A Pronator Teres-sparing Volar Approach for Osteosynthesis of Midshaft Diaphyseal Radius Fractures.

Henry's approach is widely considered the "workhorse" for exposing the volar radius and has not really changed since his original description in 1945. We describe a pronator teres-sparing volar approach to the forearm, for osteosynthesis of midshaft diaphyseal radius fractures. We believe this approach is safe, simple, and reproducible, and has several practical and theoretical advantages over Henry's original description.

A modified ulnar translocation reconstruction technique for Campanacci grade 3 giant cell tumors of the distal radius using a clover leaf plate.

BACKGROUND: Campanacci grade 3 giant cell tumors of the distal radius are locally aggressive and in close proximity to the median nerve, articular cartilage, flexor and extensor tendons, and the radial artery. Although several reconstructive techniques have been described, it is unclear to what degree these procedures restore function. DESCRIPTION OF TECHNIQUE: We present a modified ipsilateral ulna translocation technique using a clover leaf plate, for reconstruction of en bloc resected distal radius. This has the theoretical advantage of ensuring a solid, pain-free wrist arthrodesis, while preserving the forearm rotational axis and minimizing functional loss, without the associated donor site morbidity or allograft rejection issues of other reconstructive techniques. PATIENTS AND METHODS: Between 2006 and 2013, 3 patients underwent this procedure for Campanacci grade 3 giant cell tumors. All patients were right hand-dominant females, aged 24, 35, and 46 years, respectively. Two cases involved the right radius. Patients were reviewed retrospectively with clinical examination, functional assessment [the Toronto Extremity Salvage Score (TESS) for upper limb], and radiographs. The review period was 30, 51, and 41 months, respectively. RESULTS: The length of distal radius resected was 70, 50, and 35 mm, respectively. All achieved clear margins. There were no complications and there have been no recurrences. All ulnocarpal translocations achieved radiographic fusion. Patient's averaged 80-degree pronation, 70-degree supination, and clinical TESS scores of 86 at most recent follow-up. CONCLUSIONS: This technique achieved a painless and functional wrist arthrodesis with partially restored wrist motion, without complications. This technique has the advantage of negating remote donor site morbidity and/or allograft rejection issues of other techniques. LEVEL OF EVIDENCE: Level III, therapeutic study.

Chronic facial pain and Meckel cave masses as the initial presentation of neurosarcoidosis: a case report.

Sarcoidosis is a systemic inflammatory disease that can affect virtually every organ system, leading to a wide variety of clinical manifestations. Central nervous system involvement producing neurologic symptoms can occur in patients with sarcoidosis, yet rarely are these symptoms the initial manifestations of the disease. Here we present the case of a 38-year-old man who presented with a history of chronic facial pain, blurred vision, increased lacrimation, and periodontal abscesses. Physical examination revealed no evidence of infection or neoplasm. Magnetic resonance imaging revealed space-occupying lesions in Meckel cave bilaterally, with soft-tissue density extending into the left sphenoid and posterior ethmoid sinuses. Endoscopic biopsy of sinus mucosa demonstrated the presence of noncaseating granulomas and the absence of organisms, findings suggestive of neurosarcoidosis. The diagnosis was further supported by chest radiography, which demonstrated bilateral hilar adenopathy. The patient was treated with corticosteroids, and his facial pain improved markedly. In this article we discuss neurosarcoidosis and its manifestations, diagnosis, and clinical course.

Posterolateral and anterolateral approaches to unicondylar posterolateral tibial plateau fractures: a comparative study.

BACKGROUND: Lateral tibial plateau fractures that are located posterolaterally are difficult to reduce through an anterolateral surgical approach because of the lack of direct visualisation of the fracture. This study compared the results of unicondylar posterolateral tibial plateau fractures in two patient cohorts: one treated through a posterolateral direct approach and the other through an anterolateral indirect approach. PATIENTS AND METHODS: All nine patients admitted to our hospital, a tertiary care, urban, public hospital in Australia, from 2007 to 2010 with unicondylar posterolateral tibial plateau fractures were treated through a direct posterolateral transfibular approach and prospectively studied. All eight patients admitted from 2004 to 2007 with unicondylar posterolateral tibial plateau fractures were treated through an indirect anterolateral approach and retrospectively reviewed. Fracture reduction and maintenance of reduction were assessed radiographically over 2 years. Knee function was assessed clinically and using the Lysholm score. RESULTS: Fractures managed through a direct posterolateral transfibular approach were reduced with no measurable articular step on standard radiography and had no loss of reduction over time. By contrast, fractures treated through an indirect anterolateral approach had a median postoperative articular step of 5.5mm (interquartile range=4.5). These displacements worsened over time in six of the eight patients. At 2 years, patients treated through a direct approach had significantly better Lysholm scores than those treated through an indirect approach. CONCLUSION: This study suggests that a direct posterolateral transfibular approach to unicondylar posterolateral tibial plateau fractures results in improved reduction, stabilisation and functional outcomes at early follow-up compared to an indirect anterolateral approach.

Waterproof cast liners in paediatric forearm fractures: a randomized trial.

PURPOSE: Waterproof casts have been shown to provide adequate support and immobilization in fractures. This study evaluated two waterproof cast liners, namely, Wet or Dry(®) and Delta Dry(®), in terms of ease of application/removal, durability, longevity, and patient satisfaction using patient- and technician-reported outcome measures. METHODS: A total of 105 children were enrolled in a randomized trial and received a below-elbow synthetic cast with either of the two cast liners. RESULTS: The two groups were comparable with regards to age, gender, side of cast, and hand dominance. Assessment was carried out at application and removal. In the patient-reported outcomes, the Wet or Dry(®) group was rated significantly better in the odor and water resistance categories. In the technician-reported application and removal outcome measures, the Delta Dry(®) group was rated significantly higher. CONCLUSIONS: The use of waterproof cast liners appears to be safe in children with forearm fractures, with some differences in outcome between the two products trialed.

Posterolateral transfibular approach to tibial plateau fractures: technique, results, and rationale.

We describe a posterolateral transfibular neck approach to the proximal tibia. This approach was developed as an alternative to the anterolateral approach to the tibial plateau for the treatment of two fracture subtypes: depressed and split depressed fractures in which the comminution and depression are located in the posterior half of the lateral tibial condyle. These fractures have proved particularly difficult to reduce and adequately internally fix through an anterior or anterolateral approach. The approach described in this article exposes the posterolateral aspect of the tibial plateau between the posterior margin of the iliotibial band and the posterior cruciate ligament. The approach allows lateral buttressing of the lateral tibial plateau and may be combined with a simultaneous posteromedial and/or anteromedial approach to the tibial plateau. Critically, the proximal tibial soft tissue envelope and its blood supply are preserved. To date, we have used this approach either alone or in combination with a posteromedial approach for the successful reduction of tibial plateau fractures in eight patients. No complications related to this approach were documented, including no symptoms related to the common peroneal nerve, and all fractures and fibular neck osteotomies healed uneventfully.

The accuracy and precision of radiostereometric analysis in monitoring tibial plateau fractures.

BACKGROUND AND PURPOSE: The application of radiostereometric analysis (RSA) to monitor stability of tibial plateau fractures during healing is both limited and yet to be validated. We therefore evaluated the accuracy and precision of RSA in a tibial plateau fracture model. METHODS: Combinations of 3, 6, and 9 markers in a lateral condyle fracture were evaluated with reference to 6 proximal tibial arrangements. Translation and rotation accuracy was assessed with displacement-controlled stages, while precision was assessed with dynamic double examinations. A comparison of error according to marker number and arrangement was completed with 2-way ANOVA models. RESULTS: The results were improved using more tantalum markers in each segment. In the fracture fragment, marker scatter in all axes was achieved by a circumferential arrangement (medial, anterior, and lateral) of the tantalum markers above the fixation devices. Markers placed on either side of the tibial tuberosity and in the medial aspect of the fracture split represented the proximal tibial reference segment best. Using 6 markers with this distribution in each segment, the translation accuracy (root mean square error) was less than 37 mum in all axes. The precision (95% confidence interval) was less than +/- 16 mum in all axes in vitro. Rotation, tested around the x-axis, had an accuracy of less than 0.123 degrees and a precision of +/- 0.024 degrees. INTERPRETATION: RSA is highly accurate and precise in the assessment of lateral tibial plateau fracture fragment movement. The validation of our center's RSA system provides evidence to support future clinical RSA fracture studies.

Effect of environmental factors on myopic LASIK enhancement rates.

PURPOSE: To determine whether environmental factors affect laser in situ keratomileusis (LASIK) enhancement rates. SETTING: Wake Forest University Eye Center, Winston-Salem, North Carolina, USA. METHODS: This retrospective chart review comprised 368 consecutive eyes of 191 myopic patients who had LASIK by the same surgeon (K.A.W.). All patients had surgery in 2000 with the Visx Star S2 excimer laser. Refractive outcome, visual acuity, and enhancement rates were monitored closely for 1 year. Fifty-seven eyes (15.5%) had an enhancement procedure. Using enhancement procedure or percentage of correction as the outcome measure, factors that were suspected to affect LASIK results and the need for enhancement were examined; specifically, age, eye, sex, pachymetry, corneal curvature (K), preoperative spherical equivalent, ablation depth, and environmental factors (procedure room temperature, procedure room relative humidity, outdoor temperature, and outdoor relative humidity). RESULTS: Using univariate and multivariate analysis, LASIK enhancement rates strongly correlated with the following variables: procedure room humidity (P =.003; odds ratio [OR] = 1.093; 95% confidence intervals [CI], 1.030-1.160), 2-week preoperative mean outdoor humidity (P =.011; OR = 1.054; 95% CI, 1.012-1.096), outdoor temperature (P =.0059; OR = 1.039; 95% CI, 1.011-1.068), and age (P =.0497; OR = 1.034; 95% CI, 1.001-1.070). The percentage of correction strongly correlated with the following variables: procedure room humidity (P =.021), 2-week preoperative mean outdoor humidity (P =.001), outdoor temperature (P =.0052), and room temperature (P =.017). CONCLUSIONS: The 2-week-preoperative mean outdoor relative humidity, procedure room relative humidity, outdoor temperature, and procedure room temperature may have to be considered during LASIK planning. The effect of these environmental variables on LASIK outcomes warrants further evaluation.