Varicosities as an etiology of tarsal tunnel syndrome and the significance of tinel's sign: report of two cases in young men and a review of the literature.

Two cases of tarsal tunnel syndrome in two young men with surgical and radiologic details are reported. The role of varicosities as a cause of tarsal tunnel syndrome and the significance of Tinel's sign are discussed through a large review of the literature.

The natural history of a mistreated ipsilateral Galeazzi and Monteggia lesion: report of a case 39 years post-injury.

Galeazzi injury combined with ipsilateral Monteggia lesion is extremely rare. A 45-year-old male patient with a mistreated Galeazzi lesion combined with an ipsilateral Monteggia fracture at the age of 6 is presented. Thirty-nine years post-injury his elbow was asymptomatic and stable and his distal radioulnar and radiocarpal joints were also asymptomatic. The strength of the limb was equal to the unaffected contralateral upper limb and he was able to work manually as a waiter for the last 20 years without any problem. The only obvious defect was a 30 degrees lack of elbow flexion and a 10 degrees lack of forearm pronation in comparison to the normal side.

Clinical research: the patients' perspectives.

Patients' perspectives in clinical research have become increasingly interesting and important. Much effort has recently been made to understand, evaluate and promote the patients' active roles in and unique views on their involvement in clinical research, and how these may help resolve old and new problems in research planning, conduct and implementation. In this article issues regarding informed consent, differences between medical care and medical research, confidentiality, conflicts of interest and disclosure of study results are considered from the patients' point of view.

Isolated synovial cyst of the acromio-clavicular joint associated with joint degeneration and an intact rotator cuff.

The majority of acromioclavicular joint cysts are the manifestation of underlying pathology of the rotator cuff. A chronic rotator cuff tear should be the first option in differential diagnosis, when facing such a condition, although this is not always the case. A case of a 67-year-old male patient, who abruptly developed a painless lump over his right acromioclavicular joint, is presented. Imaging studies were diagnostic for a cystic lesion, and degeneration of the acromioclavicular joint without communication with the subdeltoid bursa and the glenohumeral joint. The rotator cuff was intact. Surgical treatment, with cyst removal and resection of the distal end of the clavicle, was performed. The lesion was proved to be a synovial cyst. Eighteen months postoperatively, the patient was asymptomatic and no recurrence of the cyst was evident.

Humeral diaphyseal aseptic non-unions: an Algorithm of management.

Successful operative treatment of a humeral shaft non-union may be a challenge for the surgeon. Several treatment options have been reported over the years. A systematic review of the literature was performed. Twenty-three retrieved articles (level of evidence IV) fulfilled our inclusion criteria and dealt with aseptic diaphyseal humeral non-union managed by plating, intramedullary nailing and external fixation based on Ilizarov's principles. Despite an obvious superiority of plating in the treatment of humeral shaft non-unions, there is no doubt that intramedullary nailing as well as external fixation devices have a role. An algorithm of management of the humeral shaft non-unions following a rational approach is suggested.

Release of the subscapularis tendon and muscle: a limited gain in length.

This study measured in vitro the degree of lateral advancement of the subscapularis tendon achieved by circumferential release. Thirty-eight cadaveric shoulders underwent circumferential subscapularis release with anterior capsulotomy. Release was performed in two phases. The first phase consisted of four stages: 1) cutting the capsule parallel to the superior border of the subscapularis tendon to the level of the glenoid; 2) division of the anterior capsule and blunt dissection along the glenoid neck; 3) safe separation of the capsule and muscle inferiorly; and 4) blunt, with a finger, dissection between the conjoined tendon and the subscapularis to the level of the joint line. The second phase was performed by cutting the coracohumeral ligament and the consistently found fibrous band that connects the superior aspect of the subscapularis tendon to the base of the coracoid. After each phase, 3 kg of traction were applied to the muscle and the lateral advancement of the subscapularis was measured using a millimeter caliper. The lateral advancement of the subscapularis was 5.5 +/- 3.4 mm after the first step and 9.8 +/- 4.5 mm after the second step. The difference was statistically significant (P < .001). These results indicate that, although necessary, anterior soft tissue balancing during shoulder replacement is limited.

Bioabsorbable materials in orthopaedics.

The applications of bioabsorbable implants in orthopaedic surgery have mainly been mandated from the need to eliminate implant removal operations. Although they have not gained widespread popularity among orthopaedic surgeons, they still represent an area of evolution. Considerable effort has been put into developing new bioabsorbable materials with fewer adverse effects. In this article an extensive review of the literature is presented emphasising on basic science and clinical applications of these materials. A review of the types of implants, the materials used, their biochemical properties, their adverse effects and some of the potential future applications is presented.

Fat embolism: special situations bilateral femoral fractures and pathologic femoral fractures.

Few data are available in the literature regarding fat embolism in cases of bilateral femoral and pathological femoral fractures. The incidence of bilateral femoral fractures ranges from 2-9.5% of the total number of patients with femoral fractures, and they usually occur in high energy trauma and multi-trauma patients. Although injury severity scores tend to underestimate the severity of these injuries, fat embolism seems to occur in increased frequency ranging from 4.8-7.5%. Intramedullary nailing, which is the preferred surgical treatment, triggers a systemic inflammatory response that poses an additional burden to pulmonary function. In addition, the femur is a common site of metastatic bone disease. The treatment of impending and actual pathological fractures is complicated by increased rates of lung damage due to various factors. Fat embolism during treatment--mainly with intramedullary nails--generally seems to range from 0-10%.

Stabilisation of a posteriorly unstable glenohumeral joint during total shoulder arthroplasty: A novel capsulorrhaphy technique.

Restoration of the soft tissue balance is of great importance during shoulder arthroplasty. We report a novel technique of posterior capsulorrhaphy through an anterior approach for the management of intraoperative posterior instability during implantation of the prosthesis. After the operation, the patients were able to follow a rehabilitation program with some minor restrictions, avoiding the necessity of a shoulder spica or other constrictive measures. This technique is simple, safe and sufficient to address instability due to abundance of the posterior shoulder capsule.

Intramedullary nailing for non-union of the humeral diaphysis: a review.

PubMed and Ovid Medline were searched to investigate the role of intramedullary nailing in the treatment of diaphyseal humeral non-union. Of 474 abstracts, 9 retrieved articles fulfilled our inclusion criteria and described management in 166 cases of humeral shaft non-union using several types of intramedullary nails. Union ranged from 40 to 100%; part of the variation could be explained by the quality index of the selected articles. Exchange nailing alone was not effective. Exposure of the fracture site and use of bone grafting were key to successful treatment. The total incidence of severe complications, including radial nerve damage, was very low. Thus, intramedullary nailing in the treatment of humeral shaft non-unions can lead to successful outcomes when associated with autologous bone grafting.

Bone formation blocking closure of the expanded distal fins during removal of a Seidel humeral nail.

The authors report the case of a young patient in which, during removal of a Seidel nail four years after healing of a mid shaft fracture of the humerus, bone formation into the central canal of the nail through the peripheral slots, prevented the three spread distal fins of the nail to close. The nail could only be extracted by forceful use of the extracting instrument, fortunately without complication.

Shoulder hemiarthroplasty in the management of humeral head fractures.

The results of hemiarthroplasty for shoulder fracture were evaluated in 26 patients, 20 women and 6 men with a mean age of 64.7 +/- 8.2 years. The follow-up period was 2 to 7 years. Cofield prostheses were used for the first 10 patients and subsequently 9 Global and 7 Aequalis prostheses were implanted, all cemented. The clinical outcome was assessed using the Constant-Murley scale. The mean score, at the last follow-up, was 70.4 +/- 16.4 (39-96). Mean forward elevation of the arm was 150 degrees (300-175 degrees), mean abduction was 145 degrees (30 degrees -170 degrees), and mean external rotation was 30 degrees (10 degrees-45 degrees). In most of the cases internal rotation corresponded with a position of the dorsum of the hand at the L3 vertebrae. The patients in our series achieved their optimal clinical result within the first 6 months after operation. Shoulder hemiarthroplasty is a worthwhile procedure, giving predictable results provided the patients have been carefully selected, the individual anatomy of the shoulder is restored and an aggressive rehabilitation program is implemented during the first six months after surgery.

Relevance of the restoration of humeral length and retroversion in hemiarthroplasty for humeral head fractures.

Sixteen patients, with a fracture of the upper humerus treated with hemiarthroplasty, were followed-up for 45.7 +/- 15.1 (20-72) months after surgery. The results were assessed using the Constant-Murley scale. The mean score was 75.8 +/- 15.7 (54-96) points out of a possible maximum of 100. At the time of their last follow-up they underwent CT of the fractured and contralateral humerus. Humeral length and retroversion were measured and evaluated. A very good final outcome (Constant score more than 71) was achieved in patients with a difference in retroversion less than 10 degrees and a difference in length less than 14 mm, between fractured and sound humerus. The mean difference in retroversion was 8.7 degrees and the mean difference in length was 0.65 cm, between fractured and sound humerus. We attribute the very good clinical outcome in our series to the quality of the anatomical reconstruction that was performed.

Effectiveness and pitfalls of percutaneous transpedicle biopsy of the spine.

Seventy-one percutaneous transpedicle biopsy specimens were taken from 68 patients with cervical, thoracic, lumbar, or sacral vertebral lesions, with the patients under local anesthesia. Sixty-one procedures were done with fluoroscopic guidance and seven procedures were done with computed tomography guidance. Twenty-one patients were diagnosed as having infectious spondylodiscitis, three had tuberculosis, two had coccidiomycosis, two had brucellosis, one had blastomycosis, one had an echinococcus cyst, six had primary neoplasms, 14 had metastatic neoplasms, five had osseous repair for insufficiency fractures, seven had osteoporotic fractures, and one had Paget's disease of bone. In the four remaining patients, the biopsy initially was negative but it was proven to be false-negative because of faulty biopsy technique. The percutaneous transpedicle approach for biopsy is safe, efficacious, and cost-effective. False-negative results and complications can be avoided when adhering to the technical details of this procedure.