SICOT-J - Société Internationale de Chirurgie Orthopédique et de Traumatologie
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Sequential management of tibial fractures using a temporary unicortical external fixator
No full textIntroduction: The development of damage control orthopedics (DCO) procedures has led to the development of temporary unicortical external fixators (TUEFs) intended to limit deep infectious complications and facilitate early conversion to internal fixation.
Methods: A retrospective study was conducted in two French military trauma centers, including on patients being treated for tibial fractures with a TUEF (UNYCO® − Orthofix®) followed by an early conversion to intramedullary nailing.
Results: Eleven patients with an average age of 41 were included between September 2015 and June 2017. A total of 12 TUEFs were implanted for one closed fracture and 11 open fractures, including one type I, eight types II, and two Gustilo types IIIB. The indication of DCO was related to hemodynamic instability in three cases, to the severity of soft tissue lesions in eight cases, and to the context of treatment in one case. The conversion to IM nailing was made after an average of 7.6 days. No significant loss of reduction was observed until internal osteosynthesis, which was performed with “fixator in place” in ten cases. The coverage of Gustilo type III injuries was performed by free flap transfers at the same time as IM nailing. All the patients were reviewed with an average follow-up of 16.5 months. Bone union was achieved in all cases. Two IM nailing dynamizations were carried out, but no bone grafting was required. Two cases of pandiaphysitis were observed and treated without functional complications.
Discussion: Despite a limited number of patients, this study demonstrates the reliability of the TUEF to maintain the reduction of tibial fractures and facilitate early conversion to IM nailing. Unicortical fixation does not prevent septic complications related to the severity of soft tissue injuries
Periprosthetic stress fracture around a well-fixed type 2B short uncemented stem
No full textDespite the theoretical advantages of uncemented short stems, postoperative thigh pain is still matter of concern and can be attributed to different causes. We report a peculiar case of a stress fracture around a short cementless stem with cervico-metaphyseal fixation in an otherwise healthy patient. We implanted a MiniHipTM stem in a 43 year-old male professional golf player for the treatment of primary osteoarthritis using a ceramic on ceramic bearing. Against medical advice, the patient started to play soccer at the 4th postoperative month and was completely asymptomatic to that extent; but at 8 months follow-up and without a history of trauma he started complaining about progressive hip pain. After ruling out infection and loosening, histological analysis from a bone biopsy confirmed the diagnosis of stress fracture. Although revision surgery was initially scheduled, pain started to decrease gradually with protected weight-bearing (crutches) and disappeared around the first postoperative year, remaining the patient asymptomatic at 2 and half years of follow-up, with radiographs depicting a healed fracture with a hypertrophic callus. We encourage surgeons to be aware of the existence of periprosthetic stress fractures as a source of thigh pain (sometimes intractable), and despite being infrequent, they should always be contemplated, providing that these cases can be managed conservatively with rest and limited weight-bearing. After this uncommon case, we suggest to align the stem in order to equally distribute loads onto the medial calcar and the lateral femoral cortical
Acute postoperative pain after arthroscopic rotator cuff surgery: A review of methods of pain assessment
No full textIntroduction: Pain can be severe during the first days after arthroscopic surgery, and acute pain is an important outcome in clinical trials of surgical technique or anaesthetic strategy. A standardized, validated method of assessing acute postoperative pain would improve the quality of clinical studies, and facilitate systematic reviews and meta-analyses. A step on the way towards this standard is to investigate the methods most commonly used in recent literature.
Methods: PubMed and CINAHL databases were searched, including studies of arthroscopic rotator cuff surgery with a primary pain-related outcome during the first postoperative week, published in English from 2012 to 2017.
Results: A total of 47 studies were included, all measuring pain intensity using a pain rating scale. Most frequently used was the visual analogue scale using the anchors “no pain” and “worst pain imaginable”, with recordings at 1, 2, 4, 6, 8, 12, and 24 hours postoperatively. A total of 34 studies recorded analgesic consumption, usually as average cumulated consumption in mg. Time to first analgesic request or first pain were recorded in 11 studies, and 4 different starting points were used.
Discussion: This review describes the currently most common methods of assessing acute postoperative pain in clinical trials of arthroscopic shoulder surgery involving rotator cuff repair, and the large variety of methods applied. Based on this study and international guidelines, several recommendations on how to measure and report postoperative pain outcomes in future trials are proposed
Pedicle distraction increases intervertebral and spinal canal area in a cadaver and bone model
No full textIntroduction: Lumbar spinal stenosis is degenerative narrowing of the spinal canal and/or intervertebral foramen causing compression of the spinal cord and nerve roots. Traditional decompression techniques can often cause significant trauma and vertebral instability. This paper evaluates a method of increasing pedicle length to decompress the spinal and intervertebral foramen, which could be done minimally invasive.
Methods: Three Sawbone (Sawbones Europe, Sweden) and 1 cadaveric lumbar spine underwent bilateral pedicle distraction at L4. A pedicle channel was drilled between the superior articular process and transverse process into the vertebral body. The pedicles underwent osteotomy at the midpoint. Screws were inserted bilaterally and fixated distraction of 0 mm, 2 mm, 4 mm and 6 mm. CT images were taken at each level of distraction. Foramen area was measured in the sagittal plane at L3/4. Spinal canal area was measured at L4 in the axial images. The cadaver was used to evaluate safety of osteotomy and soft tissue interactions preventing distraction. Statistical analysis was by student paired t-test and Pearson rank test.
Results: Increasing distraction led to greater Spinal canal area. From 4.27 cm2 to 5.72 cm2 (p = 0.002) with 6 mm distraction. A Maximal increase of 34.1%. Vertebral foramen area also increased with increasing pedicle distraction. From 2.43 cm2 to 3.22 cm2 (p = 0.022) with 6 mm distraction. A maximal increase of 32.3%. The cadaver spinal canal increased in area by 21.7%. The vertebral foramen increased in area by 36.2% (left) and 22.6% (right).
Discussion: For each increase in pedicle distraction the area of the spinal and vertebral foramen increases. Pedicle distraction could potentially be used to alleviate spinal stenosis and root impingement. A potential osteotomy plane could be at the midpoint of the pedicle with minimal risk to nerve roots and soft tissue restrictions to prevent distraction
Anthropometric measurements in Ponseti treated clubfeet
No full textIntroduction: We measured the foot dimensions in the Ponseti treated idiopathic clubfeet to compare differences in foot sizes, if any.
Patient and Methods: The foot length and width in unaffected, unilateral and bilateral clubfeet were measured and analysed statistically.
Results: Average follow up was 22.2 months. Bilateral feet were similar in size. The unilateral affected feet matched in size with contralateral unaffected feet. The size difference between bilateral and unilateral affected feet was not significant. The bilateral feet were significantly smaller than age matched unaffected feet [in length 0.8 cm (6.1%); p = 0.03 and in width 0.2 cm, (3.7%); p = 0.03]. The unilateral foot was comparable with contralateral unaffected foot both during and post bracing.
Conclusions: Post Ponseti treatment, inter bilateral, unilateral affected versus unaffected, bilateral versus unilateral affected feet matched in size. The overall clubfeet size especially those with bilateral disease were significantly shorter than unaffected side. The Ponseti managed unilateral foot size was comparable with unaffected foot during the bracing duration and size comparability was maintained even after bracing protocol of 3 years was over
Post-traumatic massive hand lymphedema fully cured by vascularized lymph node flap transfer
No full textPost-traumatic localized hand lymphedema is a rare situation and its diagnosis may be difficult, causing lack of care leading to failure of care. Our case study is of two young women with massive post-traumatic hand lymphedema who were treated for algodystrophy for 2 years, and whose bandages and physiotherapy were unsuccessful. Major social and psychological consequences due to difficulty with diagnosis and management resulting in inappropriate tests and therapeutic treatment were prescribed due to these issues. Noncontrast magnetic resonance lymphography revealed complete lymphatic vessel blockage in the hand and wrist. A vascularized lymph node flap harvested at the groin level was transferred to the elbow level 1 month after local dermolipectomy. These procedures resulted in the restoration of lymphatic flow. Both patients were definitely cured, and they returned to normal life within 6 months after surgery. Lymph node flap transfer associated with dermolipectomy may cure massive localized lymphedema in selected cases
Unusual indication of Cell therapy for hip osteonecrosis after pregnancy
No full textPurpose: Osteonecrosis is a rare event during or after pregnancy. Due to the low number of cases, there is no report of long-term results after conservative surgery in this population.
Method: From 1992 to 2010, 145 consecutive female patients with unilateral symptomatic (94 stage I and 51 stage II) left hip osteonecrosis (ON) related to pregnancy were treated between 4 and 16 months after delivery with percutaneous mesenchymal stem cell (MSC) injection obtained from bone marrow concentration. The average total number of MSCs (counted as number of colonies forming units-fibroblast) injected in the hip was 185 000 ± 65 000 cells (range 95 000–240 000 cells).
Results: At the most recent follow-up (average 15 years after hip surgery, range 8–25 years), among the 145 hips included in the study, 4 hips (2.7%) had collapsed and were treated with total hip arthroplasty (THA). Thirty-two of the 94 stage I had progressed to stage II; and 4 of the 51 stage II had progressed to stage III and collapse. The other 141 hips (97.3%) were without collapse and pain free. On MRI, as percentage of the volume of the femoral head, the osteonecrosis had decreased from 34.5% pre-operatively to 6% at the most recent follow-up. For women who had other children after treatment, a subsequent pregnancy was not associated with osteonecrosis.
Conclusion: Patients with hip osteonecrosis following pregnancy had a low conversion rate to THA when treated early with cell therapy
Retrospective analysis of open reduction and internal fixation of coronal plane fractures of the capitellum and trochlea using the anterolateral approach
No full textIntroduction: Coronal plane distal humeral injuries are relatively rare. Numerous classification systems have been proposed as the complexity of these fractures has been realized. We in the present series of ten patients describe the surgical technique of Open Reduction and Internal Fixation of Coronal plane fractures of the distal humerus with headless compression screws performed using the anterolateral approach.
Material and method: It was a retrospective study, the data collected from March 2010 to 2015 was analysed and the final outcome was assessed using the DASH score. Out of a total of 13 patients with distal humerus coronal plane fractures, 10 patients were available for follow up. The X-rays and CT scans were reviewed and the fractures were classified according to Dubberley and Bryan and Morrey classification. Radiographic were evaluated for presence of union or nonunion, avascular necrosis, joint line step-off (none/1-mm/>1-mm), hardware failure and instability.
Results: The average age was 41 years. The average DASH score in our study was around 24. The time to union ranged between 8–12 weeks with the average time being around 10 weeks. One patient had post traumatic Arthritis radiologically classified as Broberg and Morrey Type 2 and one patient had Heterotrophic ossification Brooker Grade 1.
Conclusion: Open reduction and internal fixation of coronal shear fractures of capitellum and trochlea using headless screw compression via the antero-lateral approach is a reliable treatment modality and results in stable fixation with restoration of a functional arc of motion.
Level of evidence: I
Low Pass-rate in postgraduate surgical examination in Nigeria and its contribution to the low surgeon workforce in the country; a review article
No full textSurgical postgraduate examiners and examinees in Nigeria complain of the low pass rate at all levels of the postgraduate surgical training examinations to which several factors are contributing. For several years there has been being a persistently low surgeon workforce in the country despite having two surgeon producing institutions been for at least 37 years. A review of the probable causes was carried out to shed more light on the matter. At the time of writing there are 52 National Postgraduate Medical College of Nigeria (NPMCN) and 46 West African College of Surgeons (WACS) accredited post graduate surgery training programs in Nigeria compared with 99 in the United Kingdom (UK) and 1056 in the United States (US). Based on available data Nigeria has approximately 572 surgery residency training slots yearly compared with approximately 646 in the UK and 4225 in the US. Examination pass rate was less than 40% for primary WACS compared with 98% pass rate in USMLE (United States Medical Licensing Examination) 3, pass rate at part I was 28.8% for WACS compared with 37% at MRCS (Membership Royal College of Surgeons) part A and 57% for MRCS part B. For the exit examination or part II WACS pass rate was 31.5% (general surgery) while it was 64% for Fellowship Royal College of Surgeons (FRCS) cumulative and 70% in the American board of surgery (ABS). Surgeon per 100 000 population was 0.69 for Nigeria compared with 11.7 and 25.6 for the UK and US respectively. In the last 35 years WACS has produced 1638 surgeons (2.8 times more than NPMCN) in surgery and NPMCN has produced 572. The frequency of examination were twice per year for both WACS and NPMCN examinations, 3 times per year for the USMLE step 3, MRCS (A & B) and Fellowship Royal College of Surgeons (FRCS) general surgery. The American Board of Surgery (ABS) is once per year for Qualifying Examination (QE) and 5 times per year for Certifying Examination (CE)
Clinical and radiographic presentation of pelvic sarcoma in children
No full textIntroduction: Pelvic sarcomas may present with vague symptoms. The aim of this study was to examine the characteristics and clinical presentations of different types of pelvic sarcoma in children.
Methods: This is a retrospective cohort study of patients up to 21 years of age with the diagnosis of pelvic sarcoma between January 2000 and June 2013. Data on demographics, tumor type and location, and clinical presentation were collected from the medical records.
Results: A total of 59 patients [37 males (62.7%) and 22 females (37.3%)] were examined in this study. Mean age at presentation was 11.3 ± 5 years (range 0.8–21 years). Thirty-six patients had Ewing sarcoma (61%), 9 osteosarcoma (6.8%), 4 undifferentiated sarcoma (6.8%), 2 (3.4%) rhabdomyosarcoma, 2 synovial cell sarcoma, and one (1.7%) of each fibrosarcoma, dermatofibrosarcoma, fibromyxoid sarcoma, chondrosarcoma, chordoma, and epithelioid sarcoma. Pain at presentation was reported in 41 patients, 13 mass, 8 limping, and 5 neurologic symptoms. Most of the bony tumors were painful (77%), while most of the soft tissue tumors were painless (70%). Nine patients presented with constitutional symptoms. Most patients presented within 4–12 months from symptoms beginning. Twenty-one patients (35.6%) presented with metastases (14 Ewing sarcoma, 6 osteosarcoma, and 1 synovial cell sarcoma). Pelvic radiographs showed lytic lesion in 11 patients, 4 sclerotic lesions, 6 mixed lesion, 6 had only soft tissue mass, 1 radiograph showed osteopenia, and 2 radiographs were reported normal.
Conclusion: Ewing sarcoma was the most common pelvic sarcoma tumor in children. In most cases, pelvic sarcoma in children presented with pain mimicking other benign conditions. Some patients presented with metastatic disease with no prognostic clinical or radiographical signs or symptoms. Pelvic sarcoma should be considered a differential diagnosis as part of children work up