A rare case of floated talar head accompanying medial subtalar dislocation.

INTRODUCTION AND IMPORTANCE: Concomitant medial subtalar dislocation and a rotated displaced talar neck fracture may result in poor outcomes. This study aimed to explain this extremely rare injury and assess the clinical outcomes following surgical treatment. CASE PRESENTATION: A 22-year-old Iranian man referred to the emergency department with a gross deformity and pain in his right foot and ankle after a falling from 2 m. Plain radiographs showed a rotated free talar head accompanying medial subtalar dislocation. Closed reduction was performed in the emergency department under sedation. Prompt open reduction and internal fixation of talar fracture was done, after removal of free osseocartilaginous fragments in the subtalar and talonavicular joints. At 25 months postoperatively, the clinical outcomes were assessed using the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale and visual analogue scale for pain which were 73 and 3, respectively. In exam, the patient had a stiffed subtalar joint without talar osteonecrosis or collapse. CLINICAL DISCUSSION: Several osseous and soft tissue barriers could prevent a successful closed reduction of a subtalar dislocation. Associated cartilage injuries or fractures may result in poor clinical outcomes such as persistent pain, limping, osteoarthritis, and osteonecrosis. Immediate open reduction and rigid fixation of associated fractures and resection of small free osseocartilaginous fragments may prevent further soft tissue damages and preserve clinical functions. CONCLUSIONS: Satisfactory clinical outcome could be expected following proper on-time approach to a subtalar dislocation associated with a rotated displaced talar neck fracture.

On-Top Plasty in Post-Axial Polydactyly: A Case Report and Recommendation to Modify the Classifications.

Post-axial polydactyly (PAP) is almost always treated by ablation of the sixth ray since the ulnar duplicate is universally inadequate and the radial one is normal. We report a patient with bilateral PAP with skeletal abnormalities in both radial and ulnar duplicates. This unusual presentation cannot be classified according to previous classifications of PAP and precludes simple ablation as the treatment of choice. Both hands of this patient were treated by on-top plasty with excellent functional and cosmetic results. A modification of the previous classifications is recommended at the end of this article. Level of Evidence: Level V (Therapeutic).

Is Carpal Tunnel Release an Effective Treatment for Patients with Suspected Concurrent Carpal Tunnel and Pronator Syndrome?

Background: Some patients with a confirmed diagnosis of carpal tunnel syndrome (CTS) on clinical examination and electrodiagnostic testing (EDX) may also have one or more clinical features of pronator syndrome (PS). However, the EDX is negative for PS. We label these patients as suspected concurrent carpal tunnel and pronator syndrome (CCPS). We suspect that this is a presentation of reverse double crush syndrome that occurs when a symptomatic distal compression neuropathy converts an asymptomatic proximal compression into a symptomatic one. We believe both compressions can be relieved by decompressing the median nerve only at the wrist. The aim of our study is to determine whether carpal tunnel release (CTR) is an effective treatment for patients suffering from CCPS. Methods: This is a prospective, cohort study of the outcomes of CTR in two matched groups with 37 patients in each group. Group A included patients with suspected CCPS and group B included patients with isolated CTS. All patients were evaluated pre-operatively and 1 year after surgery using the Boston Carpal Tunnel Questionnaire (BCTQ). At one year, patients were also assessed for residual symptoms and positive provocative tests. Results: A significant improvement in the symptom and functional severity scales (SSS and FSS) of the BCTQ was noted in both groups. The degree of improvement in SSS was similar in both groups; however, group A showed a greater improvement in FSS. This could be attributed to higher pre-operative values in some items of FSS in group A. No patients in either group had residual symptoms severe enough to necessitate further treatment. Conclusion: The outcomes of CTR are similar in patients with isolated CTS and suspected CCPS and a CTR may be sufficient to address symptoms of CTS and PS in patients with CCPS. Level of Evidence: Level II (Therapeutic).

"In Situ Vascular Nerve Graft" for Restoration of Intrinsic Hand Function: An Anatomical Study.

BACKGROUND: In combined high median and ulnar nerve injury, transfer of the posterior interosseous nerve branches to the motor branch of the ulnar nerve (MUN) is previously described in order to restore intrinsic hand function. In this operation a segment of sural nerve graft is required to close the gap between the donor and recipient nerves. However the thenar muscles are not innervated by this nerve transfer. The aim of the present study was to evaluate whether the superficial radial nerve (SRN) can be used as an "in situ vascular nerve graft" to connect the donor nerves to the MUN and the motor branch of median nerve (MMN) at the same time in order to address all denervated intrinsic and thenar muscles. METHODS: Twenty fresh male cadavers were dissected in order to evaluate the feasibility of this modification of technique. The size of nerve branches, the number of axons and the tension at repair site were evaluated. RESULTS: This nerve transfer was technically feasible in all specimens. There was no significant size mismatch between the donor and recipient nerves Conclusions: The possible advantages of this modification include innervation of both median and ulnar nerve innervated intrinsic muscles, preservation of vascularity of the nerve graft which might accelerate the nerve regeneration, avoidance of leg incision and therefore the possibility of performing surgery under regional instead of general anesthesia. Briefly, this novel technique is a viable option which can be used instead of conventional nerve graft in some brachial plexus or combined high median and ulnar nerve injuries when restoration of intrinsic hand function by transfer of posterior interosseous nerve branches is attempted.

Treatment of giant cell tumor of distal radius with limited soft tissue invasion: Curettage and cementing versus wide excision.

BACKGROUND: Intralesional curettage and adjuvant versus wide en bloc excision (WEE) as the best treatment method of giant cell tumor (GCT) of distal radius with limited soft tissue extension is a controversial topic. METHODS: Prospectively, 13 patients who had GCT of distal radius with perforation of either volar or dorsal cortex of the bone and soft tissue extension which was confined to one plane were enrolled in the study. Six patients treated with ICC and seven cases cured by WEE technique and proximal fibular arthroplasty. The results were evaluated based on recurrence, range of motion of the wrist joint, rotation of the forearm, grip and pinch power. RESULTS: The mean age of the patients treated with ICC and WEE techniques were 32.7 (range: 23-43) and 34.5 (range: 28-44), respectively. Mean follow-up period was 72 months (range: 28-148). Local recurrence was seen in 4 of 6 patients (66.7%) underwent ICC technique but in none of the 7 subjects treated with WEE technique (P value = 0.021). The overall range of flexion/extension and supination/pronation in the WEE group were 83% and 92% of the ICC group, respectively. Both of pinch and grip power were 14% less in the WEE group compared to the ICC group. CONCLUSIONS: In GCT lesion of distal radius even with limited soft tissue extension, WEE and proximal fibular arthroplasty may be a more reasonable suggestion when the patient seeks a one-shot surgery.

Recurrent aneurysmal bone cyst of talus resulted in tibiotalocalcaneal arthrodesis.

Aneurysmal bone cyst (ABC), a locally benign aggressive lytic lesion of either primary or secondary origin, seldom involves the talus. Herein, we present a 25-year-old man with recurrent ABC of the talus after curettage and bone grafting, which was managed by total resection followed by filling the defect using fibular graft and finally tibiotalocalcaneal arthrodesis due to articular surface involvement. At 18 mo postoperatively, no recurrence was detected. Arthrodesis might be a good option in cases with recurrent ABC of the talus especially with articular surface involvement.

Bilateral sandwiched scapulae: A rare presentation of hereditary multiple exostoses.

Hereditary multiple exostoses, an autosomal dominant condition, is a common benign tumor which is characterized by the development of multiple osteochondromas. Bilateral dorsal and ventral involvement of scapulae is extremely rare without any reported case in the literature. An 18-year-old girl was referred because of bilateral prominent scapulae and left-sided pain on shoulder girdle motion especially at more than 90° abduction and forward flexion. Radiograph evaluation showed multiple exostoses on ventral and dorsal surfaces of body of both scapulae; hence simple excision of the lesion was impossible. The patient was symptom-free about 18 months after partial scapulectomy of left side. Partial scapulectomy seems to be an effective treatment for the sandwiched scapula between dorsal and ventral benign tumors.

Simultaneous Volar Dislocation of Distal Interphalangeal Joint and Volar Fracture-Subluxation of Proximal Interphalangeal Joint of Little Finger: A New Mechanism of Injury.

Simultaneous volar dislocation of distal interphalangeal (DIP) joint and volar fracture-subluxation of proximal interphalangeal (PIP) joint of the same finger has not been reported yet. A 19-year-old man was referred due to pain on the deformed left little finger after a ball injury. Radiographs showed volar dislocation of the DIP joint and dorsal lip fracture of the middle phalanx with volar subluxation of PIP joint of the little finger. This case was unique in terms of the mechanism of injury which was hyperflexion type in two adjacent joints of the same finger. The patient was treated by closed reduction of DIP joint dislocation and open reduction and internal fixation of the PIP joint fracture-subluxation and application of dorsal external fixator due to instability. Finally, full flexion of the PIP joint and full extension of the DIP joint were obtained but with 10 degree extension lag at the PIP joint and DIP joint flexion ranging from 0 degree to 30 degrees. Some loss of motion in small joints of the fingers after hyperflexion injuries should be expected.

Comparison of Roll Stitch Technique and Core Suture Technique for Extensor Tendon Repair at the Metacarpophalangeal Joint level.

BACKGROUND: Proper suturing technique is needed to ensure good outcome in extensor tendon surgery. Different techniques have been reported for the repair of extensor tendon injuries at the level of the metacarpophalangeal joint (MCPJ). These reports were in vitro studies on cadaver models. Repair techniques must be clinically tested, to determine results. OBJECTIVES: The purpose of this in vivo study was to compare results of extensor tendon repair, using roll stitch and core suture techniques. PATIENTS AND METHODS: Forty two fingers, in 38 patients (aged 15- 45 years), with simple complete extensor tendon injuries in the MCPJ area, were identified and operated by a single surgeon. The patients were divided into two groups, according to the technique used for tendon repair. The first group consisted of 21 digits, in 19 patients, who were repaired with roll stitch technique, while the second group consisted of 21 digits, in 19 patients, who were repaired with core suture technique. The same splint and rehabilitation regimen (early passive range of motion) were given to all patients. The splints were removed at 6 weeks after surgery and range of motion of the operated fingers was measured and compared to uninjured hands, after 12 weeks. RESULTS: Five patients were lost to follow up or excluded from the study. There was no rupture of the repaired tendons in the groups. There was no statistically significant difference in mean MCPJ flexion, proximal interphalangeal joint (PIPJ) flexion, distal interphalangeal joint (DIPJ) flexion and total range of motion of the fingers, between the two groups. However, extension lag was significantly more common in the second group (11 of 19 digits) compared the first group (four of 17 digits). CONCLUSIONS: Roll stitch technique had superior outcome compared to the modified Kessler technique, when performed in the MCPJ area. LEVEL OF EVIDENCE: Therapeutic (Level III).

A novel external fixator of the hand: a practice pearl.

External fixation of comminuted hand fractures, especially those associated with soft-tissue injuries, is a good option and avoids several complications resulting from open surgery. Therefore, many versions of mini external fixators have been developed, including commercially fabricated implants and hand-made implants. However, these devices are costly or associated with serious complications. Through this study we have introduced a cost-effective and easy-to-apply mini external fixator.

Radial shortening osteotomy in advanced stages of Kienbock disease.

Radial shortening osteotomy is a well-accepted treatment for Kienbock disease in stages I to IIIA. The usefulness of this procedure in more advanced stages of the disease is controversial. In this study, 27 cases of stage IIIB and IV of Kienbock disease underwent radial shortening osteotomy and were followed for a mean period of 54.9 months (9 to 117 mo). Twenty-four patients had stage IIIB and 3 patients had stage IV disease. Sixteen of the affected wrists were on the dominant side. All patients were evaluated clinically and radiologically at last follow-up. Modified Mayo Score was used for clinical evaluation. The measured radiologic parameters included carpal height ratio, Stahl index, and radioscaphoid angle. In stage IIIB, 41.6% of cases had good, 54.2 had fair, and 4.2 had poor result, whereas in stage IV all patients showed poor result. The mean range of flexion-extension was 84.4% of the unaffected side. Considering the percentage of preserved motion, this procedure seems to be a good alternative to partial fusion for stage IIIB when the patient is willing to preserve more degrees of motion. Although the number of patients with stage IV disease was limited in this study, poor result in all of them may show the uselessness of this procedure in stage IV.

The safest direction of percutaneous pinning for achieving firm fixing of the fifth carpometacarpal joint.

INTRODUCTION: Traditional treatment of unstable fifth carpometacarpal joint injuries is closed reduction and pinning. The purpose of this study was to determine the safest corridor for pinning of the fifth carpometacarpal joint to prevent iatrogenic injury to the ulnar nerve and tendons. MATERIALS AND METHODS: In the first phase of study, three fresh cadavers were dissected and the safest directions of Kirschner wire (k-wire) insertion in the coronal and sagittal planes were determined for k-wire entrance 2 cm distal to the base of the fifth metacarpal. The second phase objective was to evaluate the accuracy of data obtained in the previous phase. Therefore, with five other cadavers, k-wires were inserted in a combination of maximum angles in different planes determined previously. The ulnar nerve branches and tendons were then investigate to detect possible damage. In the third phase, four fresh carpometacarpal joints were fixed with directions outside the range of the defined angles. RESULTS: The safe direction determined in the first phase was a 20°-30° coronal plane angle relative to the body of the fifth metacarpal bone and between 10° volar to dorsal to 20° dorsal to volar angle in the sagittal plane. Insertion of k-wires in the second phase could fix the fifth carpometacarpal joint firmly without penetration of the volar and dorsal cortices of the hamate. All inserted k-wires outside the defined range resulted in injuries to nerves or tendons or loose fixing. CONCLUSION: The safest corridor for pinning unstable fifth carpometacarpal injuries is 2 cm distal to the joint at an angle of 20°-30° to the coronal plane from 10° volar to dorsal to 20° dorsal to volar direction in the sagittal plane.

Porokeratosis of Mibelli with mutilation: a case report.

Porokeratosis is a rare keratinization disorder of the skin characterized by annular plaques with an atrophic center surrounded by a raised keratotic wall that spreads centrifugally. We report a case of porokeratosis of Mibelli with mutilation. A 30-year-old woman presented with atrophic plaques on the index fingers of both hands with a keratotic ridge in some margins of the plaques. There was loss of the distal phalanx of the left index finger. In the right hand, shortening of the right distal phalanx and flexion contracture of the distal interphalangeal joint were noted in the index finger.

Vascular basis of free transfer of proximal epiphysis and diaphysis of fibula: an anatomical study.

INTRODUCTION: Transfer of proximal epiphysis and diaphysis of fibula is a treatment of bony defects in children. Although there are few reports of this procedure, different arteries or combination of arteries have been used as supplying pedicle and the reported success rates are different. This is an anatomical study to clarify the vascular anatomy of this region. MATERIALS AND METHODS: A total of 16 fresh cadavers were enrolled. An incision was made in the popliteal fossa to find the popliteal artery, which was dissected distally and the lateral inferior genicular artery, anterior tibial artery, tibioperoneal trunk and its bifurcation were located. In eight subjects popliteal artery was cannulated above the level of femoral condyles and injected by latex. In the next eight cases the same material was injected in the anterior tibial artery. The next steps of dissection were done by 4.3-loupe magnification. Lateral inferior genicular artery was dissected from its origin to the fibular head and branches of anterior tibial artery were also dissected. In three specimens, the fibula and its supplying arteries were removed after dissection and put in diluted hydrochloric acid to be opened for studying the medullary vasculature. RESULTS: This study confirms the existence of not only periosteal but also intramedullary anastomosis between artery of the neck and peroneal artery. Artery of the neck was usually a branch of anterior tibial artery and in 24% of the subjects a branch of popliteal artery. In the latter condition the pedicle would be too short to permit the surgeon to do this surgery. Therefore preoperative angiography is mandatory to identify the origin of the artery of the neck. CONCLUSION: According to these dissections, a classification system of arterial supply of proximal fibular epiphysis is introduced in this article.

Levothyroxin inhibits heterotopic ossification: an experimental study in rabbits.

BACKGROUND: Heterotopic ossification is a common complication of surgery or trauma. OBJECTIVE: To investigate the efficacy of levothyroxin in inhibition of heterotopic ossification. METHODS: Heterotopic ossification was induced in 36 rabbits in three identical groups by injecting 2 mL of bone marrow in right thigh. To prevent heterotopic ossification, levothyroxin (20 microg/kg) was administered orally daily for 4 weeks to two groups of adult rabbits: group A (preload)--starting 1 week preceding bone marrow injection; group B--started on day of injection; and group C--control group (no levothyroxin) in a rabbit model. After 5 weeks the rabbits were evaluated by radiographs for evidence of ossification. At the end of the study histologic samples were taken from all the thighs. RESULTS: Imaging and histologic studies showed, with statistical significance, almost complete prevention of heterotopic ossification in group A (preload) and a marked decrease in group B, when compared with the controls. CONCLUSIONS: Levothyroxin demonstrated efficacy in preventing heterotopic ossification.

Awful considerations with LCP instrumentation: a new pitfall.

INTRODUCTION: Although the locking compression plate (LCP) system offers a number of advantages in fracture management, its successful use requires careful preoperative planning, consideration of soft tissue dissection principles, and good surgical technique. Failure to address these issues can lead to potential pitfalls. Therefore, there are many reports about potential pitfalls that can arise with inappropriate LCP instrumentation technique. Moreover, these studies may mislead the orthopaedic colleagues that the only important tip in LCP using is its mechanical considerations. But, there is no study about the potential soft tissue pitfalls that may occur. There is an attempt in this study to achieve this objective. METHODS: A prospective analysis was carried out on all patients who were hospitalized for metaphyseal fracture of tibia and LCP fixation was done for them in our trauma center over a 6-month period in 2003. Inclusion criteria included all patients with fracture of tibial metaphysis who were to undergo locking compression plating using long conventional incision (without percutaneus insertion). Therefore, 34 patients included. RESULTS: Many patients (23.5%) developed severe soft tissue damage with exposed plate, and all of them need flap coverage. CONCLUSION: Locking compression plates have a higher profile in comparison to DCP, requiring careful attention to soft tissue. Therefore, inadvisable locking compression plating with conventional incision method and retaining anatomical reduction of the fracture can lead to a higher soft tissue complication in comparison to dynamic compression plating.