Electroacupuncture for the treatment of supraspinatus calcific tendonitis.

BACKGROUND: Conservative treatment of calcific tendonitis includes rest, medications, and physical therapy. Several physiotherapy interventions such as shockwave therapy are commonly used. The aim of this study was to investigate the efficacy of an electrotherapy method called electroacupuncture, in the treatment of calcific tendonitis. METHODS: 40 patients with calcific tendonitis were randomly divided to receive either a combination of medications and electroacupuncture, or just a course of medications. Evaluated outcomes included pain using the visual analog scale, shoulder range of motion with the use of goniometer, and quality of life along with functional status using the Instrumental Activities of Daily Living Scale (IAOLDS) and the Beck Depression Inventory (BDI). Radiological evaluation for the progression of the calcific deposits was also performed. All these evaluations were performed before and at the end of treatment. A final interview with the patients regarding any recurrent episodes was performed 18-24 months after the end of treatment. RESULTS: The intervention group showed greater improvement in pain intensity (2.8 points), range of motion (forward flexion, +30; abduction +29) when compared with the control group (for all, P < .05) while there was no statistically significant difference regarding the quality of life (IOLDS +0.2; BDI 0). Radiological evaluation demonstrated total or nearly total absorption of calcific deposits in 15 patients of the intervention group and in 8 patients of the control group. CONCLUSION: The successful clinical results of electroacupuncture and the regression of calcific depositions after treatment showed that electroacupuncture may have a role as a treatment modality in calcific tendonitis.

Electroacupuncture for the Treatment of Calcific Tendonitis. A Pilot Study.

Current treatment for calcific tendonitis consists of arm rest, antiinflammatory medications, and corticosteroid injections. If unsuccessful, a lot of clinicians suggest several physiotherapy modalities, such as shockwave therapy and electrotherapy. The purpose of our study was to assess the efficacy of electroacupuncture, as a substitute for failed medical treatment in calcific tendonitis. In a pilot study, we prospectively followed 10 patients treated with electroacupuncture for calcific tendonitis who failed to respond to medical treatment. Its efficacy was assessed by evaluating the level of pain, the Beck Depression Inventory, the range of active elbow mobility, and by repeated radiological evaluation of the course of calcific deposits. All clinical and radiological observations were recorded before and within 6 months after the onset of treatment. After electroacupuncture treatment (2 Hz, 180 mA for 30-60 seconds at GB21, GB34, LI4, LI 14, LI15, TW5, TW14, Chien Chien SI9, SI12, S37, S38), the visual analog score decreased notably, and the range of motion returned to normal. Radiological evaluation demonstrated almost complete absorption of calcific deposits within 6 months, after treatment. We conclude that electroacupuncture relieved skeletal pain, improved the quality of patient's life, and contributed to total regression of the calcific depositions in followed patients. So, electroacupuncture may be a valuable treatment option for calcific tendonitis, when medical treatment fails to relieve symptoms.

Intraoperative measurement of limb lengthening during total hip arthroplasty.

BACKGROUND: Limb length discrepancy (LLD) after total hip arthroplasty (THA) is a common problem which cannot be completely resolved. Many techniques have been described in order to minimize postoperative LLD, but most of these techniques are difficult to apply. Ideal technique must be simple and accurate. The most simple technique using a suture tied on the skin has well-known limitations, but its accuracy has not been evaluated before. MATERIALS AND METHODS: Sixty THAs in sixty patients (mean age 71 years, 1:1 male to female ratio) with hip osteoarthritis (37 cases in the right, and 23 cases in the left side) were studied in this prospective study. In all surgeries, the intraoperataive measurement of limb lengthening was performed using a suture tied on the skin of the lateral pelvis. The accuracy of this technique and correlation between intraoperative and postoperative radiological measurements of lengthening were evaluated. RESULTS: The mean preoperative LLD was -7.5 mm while the mean postoperative LLD was 1.58 mm. The accuracy of this technique, defined as the mean difference between the intraoperative and postoperative measurements was 1.8 mm. A strong correlation between these two measurements was noticed (r = 0.86). CONCLUSION: The accuracy and correlation index of this simple technique were similar to those of other techniques. The studied technique is quite accurate when attention is given to certain details, such as the amount of tension applied on the suture, the position of the tied point on the skin, and the position of the leg during measurements.

Percutaneous repair of acute Achilles tendon rupture: a functional evaluation study with a minimum 10-year follow-up.

OBJECTIVE: The purpose of this study was to present the functional outcomes of percutaneous tenorrhaphy of the Achilles tendon with a minimum follow-up of 10 years. METHODS: The medical records of patients who underwent percutaneous surgery for acute unilateral Achilles tendon rupture between 2000 and 2004 were retrospectively reviewed. RESULTS: A total of 11 male patients met the inclusion criteria and were followed for a mean of 12.6 years (range: 10-13 years). The average age at the time of surgery was 39.3 years (range: 29-53 years). Patients returned to work at an average of 2.7 months (range: 1-4 months) after surgery and to normal daily activities (NDA) at an average of 4.1 months (range: 3-6 months) postoperatively. The mean strength ratio between the injured and normal sides was 90%. Compared with the contralateral normal side, the thickness of the operated tendon increased by a mean of 0.7 cm, while the circumference of the affected calf diminished by a mean of 1.1 cm. No difference in active and passive range of motion (ROM) was recorded between the affected and the contralateral normal ankle joints. Isometric plantar flexion was 87% of normal. Sensory impairment in the territory of the sural nerve was identified in 1 patient immediately after surgery. The sensory defect had completely resolved by 6 months postoperatively. CONCLUSION: Long-term outcomes of our series support the effectiveness of percutaneous tenorrhaphy in Achilles function rehabilitation of patients with acute ruptures.

Atraumatic Sacral Fracture in Late Pregnancy: A Case Report.

Study Design Case report. Objective Sacral fractures, traumatic or atraumatic, are a rather rare cause of low back pain. The majority of the cases of pregnancy-related sacral fractures are reported as a postpartum complication, and only few cases of sacral atraumatic fractures have been reported in the last trimester of the pregnancy. The aim of this study is to report a rare case of atraumatic sacral fracture in the third trimester of pregnancy. Methods We report the case of a 30-year-old Caucasian European woman during her 37th week (36 weeks and 4 days) of gestation, who complained during her scheduled obstetric examination of continuous low back pain with no associated history of trauma. The patient performed activities of daily living with a normal level of fatigue and reported no running or walking long distances. She was examined in our department, and a magnetic resonance imaging scan was performed that showed a vertical nondisplaced fracture in her left sacrum. Results The patient was treated conservatively, and analgesics were administrated according to the consensus of the orthopedic and the anesthesiology departments. No further complications were recognized in the remaining period of her pregnancy, and a healthy child was born by caesarean section. Conclusions Atraumatic fractures of the sacrum should be included in the differentiated diagnosis of pregnant patients with low back pain.

Subtalar dislocation without associated fractures: Case report and review of literature.

Isolated subtalar dislocations are unusual injuries due to the inherent instability of the talus. Subtalar dislocations are frequently associated with fractures of the malleoli, the talus, the calcaneus or the fifth metatarsal. Four types of subtalar dislocation have been described according to the direction of the foot in relation to the talus: medial, lateral posterior and anterior. It has been shown that some of these dislocations may spontaneously reduce. A rare case of a 36-year-old male patient who sustained a closed medial subtalar dislocation without any associated fractures of the ankle is reported. The patient suffered a pure closed medial subtalar dislocation that is hardly reported in the literature. Six months after injury the patient did not report any pain, had a satisfactory range of motion, and no signs of residual instability or early posttraumatic osteoarthritis. The traumatic mechanism, the treatment options, and the importance of a stable and prompt closed reduction and early mobilization are discussed.

Lateral versus medial approach for intra-articular knee injections.

OBJECTIVE: The aim of this study was to determine whether the medial or the lateral mid-patellar approach is the most reliable for intra-articular knee injections. METHODS: The study included 76 knees of 76 patients divided into 2 groups. The first group consisted of 38 patients with a knee injury and resultant knee effusion. The second group included 38 patients without any known knee pathology. Patients were matched according to age and gender. The medial joint opening (medial patellofemoral angle) was calculated on a T1-weighted transverse image by measuring the anatomic angle between the femur and the patella. The lateral joint opening (lateral patellofemoral angle) was calculated in a similar way. RESULTS: The medial patellofemoral angle was significantly higher than the lateral patellofemoral angle in both groups (p<0.001). CONCLUSION: The medial patellofemoral angle is significantly higher than the lateral patellofemoral angle in both healthy knees and knees with effusion. Therefore, the medial approach appears to be more accurate for intra-articular knee injection due to the medial joint's larger opening.

Popliteal artery damage during total knee arthroplasty.

Injury of popliteal artery during total knee arthroplasty is a relatively rare complication. We report on one case of transverse semi-dissection of the popliteal artery during the tibial cut and one case of popliteal pseudoaneurysm formation caused by Hohmann retractors. Diagnosis was made early in the first case but it was delayed in the second due to misdiagnosis of deep vein thrombosis. Both injuries were managed eventually by open surgery. Postoperative clinical examination and ultrasound imaging confirmed the successful restoration of the blood flow. This case report also describes the classification system of the type of vascular damage and describes the mechanism, the clinical presentation, diagnostic modalities and treatment options for these rare complications of total knee arthroplasty surgery.

Proximal screws placement in intertrochanteric fractures treated with external fixation: comparison of two different techniques.

BACKGROUND: To compare two different techniques of proximal pin placement for the treatment of intertrochanteric fractures in elderly patients utilizing the Orthofix Pertrochanteric Fixator. METHODS: Seventy elderly high-risk patients with an average age of 81 years were treated surgically for intertrochanteric fracture, resulting from a low energy trauma. Patients were randomly divided in two groups regarding to the proximal pin placement technique. In Group A the proximal pins were inserted in a convergent way, while in Group B were inserted in parallel. RESULTS: All fractures healed uneventfully after a mean time of 98 days. The fixator was well accepted and no patient had significant difficulties while sitting or lying. The mean VAS score was 5.4 in group A and 5.7 in group B. At 12 months after surgery, in group A the average Harris Hip Score and the Palmer and Parker mobility score was 67 and 5.8, respectively. In group B, the average Harris Hip Score and the Palmer and Parker mobility score was 62 and 5.6, respectively. No statistically significant difference was found regarding the functional outcome. The mean radiographic exposure during pin insertion in Group A and Group B was 15 and 6 seconds, respectively. The difference between the two groups, regarding the radiographic exposure, was found to be significant. CONCLUSION: Proximal screw placement in a parallel way is simple, with significant less radiation exposure and shorter intraoperative duration. In addition, fixation stability is equal compared to convergent pin placement.

Snakebites of fingers or toes by viperidae family members: an orthopaedic approach.

The purpose of this study was to review current principles of therapy for affected patients and determine whether an emergent surgical approach or expectant management should be selected in cases of snakebites of fingers or toes by Viperidae family members. Over the past five years (January 2004 to December 2009), 12 patients bitten by Vipera ammodytes were admitted in our department. We retrospectively reviewed their demographic and epidemiological characteristics as well as their symptoms, laboratory findings, and complications. All snake bites occurred at the extremities (fingers and toes). The main complications were oedema, disseminated intravascular coagulation, and decrease in haematocrit. None of the patients developed compartment syndrome or required surgical debridement. The majority of the patients with snakebites of fingers or toes by Vipera ammodytes can be treated conservatively. Surgery is indicated only in case of compartment syndrome, where fasciotomies should be performed without delay after diagnosis.

Ilizarov treatment of humeral shaft nonunion in an antiepileptic drug patient with uncontrolled generalized tonic-clonic seizure activity.

Nonunion of the humeral shaft in patients with antiepileptic drug associated metabolic bone disorder constitute a challenging surgical problem difficult to treat due to seizure activity, osteoporosis, and poor stabilization options. We report a case of nonunion of the humeral shaft in an antiepileptic drug patient with uncontrolled generalized tonic-clonic seizure activity successfully treated with Ilizarov external fixator and a follow-up of 4 years.

Femoral periprosthetic fracture in osteoporotic bone after a total knee replacement: treatment with Ilizarov external fixation.

We report 3 cases of periprosthetic fractures after total knee replacement treated with Ilizarov external fixator (Smith and Nephew plc, Memphis, Tenn) and a follow-up of at least 3 years. We used 2 rings in the supracondylar area distal to the fracture and 3 half pins proximally in all our cases leaving the knee free to move. In one patient apart from the 2-ring frame placed distal to the fracture site the fixator included another ring frame placed proximally just below the 3 half pins. Uncomplicated fracture healing with lower extremity excellent alignment was achieved in 12 weeks after surgery. In periprosthetic femoral fractures, especially in elderly patients, Ilizarov external fixator is a treatment option which provides stable fixation, prompt postoperative mobilization, and has no major complications.

Free vascularized fibular graft for treatment of pathological femoral neck fracture and osteonecrosis of the femoral head: a case report with a long-term follow-up.

We present a case of a 34-year-old white female patient who, 13 years ago, sustained a pathological intracapsular femoral neck fracture on a pre-existing aneurysmal bone cyst. Three months later radiographic and magnetic resonance imaging evaluation revealed both femoral neck fracture and stage IV osteonecrosis of the femoral head according to Steinberg classification system. Management was accomplished with combined free vascularized fibular grafting and internal osteosynthesis with a 130 degrees blade plate. Union was achieved in 7 months. Progression of osteonecrosis was arrested. Hip salvage and a satisfactory subjective and clinical outcome were achieved. At the last follow-up, 13 years postoperatively, the patient had satisfactory functional outcome.

Application of the Endomodel rotating hinge knee prosthesis for knee osteoarthritis.

One hundred thirty-six knees were treated with the Endomodel rotating hinge knee prosthesis as primary total knee arthroplasty (TKA). The indications for surgery included osteoarthritis (110 knees), rheumatoid arthritis (18 knees), and osteonecrosis (8 knees). Patients were divided into four study groups according to follow-up duration. Group A was followed up from 10 to 15 years, group B from 8 to 10 years, group C from 5 to 8 years, and group D from 2 to 5 years. The Hospital for Special Surgery knee score, as well as each parameter individually, showed statistically significant improvement in all groups postoperatively. A total of 88.23% were rated as excellent, 3.67% as good, and 8.08% as fair. The results suggest that the Endomodel rotating hinge prosthesis can be considered a good alternative for primary TKA in cases of serious axial deformity and collateral ligament deficiency and in rheumatoid arthritis patients.

Turret exostosis of the hallux.

A 22-year-old woman presented with pain on the dorsum of her left big toe. The patient had had an accident 1 year previously, when a heavy object fell on her left big toe. She experienced no pain in the hallux before the injury. Radiographic evaluation revealed a well-circumscribed osseous mass, in close relationship to the underlying dorsal cortex of the proximal phalanx. A 2 x 1.5 x 0.7 cm mass was resected. No communication was found between the undersurface of the bony mass and the medullar space of the phalanx. The histology report confirmed diagnosis of acquired osteochondroma. Removal of the bony mass resulted in disappearance of symptoms without any sign of recurrence 10 months later.

Long-term results of various therapy concepts in severe pilon fractures.

INTRODUCTION: Intra-articular fractures of the tibia plafond are among the most challenging of orthopaedic problems. This is a retrospective case-control study of surgically treated pilon fractures which was undertaken to compare the internal fixation with the two external fixation methods. METHODS: This is a case-control study of 55 patients with 55 pilon fractures. There were 36 type C and 19 type B. Of these fractures, 24 were open and 31 closed. Three surgical protocols were used. In 20 patients, Group A, a half pin external fixator with ankle spanning was performed. The mean age of patients was 42.0 years (22.0-74.0), SD 14.1 and the mean follow-up was 77.7 months (38.0-132.0), SD 25.4. In 22 patients, Group B, a single ankle sparring ring hybrid external fixator under a small arthrotomy was performed. The mean age of patients was 48.4 years (28.0-76.0), SD 12.4 and mean follow-up was 67.9 months (36.0-132.0), SD 27.8. In 13 patients, Group C, a two-staged internal fixation was performed. The mean age was 45.6 years (30.0-66.0), SD 9.7 and the mean follow-up was 78.6 months (55.0-132.0), SD 25.4. We addressed the dissimilarity of the type of fracture in each group performing supplementary stratified analyses within each fracture type group. RESULTS: Group A had union in 6.9 months, group B in 5.6 months and group C in 5.1 months; P = 0.009. Six patients (Group A), two (Group B), and one (Group C) had limitation of ankle motion; P = 0.47. One patient from group C developed infection and the plate was removed. Four patients (Group A), one (Group B), and one (Group C) have developed posttraumatic arthritis (loss of joint space and pain); P = 0.25. Seven patients from Group A have reduced their activities; P = 0.004. In stratified statistical analysis by type of fracture, the associations noted for both fracture groups combined were also noted separately within each fracture group. CONCLUSION: In this long term follow-up study, the two-staged internal fixation and the hybrid fixation with small arthrotomy were equally efficacious in achieving bone union. Patients in external fixation with the ankle spanning had a significantly higher rate of delayed union. Also more patients in this group have reduced their activities.

Bilateral absence of the patella in nail-patella syndrome: delayed presentation with anterior knee instability.

A 27-year-old man, while serving in the armed forces, presented with complaints of right knee pain of 3 months duration. The patient reported pain localized on the lateral side of the right knee, especially during long-distance walking and stair climbing, and a feeling of giving way. There was no history of recent or remote trauma to the knee joint. At that time, he presented with knee pain and instability consistent with anterior cruciate ligament (ACL) insufficiency. During physical examination, the diagnosis of nail-patella syndrome (NPS) was made, but magnetic resonance imaging (MRI) of both knees revealed intact ACLs. The reported case presents NPS as a potential nontraumatic cause of anterior knee instability. In our patient, a discrepancy between the clinical and imaging findings was present. The initial clinical examination was consistent with ACL rupture or aplasia and this led to MRI evaluation of the knee, which showed an intact ACL, contrary to the initial diagnosis. It should be noted that anterior instability has been described after patellectomy and could be attributed to complete absence of the patella, which is rare in NPS.

Low-intensity transosseous ultrasound accelerates osteotomy healing in a sheep fracture model.

BACKGROUND: Low-intensity transcutaneous ultrasound can accelerate and augment the fracture-healing process. The aim of this study was to investigate the effect of transosseous application of low-intensity ultrasound on fracture-healing in an animal model. METHODS: A midshaft osteotomy of the left tibia was performed in forty sheep. An external fixator was used to stabilize the osteotomy site. A thin stainless-steel pin was inserted into the bone, 1.0 cm proximal to the osteotomy site. Ultrasound was transmitted through the free end of this pin, with a PZT-4D transducer. In twenty animals, the treated limb received a 200-microsec burst of 1-MHz sine waves repeated at 1 kHz with an average intensity of 30 mW/cm(2) for twenty minutes daily. Twenty other animals underwent the same surgery but did not receive the ultrasound (controls). Animals were killed at seventy-five and 120 days postoperatively. Radiographic evaluation was performed every fifteen days. Mechanical testing and quantitative computed tomography were performed after death. RESULTS: Fractures treated with ultrasound healed significantly more rapidly, as assessed radiographically, than did the controls (seventy-nine compared with 103 days, p = 0.027). On day 75, the mean cortical bone mineral density (and standard deviation) was 781 +/- 52 mg/mL in the treated limbs compared with 543 +/- 44 mg/mL in the control group (p = 0.014), and the average ultimate strength (as assessed with a lateral bending test) was 1928 +/- 167 N in the treated limbs compared with 1493 +/- 112 N in the control group (p = 0.012). No significant differences were noted on day 120. CONCLUSIONS: This study demonstrated that low-intensity transosseous ultrasound can significantly accelerate the fracture-healing process, increase the cortical bone mineral density, and improve lateral bending strength of the healing fracture in a sheep osteotomy model.

Non-union of femoral neck fractures with osteonecrosis of the femoral head: treatment with combined free vascularized fibular grafting and subtrochanteric valgus osteotomy.

Femoral neck fractures, frequently complicated by non-union and femoral head osteonecrosis,present a difficult clinical situation, especially when young patients are concerned. Existing treatment options are valgus osteotomy to address the biomechanical factors or bone grafting to address the biologic factor. The authors describe the operative technique and results of combined subtrochanteric valgus osteotomy and free vascularized fibular grafting in management of five young patients with both non-union and avascular necrosis.