical significance with a 95% confidence interval (CI). A demonstrable increase was found in both forefoot and hind-foot pressures in the study group preoperatively compared with the control group. Also, a demonstrable increase was found in the pressure in both the forefoot (mean difference 50.56 ± 267.39 kPa) and the hindfoot (mean difference 57.44 ± 160.27 kPa) from preoperatively to postoperatively. This difference was not statistically significant (p = .59 [t(8) = 0.57]; 95% CI 256.10 to -154.98) for the forefoot pressures and for the hindfoot pressures (p = .31 [t(8) = 1.08]; 95% CI 180.64 to -65.76). The Short-Form 36-item scores significantly improved from preoperatively to postoperatively (p = .000054 for the physical component and p = .018 for the mental component). The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale score also improved significantly (p = .0000005). The foot pressures, as measured by using the insole sensors, showed an increase in forefoot and hindfoot pressures that was not statistically significant.

Early Results of Minimally Invasive Percutaneous Plate Osteosynthesis for Fractures of the Distal Tibia: A Retrospective Case Series and Review of the Literature.

Minimally invasive percutaneous plate osteosynthesis was developed on the concept that preservation of the soft tissue envelope during surgical management of distal tibial fractures is of paramount importance. We report on our early experience using this technique over a 1-year period with 14 such injuries that were treated by a locking compression plate via minimally invasive surgery. The surgical reduction was excellent in most of the cases and all fractures healed uneventfully. One superficial infection and a wound slough were the only complications recorded. The mean follow-up was at 15 months, and all patients were satisfied with a mean ankle-hindfoot score of 84. Early results of such management are very encouraging.

Cervicofacial and mediastinal emphysema complicating tooth extraction in an elderly patient: a preventable complication.

Subcutaneous emphysema is widely documented in the literature and well known by doctors and dentists. However, subcutaneous emphysema following tooth extraction is not very common.We report the case of a 72-year-old female who presented to the emergency department of the Bunbury Hospital in Bunbury in the state of Western Australia in Australia, with subcutaneous emphysema of the face and neck with extension into the mediastinum, following a complicated tooth extraction in 2016. It was a dramatic and scary occurrence for both the patient and dentist, but totally preventable. The investigations and treatment could have been very invasive. However, with limited and essential management, the process was kept simple and safe for the patient.

Predictive value of Tokuhashi and Tomita scores in patients with metastatic spine disease.

OBJECTIVE: Our aim was to determine the best preoperative prognostic score to safely propose operative intervention for patients with metastatic spinal disease. METHODS: This prospective cohort study included 52 consecutive patients who underwent surgery between 1997 and 2007 to alleviate pain and preserve or restore neurological function. All patients were prospectively evaluated with the Tokuhashi score and retrospectively with the Tomita score to compare their surgery indications. The relationship between the scores and overall survival time were compared. P values of less than 0.05 were considered significant. RESULTS: In predicting survival time, the Tokuhashi score was statistically significant (r=0.574, p=0.01), and the Tomita score borderline significant (r=-0.394, p=0.05). For overall survival after initial diagnosis, the Tokuhashi score was borderline significant for survival (r=0.380, p=0.05) and the Tomita score was not significant. CONCLUSION: The prognostic Tokuhashi score appears to be more valuable for surgical indications than the Tomita score in patients with spinal metastases.

Outcome of ankle arthrodesis using a transfibular approach.

Variable union rates in ankle arthrodesis using different surgical techniques have been reported in the biomedical literature. However, the advantages of a transfibular approach with sagittal splitting of the fibula have not been widely reported, even though the technique is well known and even described in surgical textbooks. We analyzed outcomes in our practice for all patients who underwent ankle arthrodesis. Over a 5-year period, 2 surgeons using the same transfibular approach performed 26 ankle arthrodeses in 25 patients. The medical records and radiographs of the patients were reviewed for duration of hospital admission, time to union, and complications. All (100%) of the ankle fusions progressed to solid union in a mean postoperative duration of 4.5 ± 1.8 months (range, 2-10 months), and the only clinically significant complication involved 1 patient with suspected complex regional pain syndrome, who responded to treatment and recovered fully.

An unusual etiology for adult-acquired flatfoot.

Rupture of the tibialis posterior tendon is widely believed to result from trauma in the presence of preexisting degenerative changes. We report a case of adult-acquired flatfoot in an otherwise healthy 19-year-old man who sustained a fracture of the medial malleolus.

Popliteal block with transfibular approach in ankle arthrodesis: a case series.

INTRODUCTION: Ankle arthrodesis is primarily undertaken to control severe pain in the ankle joint. Immediate postoperative pain is usually treated using oral analgesics, intravenous opiates and regional anaesthesia. The outcomes of ankle fusion, including patient satisfaction studies, are well documented in the literature. However, the advantage of popliteal block in the management of early postoperative pain after ankle fusion for osteoarthritis has not been widely reported. This study aims to determine the role of popliteal block using ankle fusion in the management of ankle osteoarthritis. CASE PRESENTATION: Ankle arthrodeses were performed in 27 patients over a five-year period. Eighteen patients were males (one had bilateral arthrodesis) and eight were females. Their mean age was 56 years and they were all Caucasians. The notes and radiographs of the patients were reviewed in retrospect for the duration of their hospital admission, time to union and complications. CONCLUSION: Popliteal block is a safe and effective technique for postoperative analgesia in ankle arthrodesis. By using this technique, we achieved a significant reduction in the duration of hospital stay for our patients after ankle arthrodesis. The resultant cost saving was GBP717 for each patient.