Osteosarcoma of the talus misdiagnosed as ankle arthritis: a case report.

We present a 65-year-old man with osteosarcoma of the talus that was misdiagnosed as osteoarthritis. The patient eventually underwent below-knee amputation and adjuvant chemotherapy.

Does pathological fracture affect the rate of local recurrence in patients with a giant cell tumour of bone?: a meta-analysis.

We investigated whether the presence of a pathological fracture increased the risk of local recurrence in patients with a giant cell tumour (GCT) of bone. We also assessed if curettage is still an appropriate form of treatment in the presence of a pathological fracture. We conducted a comprehensive review and meta-analysis of papers which reported outcomes in patients with a GCT with and without a pathological fracture at presentation. We computed the odds ratio (OR) of local recurrence in those with and without a pathological fracture. We selected 19 eligible papers for final analysis. This included 3215 patients, of whom 580 (18.0%) had a pathological fracture. The pooled OR for local recurrence between patients with and without a pathological fracture was 1.05 (95% confidence interval (CI) 0.66 to 1.67, p = 0.854). Amongst the subgroup of patients who were treated with curettage, the pooled OR for local recurrence was 1.23 (95% CI 0.75 to 2.01, p = 0.417). A post hoc sample size calculation showed adequate power for both comparisons. There is no difference in local recurrence rates between patients who have a GCT of bone with and without a pathological fracture at the time of presentation. The presence of a pathological fracture should not preclude the decision to perform curettage as carefully selected patients who undergo curettage can have similar outcomes in terms of local recurrence to those without such a fracture.

Does a pathological fracture affect the prognosis in patients with osteosarcoma of the extremities? : a systematic review and meta-analysis.

Opinion remains divided as to whether the development of pathological fracture affects the prognosis of patients with an osteosarcoma of the extremities. We conducted a comprehensive systematic review and meta-analysis of papers which reported the outcomes of osteosarcoma patients with and without a pathological fracture. There were eight eligible papers for final analysis which reported on 1713 patients, of whom 303 (17.7%) had a pathological fracture. The mean age for 1464 patients in six studies was 23.2 years old (2 to 82). The mean follow-up for 1481 patients in seven studies was 90.1 months (6 to 240). The pooled estimates of local recurrence rates in osteosarcoma patients with and without pathological fractures were 14.4% (8.7 to 20.0) versus 11.4% (8.0 to 14.8). The pooled estimate of relative risk was 1.39 (0.89 to 2.20). The pooled estimates of five-year event-free survival rates in osteosarcoma patients with and without a pathological fracture were 49.3% (95% CI 43.6 to 54.9) versus 66.8% (95% CI 60.7 to 72.8). The pooled estimate of relative risk was 1.33 (1.12 to 1.59). There was no significant difference in the rate of local recurrence between patients who were treated by amputation or limb salvage. The development of a pathological fracture is a negative prognostic indicator in osteosarcoma and is associated with a reduced five-year event-free survival and a possibly higher rate of local recurrence. Our findings suggest that there is no absolute indication for amputation, as similar rates of local recurrence can be achieved in patients who are carefully selected for limb salvage.

A reappraisal of functional reconstruction of extension of the knee following quadriceps resection or loss.

The current indications for functional restoration of extension of the knee following quadriceps resection or loss require reappraisal. The contribution of pedicled and free functional muscle transfer is likely to be over-emphasised in many studies, with good functional outcomes predominantly reported only in the context of cases with residual quadriceps function. In cases with total quadriceps resection or loss, all forms of reconstruction perform poorly. Furthermore, in smaller resections with loss of two or fewer components of the quadriceps, minimal impairment of function occurs in the absence of functional reconstruction, suggesting that functional restoration may not be warranted. Thus there is a paradox in the current approach to quadriceps reconstruction, in that small resections are likely to be over-treated and large resections remain under-treated. This review suggests a shift is required in the approach and rationale for reconstructing functional extension of the knee after quadriceps resection or loss. A classification based on current evidence is suggested that emphasises more clearly the indications and rationale for functional transfers.

In vivo study of novel nanofibrous intra-luminal guidance channels to promote nerve regeneration.

A novel nanofibrous construct for promoting peripheral nerve repair was fabricated and tested in a rat sciatic nerve defect model. The conduit is made out of bilayered nanofibrous membranes with the nanofibers longitudinally aligned in the lumen and randomly oriented on the outer surface. The intra-luminal guidance channel is made out of aligned nanofibrous yarns. In addition, biomolecules such as laminin and nerve growth factor were incorporated in the nanofibrous nerve construct to determine their efficacy in in vivo nerve regeneration. Muscle reinnervation, withdrawal reflex latency, histological, axon density and electrophysiology tests were carried out to compare the efficacy of nanofibrous constructs with an autograft. Our study showed mixed results when comparing the artificial constructs with an autograft. In some cases, the nanofibrous conduit with aligned nanofibrous yarn as an intra-luminal guidance channel performs better than the autograft in muscle reinnervation and withdrawal reflex latency tests. However, the axon density count is highest in the autograft at mid-graft. Functional recovery was improved with the use of the nerve construct which suggested that this nerve implant has the potential for clinical usage in reconstructing peripheral nerve defects.

Fibrolipoma of multiple nerves in the wrist.

We report fibrolipoma involving the median nerve, its palmar cutaneous branch as well as the ulnar nerve in the same hand of a 25-year-old woman. The patient presented with a lump in the wrist with signs of carpal tunnel syndrome. Multiple nerve involvement was detected on magnetic resonance imaging and further confirmed at surgical exploration and decompression. Imaging is recommended in the management of an unusual lump in the wrist.

Absence of flexor digitorum superficialis tendon in the little finger is not associated with decreased grip strength.

We examined the little finger in 402 normal subjects for the presence or absence of the flexor digitorum superficialis. All subjects also had their grip strength measured. No statistically significant difference was seen in the grip strength measurements between subjects who had a flexor digitorum superficialis tendon to the little finger and those who did not. This study demonstrates that absence of the flexor digitorum superficialis to the little finger is not associated with decreased grip strength. The implications of this in terms of repair of the flexor digitorum superficialis of the little finger are considered.

Common bacterial infections of the hand.

Infections of the hand are commonly encountered in general practice. Delay in diagnosis increases the risk of tissue loss and functional impairment. Staphyloccocal infections are most common, but polymicrobial infections are often seen in immunocompromised patients. In this pictorial essay, important and common conditions are illustrated to demonstrate key points and pitfalls in diagnosis and management.

The prevalence of absence of the palmaris longus--a study in a Chinese population and a review of the literature.

Most standard textbooks of hand surgery quote the prevalence of absence of palmaris longus at around 15%. However, this figure varies considerably in reports from different ethnic groups. We studied 329 Chinese men and women and found palmaris longus to be absent unilaterally in 3.3%, and bilaterally in 1.2%, with an overall prevalence of absence of 4.6%. There was no significant difference in its absence with regard to the body side or the sex. Our literature review revealed a low prevalence of absence in Asian, Black and Native American populations and a much higher prevalence of absence in Caucasian populations. It is clear that a standard prevalence of absence of the palmaris longus cannot be applied to all populations.

Flap reconstruction following high pressure injection injuries of the hand: a report of three cases.

High pressure injection injuries are well known to cause significant injury to the hand, with high amputation rates and poor functional outcome. Surgical treatment consists of early aggressive debridement followed by secondary closure. Flap reconstruction is a reconstruction option which can increase the chance of digit salvage, as well as give an acceptable functional and cosmetic result. We review three cases of flap reconstruction following high pressure injection injuries, and discuss their role in the treatment of these injuries.

A case of anterior interosseous nerve syndrome after peripherally inserted central catheter (PICC) line insertion.

Palsies involving the anterior interosseous nerve comprise less than 1% of all upper extremity nerve palsies. Patients often present initially with acute pain in the proximal forearm, lasting several hours to days. The pain subsides, to be followed by paresis or total paralysis of the pronator quadratus, flexor pollicis longus and the radial half of the flexor profundus, either individually or together. Patients with a complete lesion will have a characteristic pinch deformity. We report a case of anterior interosseous syndrome in a 42-year-old male. The patient was admitted initially for chronic osteomyelitis of the left calcaneum. He had a peripherally inserted central catheter (PICC) line inserted into a brachial vein for the administration of intravenous antibiotics, and developed anterior interosseous nerve palsy as a complication of this procedure. The catheter was subsequently removed and a new line was placed on the other side, and his neurological deficit has been improving since. This case highlights the potential hazards of venupuncture or arterial puncture of the brachial vein or artery respectively, even under controlled conditions with the benefit of ultrasound guidance. It also serves as a reminder to look out for the complications of these common procedures, and to be able to react appropriately when they arise.

Intraoperative single-shot "3-in-1" femoral nerve block with ropivacaine 0.25%, ropivacaine 0.5% or bupivacaine 0.25% provides comparable 48-hr analgesia after unilateral total knee replacement.

PURPOSE: To compare analgesia after intraoperative single shot "3-in-1" femoral nerve block (FNB) in combination with general anesthesia using ropivacaine 0.25%, ropivacaine 0.5% with bupivacaine 0.25% for total knee replacement (TKR). METHODS: We performed a randomized, double-blind study in 48 patients for elective TKR under general anesthesia. Patients were randomized to one of four groups (C: sham block, R1: "3-in-1" FNB using 30 mL of ropivacaine 0.25%, R2: "3-in-1" FNB using 30 mL of ropivacaine 0.5%, B: "3-in-1" FNB using 30 mL of bupivacaine 0.25%). Verbal pain score (VPS) both at rest and movement were assessed for 48 hr after TKR (0=none; 1=mild; 2=moderate; 3=severe). Total morphine consumption and its associated side effects, duration of hospitalization after operation were also compared. RESULTS: There were no differences in patients' physical characteristics, intraoperative morphine usage, operation time, tourniquet time or length of hospitalization between the four groups. When compared with group C, the VPS was significantly lower in groups R1, R2 and B at one, four, eight, 24 and 48 hr after TKR (P <0.05). The morphine requirement of groups R1, R2 and B were also significantly lower when comparing with group C up to 48 hr postoperatively (P <0.05). There were no significant differences in VPS and postoperative morphine requirement at any time between groups R1, R2 and B. CONCLUSION: "3-in-1" FNB with ropivacaine provided analgesia that was clinically comparable to that of bupivacaine up to 48 hr after TKR. Increasing the concentration of ropivacaine from 0.25% to 0.5% failed to improve the postoperative analgesia of "3-in-1" FNB.