Ilias Bisbinas

Accuracy of needle placement in ACJ injections.

Localization of the Acromioclavicular joint (ACJ) even at arthroscopic surgery may be difficult because of its small size, osteophytes, variable anatomy of the joint and capsule. Therefore injection of the ACJ in the clinic may well be inaccurate. The aim of this study was to review the clinical accuracy of needle placement in ACJ injections, if performed without the aid of image intensification. Sixty patients with 66 shoulders were injected in the Day Unit in our department. The joint was palpated clinically, and the needle was placed in the site thought to be in the AC Joint. An image intensifier was then used to check the position of the needle in the AP and axillary views. The needle was considered correctly placed if between the bony boundaries of the acromion and clavicle. This was found in only 26 injections (39.4%). The remaining 40 injections (60.6%) were misplaced, either laterally in 21 injections (31.8%), medially in 13 (19.8%), anteriorly in 3 (4.5%) and inferiorly in 3 injections (4.5%). Theses were then reinserted under image intensifier guidance. The misplaced injections would have lead to inaccurate clinical outcomes, and decision making. This study is similar to other studies in that X-ray guidance improves the accuracy of injections and surgery. However the potential error rate for the small, anatomically variable AC joint is high. There is a 60% potential for ACJ injections to be out of the joint if performed by palpation alone, and we recommend the routine use of image intensification guidance.

Discitis in toddlers: A case series and review

UNLABELLED Toddlers commonly present to medical services with non-specific symptoms. The presence of refusal to walk and nocturnal waking with crying should alert clinicians to the possibility of discitis. CONCLUSION Features that may alert clinicians to the diagnosis of discitis in young children are reviewed.

Proximal opening wedge metatarsal osteotomy for correction of moderate to severe hallux valgus deformity using a locking plate.

PurposeHallux valgus is a complex deformity of the first metatarsophalangeal joint, with varus angulation of the first metatarsal, valgus deviation of the great toe and lateral displacement of the sesamoids and the extensor tendons. The aim of the surgery is to achieve correction of the varus deviation of the 1st metatarsal which is considered by some as the primary intrinsic predisposing factor to hallux valgus deformity.MethodsWe retrospectively reviewed 85 patients (107 feet) who underwent an opening wedge osteotomy of the 1st metatarsal for correction of moderate to severe hallux valgus and metatarsus primus varus. A medially applied anatomic pre-contoured locking plate was used for fixation of the osteotomy.ResultsThe mean IMA was decreased from 15.8 (range 12–22) degrees to 7.8 (range 0–12) degrees. The mean pre-operative HVA was 39 (range 21–52) degrees and the mean postoperative HVA was 11.8 (6–19) degrees. The pre-operative AOFAS score was 52 (SD 3.1) and the postoperative score was 85 (SD 5.2).ConclusionThe proximal opening wedge metatarsal osteotomy is a safe, effective and reproducible technique for correction of moderate to severe hallux valgus deformity. The use of a locking plate provides enough control at the fragments, enhancing healing of osteotomy and maintenance of the correction even with a violated proximal lateral cortex.

Complications following Treatment of Trochanteric Fractures with the Gamma3 Nail: Is the Latest Version of Gamma Nail Superior to Its Predecessor?

Gamma nail is a cephalomedullary implant that was developed for the treatment of pertrochanteric hip fractures and has been successfully used for over 20 years. During this period, modifications of design and instrumentation have occurred to combat the intra- and postoperative complications that were associated with the use of early designs. The purpose of this study was to compare the complications observed with the use of the Gamma3 nail (G3N) with those seen following use of the previous trochanteric gamma nail (TGN). This study prospectively recorded the intra- and postoperative complications of 175 patients treated with the Gamma3 nail and compared them with those of a historical cohort of 192 patients treated with the trochanteric gamma nail. We encountered less intra- and postoperative complications with the use of Gamma3 nail. Femoral fractures and lag screw cutout were significantly lower. The reoperation rate was significantly higher in the TGN group. Gamma3 nail has proved to be a safe and efficient implant for the treatment of pertrochanteric fractures. The improvement of the biomechanical characteristics has led to a significant decrease in complication rates, demonstrating superiority over its predecessor.

Treatment of Insertional Achilles Pathology With Dorsal Wedge Calcaneal Osteotomy in Athletes

Background: Insertional Achilles tendinopathy and retrocalcaneal bursitis is difficult to treat, and several operative techniques have been used after failure of conservative management. Dorsal wedge calcaneal osteotomy has been described for the treatment of insertional Achilles pathology. It was hypothesized that dorsal wedge calcaneal osteotomy would be an effective and safe method for the treatment of athletes with insertional Achilles pathology unrelieved by nonoperative measures. Methods: Fifty-two athletes (64 feet) who had painful Achilles tendon syndrome unrelieved by 6 months of nonoperative measures were treated surgically. Dorsally based wedge calcaneal osteotomy was performed through a lateral approach, and 2 staples were used for fixation. Patients were scored pre- and postoperatively with the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot and Victorian Institute of Sports of Australia-Achilles (VISA-A) scores. Results: At a minimum follow-up of 3 years, the patients’ AOFAS and VISA-A scores improved from 59.5 ± 15.0 and 65.9 ± 11.1 preoperatively to 95.7 ± 6.2 and 90.2 ± 8.4 postoperatively, respectively. Clinical results were considered excellent in 38 patients, good in 12 patients, and fair in 2 patients. Return to previous sports activity time was 21 (SD, 8.0) weeks. One patient necessitated a revision operation. Conclusion: Operative treatment of insertional Achilles pathology in athletes with dorsal closing wedge calcaneal osteotomy was a safe and effective method that allowed for a quicker return to previous level of sports activities compared with other techniques. Level of evidence: Level IV, retrospective case series

Multifocal epithelioid hemangioendothelioma of the foot and ankle: a case report

We report on a 41-year-old man with multiple epithelioid hemangioendothelioma of the left foot and ankle. The patient was treated with curettage and fixation with 2 separate plates, but later developed local infection. Owing to the potential for malignancy, below-knee amputation was suggested, but the patient declined and was treated symptomatically with close monitoring. The patient underwent removal of the plates, excision of the distal fourth of the fibula, intralesional curettage of all lesions, and fusion of the ankle and subtalar joints with a retrograde intramedullary nail. After 5.5 years, the patient had recovered well and had no evidence of malignancy. The tumour was considered definitively benign.

Adhesive Capsulitis of the Shoulder. Is there Consensus Regarding the Treatment? A Comprehensive Review

Background: Adhesive capsulitis of the shoulder (ACS) is a common self-limiting condition characterized by disabling pain and restricted movements. Its pathophysiology is poorly understood, clinically it is characterized by stages of pain and stiffness, and finally often patients never recover fully. However, there is no consensus about available methods of treatment for ACS. The aims of this paper are to discuss and develop issues regarding approaches to management in ACS in the stages of it. Methods: A review of the literature was performed and guidelines for the treatment of that clinical entity for doctors and health care professionals are provided. Results: Anti-inflammatory medications, steroid and/or hyaluronate injections and physiotherapy is the mainstay of conservative management either alone in the first stages or in combination with other treatment modalities in the later stages. Next line of treatment, involving minor to moderate intervention, includes suprascapular nerve block, distension arthrography and manipulation under anaesthesia. In order to avoid complications of “blind intervention”, arthroscopic capsular release is gradually more commonly applied, and in recalcitrant severe cases open release is a useful option. Conclusion: Various modalities of conservative management and gradually more surgical release are applied. However, often clinicians choose on personal experience and training rather than on published evidence.

Bilateral patellar component dissociation in a patient with total knee arthroplasties

We present a case of bilateral patellar component dissociation 6 years after bilateral total knee arthroplasty. The patient had undergone arthroscopic lateral releases bilaterally for patellar maltracking. After repetitive trauma, the patient experienced patellar component dissociation, which was treated arthroscopically by removing the patellar components and leaving the patellae unresurfaced. The patients symptoms improved substantially. Our case highlights certain features of the etiology as well as the management of patellar component dissociation in the total knee arthroplasty, showing the important role of arthroscopy.

Multifocal Epithelioid Hemangioendothelioma of the Foot and Ankle Developing a Postoperative Infection—Long-term Outcome: A Case Report

A case of rare epithelioid hemangioendothelioma with multiple foot and ankle lytic lesions in a 41-year-old male is reported. The patient presented to our hospital after having received treatment elsewhere and developing a local postoperative infection. After thorough investigations and establishing the diagnosis, we initially treated the local infection and highlighted the potential risk of malignancy. Finally, respecting the patients wishes, he was treated with consideration mostly of the pending foot and ankle fractures rather than the risk of malignancy. At 9.5 years postoperatively, the patient was clinically well and asymptomatic, without clinical, laboratory, or radiologic signs of malignancy, and the previous infection might have even played a remote role in that outcome. A review of the published data regarding the treatment of this unpredictable neoplasm is also presented.

Endoscopic Versus Open Excision of Os Trigonum for the Treatment of Posterior Ankle Impingement Syndrome in an Athletic Population: A Randomized Controlled Study With 5-Year Follow-up:

Background: Open surgical excision of the os trigonum has been the traditional treatment for posterior ankle impingement syndrome (PAIS). However, the endoscopic excision has recently become quite popular. Purpose/Hypothesis: The purpose of our study was to compare the results of endoscopic versus open excision of a symptomatic os trigonum for the treatment of PAIS in an athletic population. It was hypothesized that the endoscopic technique would be superior to the open technique regarding functional outcomes, pain, and time to return to training and the previous sports level. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: From 2008 to 2011, 52 athletes underwent a symptomatic os trigonum excision; 26 athletes had an open procedure (group A) and 26 had an endoscopic procedure (group B). The American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score and the Visual Analog Score–Foot and Ankle (VAS-FA) were obtained, and the time to return to training and to previous sports level was recorded. Results: Patients in group B appeared to have significant improvement of AOFAS hindfoot score compared with those in group A (P < .05), whereas no statistical significance was found for the postoperative VAS-FA scores between the 2 groups. The mean ± SD time to return to training was 9.58 ± 3.98 weeks for group A and 4.58 ± 1.47 weeks for group B (P < .001). The time to return to previous sports level was 11.54 ± 3.89 weeks for group A and 7.12 ± 2.25 weeks for group B (P < .001). The overall complication rate was 23% for group A (6 cases) and 3.8% for group B (1 case). Conclusion: Both the open procedure and the endoscopic approach yielded acceptable outcomes in terms of function and pain. However, complication rates were remarkably lower with endoscopic treatment, and the time to return to full activities was much shorter. Endoscopic excision of the os trigonum is a safe and effective treatment option for athletes who require early return to their previous sports level.