Traumatic carotid cavernous fistulas. Rare and life threatening.

Purpose: Carotid-cavernous fistulas (CCFs) are often underdiagnosed or misdiagnosed. In polytraumatized patients, the focus is primarily on treating potentially life-threatening conditions such as increased intracranial pressure and hemorrhages. This case report aims to identify common diagnostic mistakes in rare pathologies. Objective: We present a case of a young female patient who was admitted to the emergency room after a motorbike accident. The patient's vital parameters were successfully stabilized, and she spent approximately four weeks in the ICU and neurosurgical ward. The patient exhibited limited communication, ophthalmoplegia, and a swollen, red left eye. After four weeks, the patient's parents initiated admission to our department due to the suspicious red swollen eye. Angiography revealed a complete rupture of the internal carotid artery (ICA) into the cavernous sinus, and occlusion of the ICA showed significant improvement in the eye edema and the patient's mental state. Two days later, the patient was able to communicate with complex sentences. Three months after the occlusion, the patient showed positive progress, posting dancing videos on TikTok. Conclusion and Importance: A carotid-cavernous fistula presenting with a red swollen eye can be misdiagnosed as retrobulbar hematoma or conjunctivitis. Failure to recognize and treat it promptly can lead to severe morbidity.

Arthroscopically-assisted mini open partial synovectomy for the treatment of localized pigmented villonodular synovitis of the knee. A retrospective comparative study with long-term follow up.

PURPOSE: The purpose of this study was to present the long-term results of treatment of localized pigmented villonodular synovitis (LPVNS) comparing two operative procedures of excision of the lesion-the arthroscopic and the arthroscopically assisted mini-open. We hypothesized that the latter approach allowed for treatment of LPVNS with acceptable recurrence rates, complication rates and functional outcomes. METHODS: Between 1990 and 2006, 21 patients with LPVNS were treated with partial synovectomy through an arthroscopically-assisted mini open technique (group A), and 23 patients were treated with an arthroscopic excision of the lesion (group B). All patients were clinically examined at one, three, and 12 months post-operatively and graded by the Lysholm knee score and the Ogilvie-Harris score. RESULTS: The mean Lysholm score was improved from 58.7 ± 9 to 94.2 ± 7 for group A (p < 0.05) and from 57.4 ± 9.1 to 95.5 ± 8 for group B (p < 0.05). The mean Ogilvie-Harris score was improved from 7.2 ± 2 to 11.2 ± 0.9 for group A and from 7.1 ± 2 to 11.75 ± 0.5 for group B (p < 0.05). We encountered two cases of CRPS and one case of recurrence of the lesion in group A and no complications for group B. CONCLUSIONS: Arthroscopically-assisted mini open partial synovectomy is a safe alternative treatment, especially for surgeons without extended experience in arthroscopic techniques. The arthroscopic localization of the precise position of the lesion and its subsequent mini-open excision is a safe and effective technique with very low morbidity and recurrence rate and equivalent functional outcome to fully arthroscopic excision due to limited incision. LEVEL OF EVIDENCE: Retrospective comparative study, Level III.

Distal Locking Screws for Intramedullary Nailing of Tibial Fractures.

Recently introduced tibial intramedullary nails allow a number of distal screws to be used to reduce the incidence of malalignment and loss of fixation of distal metaphyseal fractures. However, the number of screws and the type of screw configuration to be used remains obscure. This biomechanical study was performed to address this question. Thirty-six Expert tibial nails (Synthes, Oberdorf, Switzerland) were introduced in composite bone models. The models were divided into 4 groups with different distal locking configurations ranging from 2 to 4 screws. A 7-mm gap osteotomy was performed 72 mm from the tibial plafond to simulate a 42-C3 unstable distal tibial fracture. Each group was divided in 3 subgroups and underwent nondestructive biomechanical testing in axial compression, coronal bending, and axial torsion. The passive construct stiffness was measured and statistically analyzed with one-way analysis of variance. Although some differences were noted between the stiffness of each group, these were not statistically significant in compression (P=.105), bending (P=.801), external rotation (P=.246), and internal rotation (P=.370). This in vitro study showed that, when using the Expert tibial nail for unstable distal tibial fractures, the classic configuration of 2 parallel distal screws could provide the necessary stability under partial weight-bearing conditions.

Arthroscopic 4-point suture fixation of anterior cruciate ligament tibial avulsion fractures.

Tibial eminence avulsion fractures are rare injuries occurring mainly in adolescents and young adults. When necessary, regardless of patient age, anatomic reduction and stable internal fixation are mandatory for fracture healing and accurate restoration of normal knee biomechanics. Various arthroscopically assisted fixation methods with sutures, anchors, wires, or screws have been described but can be technically demanding, thus elongating operative times. The purpose of this article is to present a technical variation of arthroscopic suture fixation of anterior cruciate ligament avulsion fractures. Using thoracic drain needles over 2.4-mm anterior cruciate ligament tibial guidewires, we recommend the safe and easy creation of four 2.9-mm tibial tunnels at different angles and at specific points. This technique uses thoracic drain needles as suture passage cannulas and offers 4-point fixation stability, avoiding potential complications of bony bridge fracture and tunnel connection.

Concomitant acromioclavicular and miliary tuberculosis.

A 48-year-old man was being treated unsuccessfully for miliary tuberculosis for 5 months until he presented with acromioclavicular joint swelling. Imaging of the shoulder revealed destruction of the acromioclavicular joint and the patient was brought to the operating theatre and underwent the excision of the distal end of the clavicle, synovectomy and drainage of the abscess. Surgery was followed by prompt clinical, functional and radiological improvement. Histopathology confirmed the diagnosis of acromioclavicular tuberculosis. Resistance to appropriate antituberculous treatment in patients with miliary tuberculosis can sometimes be a result of undiagnosed extrapulmonary site of infection.

Reverse cutting guidewire for intramedullary nailing: a solution for a common yet undocumented and unresolved complication.

In 6 of the 81 patients who were treated with intramedullary nailing for a femoral or tibial fracture the ball-tipped guidewire was impossible to remove manually after nail implantation. In four cases we had to remove the implant and to re-insert the nail. While this is a relatively common complication well known to orthopaedic and trauma surgeons, it has not been previously reported. We developed and tested in vitro a reverse cutting guidewire that was able to successfully deal with this problem obviating the need for implant removal and re-insertion.

Floating elbow injuries in adults: prognostic factors affecting clinical outcomes.

BACKGROUND: Floating elbow fractures in adults are rare and complex injuries with unpredictable outcomes. The present study was designed to assess our experience, analyze possible compilations and illustrate prognostic factors of the final outcome. METHODS: Between 2002 and 2009, 19 patients with floating elbow fractures were treated in our department (mean follow-up, 26 months). The fractures were open in 10 patients (52.6%), and concomitant nerve palsy was present in 10 patients. Although the term "floating elbow" refers only to concomitant ipsilateral humeral and forearm shaft fractures, we also included injuries with intra-articular involvement. We categorized the patients into 4 groups: group I (10 patients) included shaft fractures of humerus and forearm, group IIa (5 patients) and IIb (1 patient) included partial intra-articular injuries, and group III (3 patients) involved only intra-articular comminuted fractures of the elbow region. RESULTS: Fracture healing was observed 14 weeks postoperatively, except in 2 patients, in which elbow arthroplasty was applied, and in 1 with brachial artery injury. Nine patients with nerve neuropraxia recovered 4 months postoperatively, and tendon transfers were necessary in 1 patient. Recovery in patients with nerve palsy was worse than in those without nerve injury (Mayo Elbow Performance Score, 73 vs 88.34; Khalfayan score, 72 vs 88.3). In addition, intra-articular involvement (groups II and III) negatively influenced the final clinical outcome compared with isolated shaft fractures (group I; Mayo Elbow Performance Score, 71.1 vs 88.5; Khalfayan score, 72.67 vs 86.1). CONCLUSIONS: Although the nature of floating elbow injuries is complex, the presence of nerve injury and intra-articular involvement predispose to worse clinical outcomes.

Long head of the biceps pathology combined with rotator cuff tears.

The long head of the biceps tendon (LHBT) is an anatomic structure commonly involved in painful shoulder conditions as a result of trauma, degeneration, or overuse. Recent studies have pointed out the close correlation between LHBT lesions and rotator cuff (RCT) tears. Clinicians need to take into account the importance of the LHBT in the presence of other shoulder pathologies. This paper provides an up-to-date overview of recent publications on anatomy, pathophysiology, diagnosis, classification, and current treatment strategies.

Hemiarthroplasty for pigmented villonodular synovitis of the shoulder: a report of two cases.

Pigmented villonodular synovitis is a reactive condition characterised by exuberant proliferation of synovial villi and nodules. It may be localised or diffuse and can cause severe articular damage. This report is of 2 patients with pigmented villonodular synovitis of the shoulder causing extensive arthritic changes. Both patients underwent shoulder hemiarthroplasty and total synovectomy and achieved satisfactory painless range of motion, with no signs of local recurrence or loosening of the prosthesis after 4 to 5 years of follow-up.

Autologous bone marrow grafting combined with demineralized bone matrix improves consolidation of docking site after distraction osteogenesis.

BACKGROUND: Distraction osteogenesis is used for the reconstruction of extensive osseous defects. Delay in docking site consolidation results in significant prolongation of this surgical procedure. The primary aim of the present study was to retrospectively compare three different treatment options, all aimed at improving and accelerating docking site consolidation. We further sought to clarify whether the application of autologous bone marrow cells combined with demineralized bone matrix would substantially improve docking site consolidation. METHODS: Between 1995 and 2008, forty-three patients (mean age, 38.28 years) were managed with bone transport for the treatment of a tibial bone defect (mean length, 9.49 cm). The patients were divided into three groups according to the "docking site procedure" used: closed compression (Group A), surgical debridement of the docking site and application of autologous iliac bone graft (Group B), or surgical debridement and local application of bone marrow concentrate and demineralized bone matrix (Group C). Docking site consolidation was assessed both radiographically and clinically, and the results were statistically analyzed. RESULTS: The median "healing time" required for docking site consolidation was significantly longer in the compression group as compared with the demineralized bone matrix plus bone marrow group (p = 0.021), whereas there was no difference between the other groups. There was no significant difference among the groups in terms of complication rates (p = 0.702). Docking site consolidation was completed prior to regenerate consolidation in nine of the ten patients in Group C and in 13.6% of the patients in Group B, whereas in all of the remaining patients, completion of regenerate healing always preceded docking site consolidation. CONCLUSIONS: The application of demineralized bone matrix and autologous bone marrow is at least equivalent to autologous cancellous bone graft in terms of substantially reducing docking site healing time compared with closed compression alone. The application of demineralized bone matrix and autologous bone marrow is an effective treatment option, with minimal donor site morbidity, for reducing consolidation time of the docking site in tibial defects treated with distraction osteogenesis.

New trends in fixation of proximal humeral fractures: a review.

Surgical treatment of proximal humeral fractures continues to be a challenge especially in osteoporotic patients. Locking plates and intramedullary nails have been used with satisfactory results but the previous reported complications have not been substantially reduced. Most of the existing studies involve a small number of patients followed up for a rather short period of time. Since proximal humeral fractures constitute a heterogenous group of complex fractures in an even more heterogenous population, no single fixation method is a panacea. Choice of implant and method of fixation should be selected according to individual patient and fracture pattern characteristics based on clearly defined indications and contraindications. Based on the findings of the existing clinical studies the authors propose a treatment algorithm.

Functional outcome and structural integrity following mini-open repair of large and massive rotator cuff tears: a 3-5 year follow-up study.

BACKGROUND: Mini-open approach has been considered for years the gold standard for rotator cuff repairs. Nevertheless, the rate of tendon-to-bone healing, and that of cuff re-tear, still remains unclear. METHODS: Between 2001 and 2004, 37 shoulders (32 patients) with a mean age of 54.8 years (range, 34-72) and a large or massive cuff tear were repaired with a mini-open procedure. At a minimum of 3 years postoperatively (range, 36-60 months), 27 shoulders (23 patients) underwent functional evaluation and US investigation of cuff integrity. RESULTS: The rotator cuff was completely healed and watertight in 13 cases (48.1%), while recurrent defects were detected in the remaining 14 shoulders (51.9%). In 12 cases (92.5%), the recurrent tears were smaller and in 2 (7.5%) larger than the initial tear. Despite the high re-tear rate, the overall Constant and UCLA scores improved from of 38.4 to 72.1 and 11.2 to 29.4, respectively. However, only "large" re-tears were correlated with a worse functional outcome (P < .005). The preoperative tear size was negatively associated with tendon healing. Patients with an intact rotator cuff repair were, on average, 15 years younger (49.9) than those who sustained a tear recurrence (64.14) (P < .005). DISCUSSION: Our results suggest that large and massive rotator cuff tears treated with mini-open technique using a tendon-grasping suture have a very satisfactory clinical outcome, despite a significant re-tear rate. Patient age, the size of the initial tear, as well as the size of a potential re-tear are factors affecting the final clinical outcome.

Surgical treatment of a twice recurrent chondrosarcoma of the pubic symphysis: a case report and review of the literature.

The case of a patient with a second recurrence of a chondrosarcoma of the pelvis and pubic symphysis is presented, in order to show the difficulties of the surgical treatment and the long course of the tumor.A 56-year-old woman having already been operated upon twice within two decades, presented with a large, mass of the pubic symphysis, extending into the left proximal thigh.Preoperative imaging revealed a large tumor occupying the pubic symphysis and the pubic bones up to the ischial tuberosities, extending into the soft tissues of the inner surface of the left thigh and displacing the urinary bladder, the urethra and the vagina.Intraoperatively, a radical excision of the tumor was performed, including removal of the osseous substrate of the anterior pelvis. The anterior abdominal wall was supported with a special synthetic mesh secured on the osseous stumps in order to prevent visceral herniation. Histological examination showed grade I to II chondrosarcoma, while the patient's postoperative course was uncomplicated.At the latest follow-up two years postoperatively, the patient is pain-free and ambulatory with no signs of tumor recurrence, genitourinary complications or visceral herniation.

Mid-term results of internal fixation of proximal humeral fractures with the Philos plate.

OBJECTIVE: To report our experience from the use of the Philos plate for the treatment of three- and four-part proximal humeral fractures and to investigate factors influencing the final outcome. MATERIALS AND METHODS: Between April 2005 and September 2007, 29 Philos plates were implanted in 17 women and 12 men, with a mean age of 62.3 years (range: 28-80 years). Positioning of the plate was performed under fluoroscopic control, through a deltopectoral approach and with the patient in the beach chair position. 27 patients were available for follow-up (mean: 17.9 months; range: 12-39). Follow-up included plain shoulder radiographs and functional assessment with Constant-Murley score. RESULTS: Healing of the fracture occurred uneventfully within 6 months. In three patients, humeral head collapsed due to aseptic necrosis after fracture healing and the plate had to be removed in two cases. In one patient, fracture healing occurred in >10 degrees varus displacement. The clinical result according to the Constant-Murley score was 86 points (range: 58-112). CONCLUSIONS: Internal fixation with the Philos plate seems to be a reliable option in the operative treatment of upper end humeral fractures, especially in osteoporotic bone. It allows secure fracture fixation and quick shoulder mobilisation, while quick and uneventful fracture healing and very satisfactory clinical results are achieved.

Suction during orthopaedic surgery. How safe is the suction tip?

The use of a suction system is mandatory in most orthopaedic procedures. In the unlikely event of contamination of the system, deep wound infection could occur, jeopardising the operation. We have prospectively studied 50 patients who underwent elective and orthopaedic trauma procedures during which a suction system was used. At the end of each procedure the suction catheter tip was sent for culture and microbiology. The suction tips showed bacterial contamination in 27 cases (54%). Staphylococcus species were responsible in 21 cases (77.8%). The tip was contaminated in only 1/11 procedures lasting less than one hour (9.1%), as compared with 26/39 procedures when operative time exceeded one hour (66.7%). However, deep wound infection was recorded in only one case. We believe that despite the low risk of deep wound infection, changing the suction tip every hour in long orthopaedic procedures or using the on/off switch is well justified in an effort to minimise the chances of deep wound infection.

Ultrasonography of symptomatic rotator cuff tears compared with MR imaging and surgery.

PURPOSE: To compare the accuracy of ultrasonography and magnetic resonance imaging in the detection of rotator cuff tears. MATERIALS AND METHODS: Ninety-six patients with clinically suspected rotator cuff pathology underwent ultrasonography and magnetic resonance imaging of the shoulder. The findings in 88 patients were compared with arthroscopy or open surgery. RESULTS: Full-thickness tear was confirmed in 57 cases, partial-thickness tear in 30 cases and degenerative changes without tear in 1. In all 57 cases of full-thickness tear and in 28 out of 30 cases of partial-thickness tear the supraspinatus tendon was involved. The accuracy in the detection of full-thickness tears was 98 and 100% for ultrasonography and magnetic resonance imaging, respectively. The accuracy in the detection of bursal or articular partial-thickness tears was 87 and 90% for ultrasonography and magnetic resonance imaging, respectively. CONCLUSIONS: In experienced hands ultrasonography should be considered as an accurate modality for the initial investigation of rotator cuff, especially supraspinatus, tears.

Atraumatic haemarthrosis following total knee replacement treated with selective embolisation.

Spontaneous haemarthrosis in the absence of anticoagulant medication or a bleeding disorder is a very rare complication after total knee arthroplasty. A case of recurrent spontaneous haemarthrosis following total knee replacement in a 69-year-old patient is reported. Angiography was used to aid the diagnosis. It demonstrated an abnormal blush of vessels around the anterior aspect of the knee joint, that was fed by genicular branches and a recurrent branch of the anterior tibial artery. Selective embolisation of the bleeding vessels with coils led to immediate control of the bleeding. No further recurrence of haemarthrosis has been recorded.

Treatment of tuberculous spondylitis with anterior stabilization and titanium cage.

UNLABELLED: We retrospectively reviewed 12 patients with spinal tuberculosis of the thoracic and lumbar spine who had radical débridement, anterior decompression, interbody arthrodesis with an anterior interbody titanium cage, and autologous bone grafts, combined with a standardized perioperative antituberculous regimen. Their mean age was 55.1 years and they were observed for a mean of 65.3 months. Indications for surgery included epidural abscess, structural destruction with instability, progressive kyphosis, and/or neurologic deterioration. Kyphotic deformity was corrected from a mean of 24.6 degrees (range, 15 degrees-32 degrees) to a mean of 10 degrees (range, 4 degrees-18 degrees). Tuberculous infection was controlled and bony fusion was achieved in all patients. No recurrence of infection or construct failure was recorded. All patients were safely mobilized within the first postoperative week; back pain fully resolved in eight patients and improved in the remaining four. We conclude that radical débridement followed by anterior stabilization with a titanium cage and bone grafting is a reasonable alternative for tuberculous spondylitis requiring surgical treatment. It enables accurate and lasting deformity correction and provides adequate stability to allow early mobilization. The presence of a titanium cage in an area of mycobacterial infection did not preclude infection control or lead to recurrence. LEVEL OF EVIDENCE: Therapeutic study. Level IV (case series). Please see Guidelines for Authors for a complete description of levels of evidence.

Reduction of postoperative spinal infections based on an etiologic protocol.

UNLABELLED: Acute postoperative spinal infections are serious complications. We saw a sudden increase in the infection rate in our unit during a 6-month period. This led us to construct an assessment protocol combining risk factors into a mnemonic we named the "Nine Ps Protocol" (patient-related factors, personnel, place, preoperative length of stay, procedure, prosthetics, prophylaxis, packed red blood cells, and pus cultures). We reviewed 102 consecutive patients having spine surgery in three sequential 6 month periods: Group A included 34 patients before the outbreak of infection and Group B included 26 patients during the outbreak of infection. We prospectively applied the protocol in 26 patients (Group C) after the outbreak. After the implementation of the protocol the infection rate dropped from 16.7% (Group B) to 3.6% (Group C). Increased risk factors for postoperative infection included advanced age, posterior instrumented fusion, high allogenic blood transfusion rates, and suboptimal sheet and dressing changing conditions. We propose the Nine Ps Protocol as a useful clinical tool for the etiologic assessment and prevention of spinal infections. LEVEL OF EVIDENCE: Prognostic study, Level II (Lesser quality prospective study [eg, patients enrolled at different points in their disease or < 80% followup]). Please see Guidelines for Authors for a complete description of levels of evidence.