Reverse shoulder arthroplasty with glenoid bone grafting for anterior glenoid rim fracture associated with glenohumeral dislocation and proximal humerus fracture.

BACKGROUND: Large fractures of the anterior glenoid rim can result in persisting instability and osteoarthritis of the glenohumeral joint When this fracture is associated with a glenohumeral dislocation and proximal humerus fracture could be a concern. The goal of this paper was to evaluate the clinical and radiological outcomes and complications of reverse shoulder arthroplasty (RSA) and glenoid bone graft in cases with a significant anterior glenoid fracture associated with a proximal humerus fracture. HYPOTHESIS: RSA and step bone graft harvested from proximal humeral head could be a viable option in the treatment of this complex injury. DESIGN: Retrospective case series. MATERIAL AND METHODS: Twenty-six patients underwent RSA and glenoid bone graft in a single stage procedure were evaluated at an average 32 months postoperatively. There were 18 women and 8 men with a mean age of 68.5 years (range 63-75 years). Reverse shoulder arthroplasty with a contoured glenoid bone graft placed underneath the baseplate using humeral head autograft was utilized in all cases. Clinical outcomes were evaluated with range of motion, Constant score and self-reported subjective outcome rated as excellent, good, fair or poor. Radiographic evaluation was performed to evaluate for baseplate displacement or loosening, bone graft union, resorption or collapse. RESULTS: At final follow-up, average active elevation was 135° (range 110°-145°), abduction 122° (range 60°-160°), and external rotation 30° (range 0 to 45°). The mean Constant score was 68.2 (range 54-83). The clinical results were rated as excellent by 15 patients, good by 9, and fair by 2. Radiographic evaluation showed the disc of cancellous bone graft healed without any signs of graft resorption or migration in all 26 cases. No reoperation was performed on any patient in this series. DISCUSSION/CONCLUSION: RSA with glenoid bone grafting produces satisfactory short-term outcomes with acceptable complication rates for treatment of patients greater than 60 years old with proximal humerus fractures associated with an anterior glenoid rim fracture. Further studies are necessary to determine the extended viability of this procedure. LEVEL OF EVIDENCE: III.

Intramedullary clavicle fixation with single large fragmentary screw.

BACKGROUND: The treatment of clavicle fractures has historically been nonoperative, but several studies have recently shown the merits of operative management for specific fractures patterns. We developed a novel technique utilizing a 6.5-mm cannulated screw for fixation of displaced midshaft clavicle fractures. MATERIALS AND METHODS: We present 15 consecutive patients treated with this technique between 2007 and 2012. All patients were male, and all 15 suffered a traumatic injury involving a fall directly onto the affected side. Mean time from injury to surgery was 12 days (range 3-24 days). Decision for surgery was based on the displacement and shortening of the fracture, either at least 20 mm of shortening or displacement with no bony apposition. After surgery, all patients were placed in an abduction brace for 6 weeks. No motion was allowed for the first 3 weeks, followed by passive shoulder motion below 90° of forward flexion under the supervision of a therapist for the next 3 weeks. RESULTS: All 15 patients progressed to union at an average of 5.7 months (range 3-12). Three patients had superficial wound infections. Hardware removal was performed in 6 of the 15 patients at an average of 12 months (range 5-24). All patients regained full range of motion and strength in comparison with contralateral extremity. CONCLUSION: This novel technique limits soft tissue stripping. It has the advantages of using an implant familiar to most orthopedists and available in most hospital settings. We believe this technique is ideally suited for transverse fractures patterns, less than 14 days old, in males greater than 180 cm with clavicles large enough to accommodate a 6.5-mm screw.

Reversible renal allograft dysfunction and proteinuria from nutcracker-like syndrome: a case report.

A 27-year-old Hispanic man with hypertension and renal failure was on hemodialysis for 4 years prior to receiving a living donor renal transplant from his 19-year-old sister. His serum creatinine decreased to 1.7 mg/dL at 3 weeks posttransplant with a urine protein creatinine ratio (UP) of 0.1 (g/g). Over the next 2 months, he experienced repeated episodes of allograft dysfunction with elevation of creatinine and proteinuria levels, associated with a lymphocele. Doppler studies of the allograft revealed renal vein compression. His symptoms responded to aspiration of the fluid collection, resolving completely with surgical drainage. We believe that the episodes of allograft dysfunction and proteinuria were related to recurrent lymphocele, causing a nutcracker-like syndrome.

Falsely raised TSH levels due to human anti-mouse antibody interfering with thyrotropin assay.

The case of a 39-year-old woman who was referred for weight gain and amenorrhoea is reported. Laboratory evaluation showed high levels of thyroid-stimulating hormone (TSH). The patient was started on increasing doses of levothyroxine for subclinical hypothyroidism. TSH remained persistently raised and the patient became thyrotoxic. Evaluation at another laboratory showed normal levels of TSH, raising the possibility of interfering substances. TSH levels were normalised with the addition of mouse serum to the patient's sample, confirming the presence of human anti-mouse antibodies as the interfering substance in the TSH assay.

Reversible acute adrenal insufficiency caused by fluconazole in a critically ill patient.

A 38 year old man with history of obstructive sleep apnea and polycythaemia presented with hypercapnic respiratory failure that required intubation. He developed fever with infiltrates on chest radiography that required empiric antifungal therapy with fluconazole along with broad spectrum antibiotics. He developed acute adrenal insufficiency that recovered after fluconazole was stopped. It is believed that this complication of adrenal suppression attributable to fluconazole is underrecognised and it may be prudent to monitor all critically ill patients who are given fluconazole for this complication.

Long-term results of the dial osteotomy in the treatment of high-grade acetabular dysplasia.

UNLABELLED: The dial osteotomy, an acetabular reorientation procedure based on radiographs, was developed by R. H. Eppright for treatment of hip dysplasia; however, long-term results are not recorded. The aim of this study was to evaluate retrospectively the results of the dial osteotomy as done in 37 patients (44 hips) at an average followup of 12.6 years. Articular pressures with the application of a time and pressure algorithm were calculated from radiographs to correlate calculated intraarticular pressures with progression of degenerative disease. Clinical results at followup were 32 (73%) satisfactory and 12 (27%) unsatisfactory hips. Six (13%) hips failed between 10-20 years (average 14.7 years). A satisfactory result correlated with the preoperative functional score. Radiographically, the anterior center-edge angle increased from an average of 6.7 degrees to 37.9 degrees. At followup, radiographic indices of degeneration indicated that eight (18%) hips had improved, 18 (41%) had stabilized, and 18 (41%) had deteriorated. Severin indices improved in 21 (48%) hips. Joint space width at followup provided the only correlation between radiographic parameters and clinical result. Contact pressures were reduced from 4.45 MPa to 1.12 MPa. The cumulative exposure to articular pressures averaged 61.6 MPa-years, and did not correlate with radiographic parameters or clinical success. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series--no, or historical control group). See the Guidelines for Authors for a complete description of levels of evidence.

Tuberosity malposition and migration: reasons for poor outcomes after hemiarthroplasty for displaced fractures of the proximal humerus.

The purpose of this study was to evaluate the results of hemiarthroplasty for displaced proximal humeral fractures and to assess clinical and radiologic parameters that could explain unsatisfactory results. Sixty-six consecutive patients (45 women and 21 men) with a mean age of 66 years (range, 31-85 years) were followed up postoperatively for a mean of 27 months (range, 18-59 months), both clinically and radiologically. Subjectively, 29 patients were very satisfied, 9 were satisfied, and 28 were unsatisfied. Postoperative active elevation averaged 101 degrees +/- 33 degrees, external rotation averaged 18 degrees +/- 15 degrees, and internal rotation averaged the L3 level (+/-3 vertebrae). The absolute Constant score averaged 56 of 100 points (range, 20-95 points). Initial tuberosity malposition was present in 18 patients (27%). Tuberosity detachment and migration were noted in 15 patients (23%). Tuberosity migration could be observed after initial tuberosity malpositioning, as well as after initial correct positioning. Final tuberosity malposition occurred in 33 patients (50%) and correlated with an unsatisfactory result, superior migration of the prosthesis, stiffness or weakness, and persistent pain. Factors associated with failure of tuberosity osteosynthesis were poor initial position of the prosthesis (specifically, excessive height and/or retroversion), poor position of the greater tuberosity, and women over age 75 years (likely with osteopenic bone). Techniques to improve tuberosity osteosynthesis, including modifications to current prosthetic design and instrumentation to allow for a more anatomic reconstruction, should lead to more predictable and satisfactory results.

Shoulder arthroplasty for the treatment of the sequelae of fractures of the proximal humerus.

The purpose of this multicenter study was to analyze the results of shoulder arthroplasty for the treatment of the sequelae of proximal humerus fractures and establish an updated classification system and treatment guidelines for these complex situations. Seventy-one sequelae of proximal humerus fractures were treated with shoulder replacement with the use of the same nonconstrained, modular, and adaptable prosthesis: the Aequalis prosthesis (Tornier Inc, St Ismier, France). The average time between initial fracture and shoulder arthroplasty was 5 years and 5 months. On the basis of anatomic classification schemes, sequelae were divided into 4 types: type 1, humeral head collapse or necrosis with minimal tuberosity malunion (40 cases); type 2, locked dislocations or fracture-dislocations (9 cases); type 3, nonunions of the surgical neck (6 cases); and type 4, severe malunions of the tuberosities (16 cases). The mean postoperative follow-up was 19 months (range, 12 to 48 months). Overall, the postoperative Constant score was excellent in 11 cases (16%), good in 19 cases (26%), fair in 18 cases (25%), and poor in 23 cases (33%). There were 18 complications (27%). Fifty-nine of 70 patients (81%) stated that they were satisfied with the result. The most significant factor affecting functional outcome was greater tuberosity osteotomy (P <.005). Regarding both surgical treatment and postoperative prognosis, we identify 2 categories of proximal humerus fracture sequelae: category 1, intracapsular/impacted fractures sequelae (associated with both cephalic collapse or necrosis [type 1] and chronic dislocation or fracture-dislocation [type 2]), in which an articulating joint can be reconstructed without a greater tuberosity osteotomy; and category 2, extracapsular/disimpacted fractures sequelae (associated with both surgical neck nonunions [type 3] and severe tuberosity malunions [type 4]) where the proximal humerus cannot be reconstructed without a greater tuberosity osteotomy. All of the excellent and good postoperative Constant scores were obtained in type 1 and 2, in which osteotomy of the greater tuberosity was not required. All patients in type 3 and 4, who underwent a greater tuberosity osteotomy, had either fair or poor results and did not regain active elevation above 90 degrees. We conclude that a greater tuberosity osteotomy is the most likely reason for poor and unpredictable results after shoulder replacement arthroplasty for the treatment of the complex sequelae of proximal humerus fractures. Shoulder arthroplasty for the treatment of the sequelae of fractures of the proximal humerus should be performed without an osteotomy of the greater tuberosity when possible. If prosthetic replacement is possible without an osteotomy, surgeons should accept the distorted anatomy of the proximal humerus and adapt the prosthesis and their technique to the modified anatomy. A modular and adaptable prosthesis with both adjustable offsets and inclination may allow surgeons to adapt to a large number of malunions and may help to avoid the troublesome greater tuberosity osteotomy in a higher proportion of cases.

Tufted angioma in a case of neurofibromatosis type I.

Tufted angiomas are rare benign tumours with a characteristic histopathological appearance. Their occurrence in neurofibromatosis type 1, a genodermatosis in which vascular malformations are not uncommon, has hitherto not been reported. Some of the characteristic features of tufted angiomas are discussed.

Entomophthoromycosis in India--a 4-year study.

Ten cases of entomophthoromycosis encountered in a period of 4 years in Tamilnadu are reported. Basidiobolomycosis accounted for eight cases and was seen predominantly in children. Two cases of conidiobolomycosis were seen in elderly patients. Potassium iodide was the drug of choice in the treatment of entomophthoromycosis. All our patients, except one, responded with complete resolution of their lesions.

Postpemphigus acanthomata: a sign of clinical activity?

BACKGROUND: Pemphigus is a group of vesiculobullous disorders in which the blisters usually heal with hyper or hypopigmentation. The appearance of acanthomata at sites of previous blisters has been noted in some cases. METHODS: All cases of pemphigus admitted to the Madras Medical College hospitals during a 2-year period from March 1993 to March 1995 were taken into the study and screened for the presence of acanthomata. RESULTS: Fifty-two cases of pemphigus were identified, 47 of pemphigus vulgaris and five of pemphigus foliaceus; and of these 13 developed acanthomata when the blisters healed. Ten of these cases were of pemphigus vulgaris and three were of pemphigus foliaceus; biopsy of these lesions showed hyperkeratosis, acanthosis, papillomatosis, and intraepidermal clefting. Immunofluorescence carried out in two of these acanthomata also showed intercellular fluorescence. CONCLUSIONS: The occurrence of acanthomata in healed lesions of pemphigus is not uncommon; because histopathologic and immunofluorescence evidence of disease activity is present, cases of this sort require careful follow-up.

Mutilating acral keratoderma.

A 15-year-old male, born of non-consanguineous marriage started developing thickening of skin of sole of the both feet at the age of 7 which progressed to involve whole of both feet by 11th year. Patient later developed painful autoamputation of little toes of both feet due to pseudoainhum. Involvement of the palms was limited to a localised area over palmar aspect of right middle finger and was non-progressive. No other family member was affected. This may represent a variant of Vohwinkel's syndrome or the rarer form of acral keratoderma.

Tuberous sclerosis.

Although tuberous sclerosis has been described with a diagnostic triad, it is not present consistently in all cases. Variety of skin manifestations were reported in tuberous sclerosis. This studay was undertaken to assess the frequency of various skin changes in tuberous sclerosis. Ten consecutive cases of tuberous sclerosis were studied. Angiofibroma was the commonest cutaneous manifestation. Atypical fibroxanthoma, dermatofibroma and neurofibroma were also noticed as interesting associations.

Aggressive infantile fibromatosis.

An 8-month-old infant presented with 2 ulcerated indurated plaques in the right lower limb. The lesions grew rapidly initially but for the last 2 months, they have been stationary. Biopsy showed proliferation of fusiform fibroblasts some of which were arranged in whorls. The clinical picture and the histopathology suggested the diagnosis of an aggressive infantile fibromatosis. This is one of the types of juvenile fibromatoses, a group of tumours characterised by fibrous tissue proliferation present at birth or acquired early in childhood.

Atypical gorlin's syndrome.

A 21-year-old woman presented with complaints of skin lesions on her face, palms and soles. On examination, 8 to 10 well-defined, pigmented nodules with raised and pearly borders were seen on the face. Multiple pits were present on the palms and soles. Biopsy of both lesions revealed the presence of basal cell epitheliomas. The patient also gave history of removal of a keratocyst of mandible 10 years back. The case was diagnosed as Gorlin's syndrome. It is atypical due to the low number of basal cell epitheliomas, the occurrence of only a single odontogenic cyst and the absence of other features usually associated with this condition.