ABSTRACT
Background: Post-traumatic central slip injuries, resulting in boutonniere deformity, are a complex issue that can significantly impact hand function and quality of life. The deformity should be easily reducible in the acute phase, but if left untreated, it shortens the oblique retinacular ligament, leading to chronic contracture. This is a challenging issue in hand surgery, as chronic central slip defects cannot be sutured like other tendon. Various methods for reconstructing central slips have been discussed, but the best method for subacute or chronic injuries remains unclear. This case presents a case of chronic traumatic boutonniere deformity with central slip defect reconstruction. Case report: A 65-year-old male patient presented with swelling and boutonniere deformity on the digiti III of the right hand. The patient had previously fallen from a motorcycle, and the patient's right middle finger got was by a motorcycle six months ago. After the incident, the patient's right middle finger cannot be fully extended. The patient's right hand showed edema with flexion of the interphalangeal (PIP) joint and hyperextension of the distal interphalangeal (DIP) joint. The Range of Motion (ROM) of the PIP joint right middle finger was 45-110 degrees. The X-ray of the right hand AP/oblique showed no bone involvement in the deformity. The patient underwent central slip defect reconstruction utilizing the partial ulnar side of the flexor digitorum superficial tendon. A PIP joint extension splint was applied for 2 weeks. Active and passive exercise of the ROM of the PIP joint began after 2 weeks of PIP extension joint splinting. The patient's ROM of the PIP joint (0-90 degrees) significantly improved 1 month after surgery. The patient's ROM of the PIP joint returned to normal after 2 months after surgery. The function of the patient's right hand is evaluated with the DASH score, which improves significantly from 50 to 4.2. Conclusion: Central slip defect reconstruction utilizing the partial ulnar side of the flexor digitorum superficial tendon is a reliable method for traumatic chronic boutonniere deformity and results in great functional outcomes after 2 months of follow-up. Central slip defect reconstruction utilizing the partial ulnar side of the flexor digitorum superficial tendon is a simple and cost-effective method compared to other methods.
ABSTRACT
BACKGROUND: The scalpel was once the gold standard for surgical incisions. Electrosurgery has started to supplant scalpels but is not yet acceptable for skin incisions due to the risk of burns and deeper injury relative to the scalpels' neat incision with less tissue damage. The unnecessary burden of excessive scar formation makes comparing these two methods challenging. Therefore, this study aims to compare post-incision skin scarring created after monopolar electrosurgery and scalpel surgery, and evaluate the Patient and Observer Scar Assessment Scale (POSAS) suitability for assessing skin incision scars by comparing patients' and observers' scores. METHODS: This self-controlled study involved patients undergoing elective and emergency skin surgery procedures. A singular wound site was created using two incision methods (monopolar electrosurgery and scalpel) simultaneously. Post-incision scar tissue formation was evaluated using the POSAS, a subjective scar assessment tool that involved patients self-reporting on pain, itching, color, thickness flexibility, and surface relief. Observer-rated vascularity, pigmentation, thickness, flexibility, and surface relief both using a 5-point Likert-type scale. We performed this assessment three months post-surgery, and the results were analyzed by a battery of statistical tests and linear mixed models. RESULTS: Twenty patients were included in this study. Data analyzed using the paired t-test or Wilcoxon rank-sum test indicated no statistically significant differences between the scar tissue created by monopolar electrosurgery and scalpels according to both the patients and the observers. Correlation analyses between the patients' and observers' total POSAS scores indicated these followed a moderate linear relationship (r = 0.51; p < 0.001). Linear mixed models further supported the agreement of POSAS total scores between patients and observers. They also confirmed that electrosurgery was not inferior to the scalpel technique. CONCLUSION: Scar tissue from skin incisions made by monopolar electrosurgery were indistinguishable from those created with a scalpel. The POSAS instrument is an acceptable means of assessing scar formation on the skin.
ABSTRACT
Acute pain is the most common early complication after total knee arthroplasty causing delayed mobilization and increased demands of morphine, leading to higher operative cost. Several studies have assessed the effectiveness, side-effects, and ease of use of various analgesics. Preemptive analgesia with combined celecoxib and pregabalin has been reported to yield positive outcomes. In this randomized, double-blind controlled clinical trial, 30 subjects underwent surgery for total knee arthroplasty using 15-20mg bupivacaine 5% epidural anesthesia. All subjects were divided into three groups. Group 1 was given celecoxib 400mg and pregabalin 150mg 1 hour before the operation, Group 2 was given celecoxib 200mg and pregabalin 75mg twice daily starting from 3 days before the operation, and Group 3 was given a placebo. The outcome was measured with Visual Analog Scale, knee range of motion, and postoperative mobilization. There was a significant difference in postoperative morphine usage between the groups that were administered with preemptive analgesia and the placebo group, but no significant difference was found between Group 1 and Group 2 that were given preemptive analgesia at different doses. ROM and postoperative mobilization were not significantly different among the three groups. Two patients in the first group, one patient in the second group, and one patient in the third group developed nausea. Preemptive analgesia is proven to reduce postoperative usage of morphine independent of the dosage. We recommend the use of combined celecoxib and pregabalin as preemptive analgesia after the total knee arthroplasty procedure. This trial is registered with NCT03523832 (ClinicalTrials.gov).
ABSTRACT
INTRODUCTION: Osteofibrous dysplasia is a rare non-neoplastic disease that is almost exclusive to pediatric tibial diaphysis. Wide excision of the lesion is recommended to avoid recurrence. However, such radical surgery will results in large segmental bone defects that will require further extensive reconstructive surgery. We report a novel approach of treating bone defect by implementing the diamond concept of bone healing using autologous bone marrow derived mesenchymal stem cells (BM-MSCs). PRESENTATION OF CASE: An eight-year-old Indonesian male presented with severe bowing deformity of the left lower leg. Radiographic and histological analysis confirmed the diagnosis of osteofibrous dysplasia. A wide excision of the defect was made leaving a critical-sized bone defect. A combination of autologous transplantation of 50 million BM-MSCs, hydroxyapatite (HA) granules, bone morphogenic protein 2 (BMP-2) and Djoko-Zarov hybrid circular external fixator was used to treat the defect. The outcomes measured were subjective complaints, functionality based on LEFS and radiological assessments. DISCUSSION: Radiographic assessments showed successful new bone tissue formation and integration of implanted HA granules. The external fixator was removed at 42 weeks after adequate callus formation and clinical stability was achieved. The patient underwent progressive functional improvements and reached a near normal functionality of 90% LEFS at 84 week. No therapy side effect or complication was reported. CONCLUSION: Osteofibrous dysplasia was successfully excised without signs of recurrence after 84-week follow-up. Autologous transplantation of augmented BM-MSCs has successfully created new normal bone tissue without causing any side effect and had significantly improved the patient's quality of life.
