Preliminary results: continuous double luminal catheter drainage for the management of septic hip arthritis in children.

Septic arthritis in children is considered an orthopedic surgical emergency, which requires prompt intervention to prevent later sequela. In the last decades, several minimal invasive techniques were suggested as an alternative to the standard treatment of septic arthritis in the pediatric hip via open arthrotomy. We aimed to investigate the efficacy and safety of a new minimal invasive technique-double luminal catheter drainage (DLDC)-in treating septic hip arthritis in children. Retrospective case series analysis was performed on all patients 1-18 years of age diagnosed with septic hip arthritis and treated by the new suggested minimal invasive technique between the years 2009-2019 at medium-sized medical center. Five patients were treated by DLDC with a follow-up period of 12 months posttreatment. The diagnosis was based on joint aspirated fluid analysis criteria. During the follow-up period, no later sequel, including avascular necrosis, or infection recurrence were observed. The new minimal invasive treatment technique suggested in this study seems to be efficient and safe in treating septic hip arthritis in children without later sequela or the need for open arthrotomy, especially if performed early on. However, due to the small study sample, no generalization of the findings can be made as future studies with larger study samples are needed to validate the DLDC technique.

Trimalleolar fracture: The endless posterior malleolus fracture debate, to repair or not to repair?

Ankle fracture is one of the most common fractures presenting in the emergency department. The fracture varies from unimalleolar, bimalleolar or trimalleolar. Involvement of the posterior malleolus is common and ranges from small avulsions to large intraarticular fragments causing subluxation of the talus. If left untreated, the resulting step-off, comminution or posterior talar subluxation may lead to osteoarthritis and further disability. To date, no consensus exists regarding the management of posterior malleolus fractures in the set-up of trimalleolar fractures. In this review we provide an overview of the literature on the available treatment options for posterior malleolar fracture in the set-up of trimalleolar fractures.

Case Report: Surgical Management of Painful Manubriosternal Pseudoarthrosis.

A 31-year-old male amateur bodybuilder presented with a 2-year history of chronic pain over the sternum and a clicking sensation in the chest wall on movement. Ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) showed no cause for his symptoms. Dynamic ultrasound scan performed at a specialist sports center revealed pseudoarthrosis of the manubriosternal joint (MSJ). After a period of conservative management (rest and analgesia), he failed to improve and underwent debridement and fusion of the MSJ with plates and screws. At follow-up 23 months later, he remains pain-free and has returned to weight lifting and bodybuilding.

Effects of transcutaneous electrical nerve stimulation (TENS) on acute postoperative pain intensity and mobility after hip fracture: A double-blinded, randomized trial.

BACKGROUND: Transcutaneous electrical nerve stimulation (TENS) is a noninvasive modality which may be used to reduce acute postoperative pain. Intense perioperative pain within the first few days after hip fracture surgery is common and is related to negative consequences such as restricted and delayed ambulation. OBJECTIVE: The objective of the present study was to examine the effect of incorporating TENS treatment on pain intensity, and mobility, with standard rehabilitation care during the acute post-operative phase following Gamma-nail surgical fixation of extracapsular hip fractures. MATERIALS AND METHODS: Forty-one patients were randomly assigned to a supplement of 30 mins of active TENS or sham TENS. The standard rehabilitation care included five daily 30 mins physical therapy treatments beginning 24 hrs after surgery. Outcome measures were: pain intensity at rest, at night and during ambulation (assessed with the Numeric Rating Scale; Functional Ambulation Classification instrument; time to complete five sit-to-stand tests; and two-minute walk test). Data were analyzed with Wilcoxon score rank tests. Significance was set at p≤0.05. RESULTS: Significantly greater pain reduction during walking was noted in the active TENS group compared to sham TENS group (differences between the fifth and the second days: 2.55±1.37 vs 1.06± 1.11, respectively; p=0.0011). Additionally, advantage of active TENS was demonstrated in greater increase in walking distance on the fifth day and higher level of mobility compared to the sham TENS group. No additional effects of active TENS were noted on pain intensity at rest and at night and on five times sit-to-stand performance. CONCLUSION: Addition of TENS to the standard care of elderly patients in the early days following Gamma nail surgical fixation of extracapsular hip fracture is recommended for pain management while walking and functional gait recovery. The effect of TENS on long-term functional outcomes should be explored in future studies. TRIAL REGISTRATION: The trial was registered at the ISRCTN registry: ID ISRCTN32476360.

A new minimally invasive surgical technique for medial retinaculum repair following traumatic patellar dislocation.

A new surgical method is introduced offering a less invasive approach to reattach the medial retinaculum following acute patellar dislocation. This retrospective analysis comprised 12 cases of medial retinacular repair in 10 patients. The surgical technique achieved reinforced reattachment of the torn region of the medial retinaculum for improved patellar support and stabilization. During follow-up, no recurrent patellar dislocations occurred, except where one patient reported a subjective feeling of patellar dislocation. The average Kujala score for our sample group after 2 years was 89.2. A plethora of methods are described in the literature to repair a tear to the medial patellofemoral ligament, which attaches at the superomedial patella. However, it is our contention that traumatic patellar dislocation invariably results in osteochondral avulsion at the inferomedial patella, refuting medial patellofemoral ligament involvement, and, rather, implicating the inferior aspect of the deep layer of medial retinaculum. Our surgical technique enables stable fixation of the region, decreasing the rate of recurrent dislocations. No grafts are used, permitting tendinous and ligamentous anatomy to remain intact. We further postulate that performing a CT examination preoperatively may reduce time between diagnosis and surgery, in addition to locating fracture sites more precisely.

Ulnar nerve monitoring during percutaneous pinning of supracondylar fractures in children.

BACKGROUND: Supracondylar fractures of the humerus in children are frequently managed by closed reduction and percutaneous pinning. Insertion of medial and lateral pins is more stable than lateral pinning alone, but carries an increased risk for ulnar nerve damage. This study describes the use of electrical stimulation concurrent with medial pin insertion as a monitoring technique for avoiding iatrogenic ulnar nerve injury. METHODS: A retrospective review was conducted on 138 children, mean age 5.6 years (SD±2.5), who were admitted to the hospital between 2007 and 2010 with uncomplicated supracondylar fractures, Gartland type II and above, and intact neurovascular presentation. The location of the ulnar nerve was identified and marked preoperatively by observing twitch contractions in response to electrical stimulation. The medial pin served as an active electrode during pin insertion, and repeated stimulation throughout the insertion process ensured no contact with the response of the ulnar nerve. After pin insertion, ulnar nerve stimulation was used again to ensure nerve continuity viability. RESULTS: All fractures were stabilized with 2 to 4 cross K-wires (size 1.6 mm), with number depending on stability of the fracture. The children were discharged home 2 days after fracture fixation, with no iatrogenic ulnar nerve injury observed in any of the children. The only postoperative complication involved 2 cases of anterior interosseus nerve neuropraxia, which resolved spontaneously after 4 to 6 months. Primary fracture healing was achieved without nonunions or delayed unions in all cases. CONCLUSIONS: Ulnar nerve stimulation before and during the percutaneous pinning of supracondylar fractures in children is a simple, economical, and easy-to-implement technique that can prevent iatrogenic ulnar nerve injury. LEVEL OF EVIDENCE: Level IV.

[Fat embolism syndrome following injuries and limb fractures].

Fat embolism syndrome is a clinical entity characterized by varying degrees of cerebral dysfunction, pulmonary changes and petechial rash that usually develop within 24-48 hours in a small percentage of victims after trauma and Long bone fractures. Deterioration can occur within a few hours Leading to unconsciousness or acute respiratory insufficiency, similar to adult respiratory distress syndrome (ARDS). The pathophysiology is still not clearly understood and there are two theories--the mechanical and biochemical cascade of events. It seems that the most significant diagnostic sign is hypoxemia with relatively normaL values of PaCO2 leading to development of radiographic "snow-like appearance" of the Lungs, resulting from the typical interstitial lung edema. Treatment consists of early fracture fixation, volume replacement, respiratory support and analgesia carefully managed since some of the patients may develop acute respiratory distress. The role of steroids and other drugs is still under debate. The vast majority of patients may heal without any complications, while 5%-10% of the patients may develop some neurological complications manifesting as behavior disturbances. The aim of this review is to update the clinical and pathophysiological aspects of fat embolism syndrome and to describe the various aspects of prevention and treatment.

Kohler disease: diagnoses and assessment by bone scintigraphy.

Limping is a frequent occurrence in children and may be caused by various conditions, including trauma, inflammation, infection, and malignancy. Nontraumatic avascular necrosis of the tarsal bones should be included in the differential diagnosis. Accumulated data have supported the superiority of bone scans to radiography in the early diagnosis of avascular necrosis. Bone scintigraphy is a useful tool for investigating pain when symptoms, laboratory examinations, and radiography do not point to a specific diagnosis. In the early phase of disease, bone scans may demonstrate decreased tracer uptake (photopenic region), subsequently a hot area is seen during the reparative process. Although magnetic resonance imaging has important implications in the diagnosis of avascular necrosis, bone scintigraphy with its ready availability has a significant role as a primary tool in the evaluation of a limping child.

[Osteoid osteoma of the wrist joint resembling tenosynovitis].

Osteoid osteoma of bones of the wrist joint is a relatively rare lesion. This article presents a series of three patients, one with osteoid osteoma of the styloid process of the radius and two with osteoid osteoma of the capitate bone. All of them had clinical symptoms resembling those of stenosing tenosynovitis of the wrist joint. X-rays, tomography and bone scan revealed the characteristic findings of osteoid osteoma. Histological examination confirmed the diagnosis. Treatment consisted of "en bloc" excision of these tumors. Following surgery patients were asymptomatic and had normal mobility of the affected wrist. In the first patient this has been maintained for the succeeding 27 years. It is suggested that in any case of persistent unexplained pain of the wrist or clinical symptoms resembling those of tenosynovitis, osteoid osteoma of the styloid process of the radius or of the carpal bones should also be included in the differential diagnosis. The recommended treatment of osteoid osteoma is "en bloc" excision of this tumour in the affected bone, resulting in complete relief of pain and absence of functional disturbances.

[Limb fractures in organ transplanted patients].

Patients that have had organ transplantation receive immunosuppressive therapy to prevent organ rejection. Along with this therapy comes a higher incidence of osteoporosis, which may lead to an increased frequency of fractures in post-transplant patients. This article presents three patients who underwent organ transplantation and had subsequent fractures: subcapital fracture of the femoral neck treated with hemiarthroplasty of the hip, in a patient 8 years post cardiac transplantation; minimally displaced intertrochanteric fracture treated by percutaneous pinning, in a patient one year post lung transplantation; minimally displaced subcapital fracture treated by percutaneous pinning, in a patient 3 months post liver transplantation. Each patient was operated upon successfully and without complications. The three patients were able to resume their activities of sitting and walking after only a few days. In our opinion, preventive treatment for osteoporosis is crucial for candidates of solid organ transplantation. This treatment should be initiated prior to surgery and continued after as well. Transplant patients receiving immunosupression therapy with subsequent osteoporotic fractures of the extremities should undergo early surgical intervention in order to enable a short and quick rehabilitation and early return to normal activities of daily living.

Imaging of primary sternal osteomyelitis in a patient with Crohn's disease.

A 41-year-old man with known Crohn's disease presented with chest pain and fever. Plain film and CT of the chest were normal, but bone scan and gallium scans showed intense sternal uptake. Surgery revealed staphylococcal osteomyelitis of the sternum. Following appropriate antibiotic treatment, the patient's symptoms resolved and follow-up gallium scans became normal. This is the first report of the association of sternal osteomyelitis and Crohn's disease, although other sites have been described. Sternal osteomyelitis has a high morbidity and the index of suspicion for this condition must be high even in the face of initially negative imaging.

Correction of combined angular and rotational deformities by the Ilizarov method.

Deformities of the lower extremities are often a combination of angular and rotational components. The rotational component of combined deformities may be difficult to measure using plain radiography. Based on the current study, the computed tomography rotational malalignment test was developed. Evaluation of lower extremity alignment was done on 56 patients. Rotational malalignment was diagnosed in 14 limbs of nine patients. In all patients, correction of angular and rotational deformities was done simultaneously using an Ilizarov external fixator. The frame included a standard angular distraction system and a derotation block interconnected via an additional empty ring. In all cases, successful correction of angular and rotational deformities was achieved. The pain was eliminated in all seven patients having preexisting chronic joint pain. There were no cases of deep infection or nonunion. This simple and reliable method allowed precise analysis of the deformity in the transverse plane. Preoperative frame construction incorporating the derotational module decreased the time of the operation and allowed one-stage correction of rotational and angular deformities without additional manipulations.