'Reverse' scarf osteotomy for bunionette correction: Initial results of a new surgical technique.

BACKGROUND: The bunionette or tailor's bunion is a lateral prominence of the fifth metatarsal head. It is usually characterised by a wide intermetatarsal angle (IMA) between the 4th and 5th metatarsals, varus of the metatarsophalangeal (MTP) joint, pain and callus formation. Various distal, shaft and basal osteotomies have been described in the literature. We have described a reverse scarf osteotomy for bunionette correction. PATIENTS AND METHODS: We have used a 'reverse' scarf osteotomy in 12 cases (10F: 2M) with a mean follow-up of 12 months (range 5-22 months) with radiographs and clinical scoring. RESULTS: Post operatively, mean IMA improved from 13.1° to 7.27° (range 2.0-11.5°); mean 5th MTP angle improved from 19.9° to 6.36° (range 2.8-9.0°) and postoperative mean AOFAS improved from 54.25 to 89.58 (range 70-100). CONCLUSION: 'Reverse' scarf osteotomy in the correction of bunionette deformity offers promising results in the short term.

Malreduction of syndesmosis--are we considering the anatomical variation?

Previous studies have demonstrated the need for accurate reduction of ankle syndesmosis. Measurement of syndesmosis is difficult on plain radiographs. A computed tomography (CT) scan allows better visualisation of the transverse relationship between the fibula and incisura fibularis. The difference ('G' a term we coined for ease of description) between the fibula and the anterior and posterior facets of the incisura fibularis was compared between normal and injured ankles following syndesmotic fixation in 19 patients. The mean diastasis (MD) was also calculated, representing the average measurement between the fibula and the anterior and posterior incisura. When compared with the normal side, eight out of 19 (42%) cases were found to have a residual diastasis even after fixation across the syndesmosis. However, if a standard value of G (2mm) was used for the injured leg only, all of the 19 cases would have abnormal values of 'G' following reduction. Our study has clearly demonstrated the need for individualising the assessment method to guide surgeons and radiologists prior to revision surgery. A standard value of 'G' of 2mm as the normal limit cannot be applied universally, as apparent from the data presented in this study.

Percutaneous fusion of the sacroiliac joint with hollow modular anchorage screws: clinical and radiological outcome.

We reviewed 15 consecutive patients, 11 women and four men, with a mean age of 48.7 years (37.3 to 62.6), who between July 2004 and August 2007 had undergone percutaneous sacroiliac fusion using hollow modular anchorage screws filled with demineralised bone matrix. Each patient was carefully assessed to exclude other conditions and underwent pre-operative CT and MR scans. The diagnosis of symptomatic sacroiliac disease was confirmed by an injection of local anaesthetic and steroid under image intensifier control. The short form-36 questionnaire and Majeed's scoring system were used for pre- and post-operative functional evaluation. Post-operative radiological evaluation was performed using plain radiographs. Intra-operative blood loss was minimal and there were no post-operative clinical or radiological complications. The mean follow-up was for 17 months (9 to 39). The mean short form-36 scores improved from 37 (23 to 51) to 80 (67 to 92) for physical function and from 53 (34 to 73) to 86 (70 to 98) for general health (p = 0.037). The mean Majeed's score improved from 37 (18 to 54) pre-operatively to 79 (63 to 96) post-operatively (p = 0.014). There were 13 good to excellent results. The remaining two patients improved in short form-36 from a mean of 29 (26 to 35) to 48 (44 to 52). Their persistent pain was probably due to concurrent lumbar pathology. We conclude that percutaneous hollow modular anchorage screws are a satisfactory method of achieving sacroiliac fusion.

Combined femoral and Chiari osteotomies for reconstruction of the painful subluxation or dislocation of the hip in cerebral palsy. A long-term outcome study.

In order to treat painful subluxation or dislocation secondary to cerebral palsy, 11 patients (12 hips) underwent combined femoral and Chiari pelvic osteotomies with additional soft-tissue releases at a mean age of 14.1 years (9.1 to 17.8). Relief of pain, improvement in movement of the hip, and in sitting posture, and ease of perineal care were recorded in all, and were maintained at a mean follow-up of 13.1 years (8 to 17.5). The improvement in general mobility was marginal, but those who were able to walk benefited the most. The radiological measurements made before operation were modified afterwards to use the lateral margin of the neoacetabulum produced by the pelvic osteotomy. The radiological migration index improved from a mean of 80.6% (61% to 100%) to 13.7% (0% to 33%) (p < 0.0001). The mean changes in centre edge angle and Sharp's angle were 72 degrees (56 degrees to 87 degrees; p < 0.0001) and 12.3 degrees (9 degrees to 15.6 degrees; p < 0.0001), respectively. Radiological evidence of progressive arthritic change was seen in one hip, in which only a partial reduction had been achieved, and there was early narrowing of the joint space in another. Painless heterotopic ossification was observed in one patient with athetoid quadriplegia. In seven hips the lateral Kawamura approach, elevating the greater trochanter, provided exposure for both osteotomies and allowed the construction of a dome-shaped iliac osteotomy, while protecting the sciatic nerve.

The use of multi-media messaging in the referral of musculoskeletal limb injuries to a tertiary trauma unit using: a 1-month evaluation.

OBJECTIVES: New developments in telecommunications will have a profound effect on the delivery of medical care throughout the world. In Northern Ireland three trauma centres provide fracture care for their own and surrounding Emergency Departments. All trauma referrals are currently taken by telephone. It is our experience that the verbal description of the radiographs of a musculoskeletal limb injury can be inaccurate, necessitating us to view the plain films of the patient. By utilising a recent advance in telecommunications technology, the launch of mobile handsets with multi-media messaging (MMS) service capability, it is now possible to digitally capture and instantly send an image of a plain film. PURPOSE: To evaluate the use of multi-media messaging as a supplement to the telephone referral of musculoskeletal limb injures. METHOD: : Following a referral using, the emergency physician and the trauma surgeon evaluated the multi-media consult through a survey questionnaire. RESULTS: Between the 1st December 2003 and the 1st January 2004, 46 multi-media consultations were performed. Picture quality was acceptable in all but one of the referrals. In 35 of the 46 referrals the multi-media image of the plain films was felt to improve the management of the patient. In 8 of the 46 referrals the multi-media image of the plain films was felt to change the management of the patient. CONCLUSION: A multi-media messaging store- and forward telemedicine system has potential to facilitate the rapid, cost-effective management of musculoskeletal limb injuries thereby enhancing clinical care.

A new technique of fixation of radial head fractures using a modified tubular plate.

Radial head fractures are fairly common, occurring in 17-44% of all elbow injuries. Mason Type 2 fractures may be fixed using mini fragment screws, this fixation often needing augmentation with a plate to make the construct rotationally stable. However, the drill holes needed to fix the plate to the radial head, carry the risk of inflicting more injury to the fractured fragments. In our case, the radial head fracture was fixed with a modified one-third tubular plate. The plate was cut through the distal hole and the two cut ends were bent into hooks. These two hooks were engaged into two breaches made on the margin of the radial head and this provided rotational stability to the head without causing further damage. The fracture healed well and the patient regained full movement in the elbow. We conclude that this method may be used to fix fractures of the radial head, which require additional support with a plate.

Elastofibroma dorsi--a case report and review of literature.

Elastofibroma dorsi, named for its characteristic location, is a benign soft tissue tumour occurring most often in the infrascapular region of elderly women. It has been infrequently reported in other anatomic locations. Elastofibroma is a rare non-encapsulated benign tumour characterised by the proliferation of elastin fibres in a stroma of collagenous and fatty connective tissue. This presents as an obvious swelling deep to the scapula, making the scapula prominent, causing periscapular pain, discomfort and loss of range of motion in the shoulder. This article presents a typical case and a brief review of the literature. The clinical aspects and the characteristic magnetic resonance findings are discussed to help emphasise the fact that these tumours are entirely innocuous and need not be subjected to surgical excision.

Irreducible acute anterior shoulder dislocation.

Irreducible acute anterior dislocation of the shoulder has rarely been reported in the literature. This report describes a shoulder dislocation in a patient, which required open disimpaction of the humeral head from the glenoid before reduction of the glenohumeral dislocation could be achieved.

Popliteus tendon rupture: a case report and review of the literature.

Isolated rupture of the popliteus musculotendinous unit is an uncommon injury. A case is here reported of a semiprofessional athlete with a ruptured popliteus tendon without significant instability of the knee. The diagnosis was made by magnetic resonance imaging and confirmed by arthroscopy.

Stress fracture of the hook of the hamate.

Fractures of the hook of the hamate have rarely been reported. They have usually resulted from blunt trauma or a sharp strike against the hamate hook while swinging a golf club, baseball bat, or tennis racquet. Patients present with acute onset of pain localised over the ulnar aspect of the wrist and reduction in grip strength. In the case reported here, the patient complained of gradual onset of pain on the ulnar aspect of the wrist after altering his grip for serving in tennis. Once the diagnosis was made, the fracture was treated conservatively and the patient made a complete recovery.