Israel Dudkiewicz

The epidemic of ankle fractures in the elderly--is surgical treatment warranted?

Abstract Ankle fractures in the elderly are extremely common (up to 184 fractures per 100,000 persons per year, and of these approximately 20%–30% occur in the elderly). The medical literature contains no research that has investigated ankle fractures in the elderly. A prospective, randomised study was conducted of 84 patients with displaced ankle fractures, who were over the age of 65 years and were assigned to operative or conservative treatment after closed reduction. The results of treatment assessed according to the American Orthopedic Foot and Ankle Society (AOFAS) Score showed a mean of 91.37 ± 8.96 in the non-operated group compared with 75.2 ± 14.38 (P = 0.001) in the operated group. The costs of treatment were accordingly higher. These results call for consideration of a non-operative approach to the treatment of well-reduced ankle fractures in the elderly. Increased efforts should be invested in the prevention of these common fractures.

Congenital muscular torticollis in infants : Ultrasound-assisted diagnosis and evaluation

Ultrasonography is considered the modality of choice for differentiating congenital muscular torticollis from other pathologies in the neck. The authors present their experience with ultrasound examination for the evaluation and management of congenital muscular torticollis. Twenty-six infants, 14 boys and 12 girls, age ranging from 1 to 16 weeks, with torticollis and a palpable mass were examined. Ultrasound showed a well-defined mass in the sternocleidomastoid muscle. The lesions ranged in size from 8 to 15.8 mm on maximal transverse diameter, with length ranging from 13.7 to 45.8 mm. Clinically the torticollis disappeared between 1 to 6 weeks, with complete clinical reduction of the palpated mass between 2 and 8.5 weeks. The ultrasonographic disappearance of the mass was delayed by an average of 2 weeks in comparison to the clinical disappearance of the mass. Ultrasound is advocated for the diagnosis and follow-up of congenital muscular torticollis because it noninvasively provides reliable and dynamic information without sedation.

Trends in Femoroacetabular Impingement Research Over 11 Years

Femoroacetabular impingement is the abutment between the proximal femur and the rim of the acetabulum. It is a common cause of labral injury that has been identified as an early cause of hip osteoarthritis. The diagnosis of femoroacetabular impingement of the hip is currently well defined in orthopedic surgery but should attract the attention of physicians in other disciplines. Conversely, much less is known about the etiology and natural history of femoroacetabular impingement.The goal of this study was to assess the number of articles published on femoroacetabular impingement over 11 years in orthopedic vs nonorthopedic medical journals, and to evaluate the quality of available evidence. PubMed and OvidSP databases were searched for articles on femoroacetabular impingement published from 1999 to 2009. Articles were characterized by publication type and journal type per year. Regression analysis was used to determine the effect of publication year on number of publications of each type. The search yielded 206 publications on femoroacetabular impingement during the evaluation period. Seventy-two percent were published in orthopedic journals. Overall, the number of publications increased exponentially with time. There was an increase in clinical trials over the course of the study period. However, studies with high-quality evidence were scarce. The increase in data from orthopedic and nonorthopedic disciplines is welcome. Nevertheless, high-quality evidence on femoroacetabular impingement is lacking. We believe the current trend toward evidence-based orthopedic surgery will impact future research on this relatively new disorder.

Hydatid cyst presenting as a soft-tissue thigh mass in a child

Abstract We report a rare case of intramuscular hydatid cyst in a boy who presented clinically as having a soft-tissue thigh mass. A high level of awareness concerning the occurrence of these cysts is important, especially in regions where Echinococcus is endemic. Surgical treatment follows the principles of malignant tumour, namely, wide surgical resection.

Total Hip Arthroplasty After Childhood Septic Hip in Patients Younger Than 25 Years of Age

Childhood septic hip should usually be treated immediately by arthrotomy and antibiotic. Even if treated correctly, the affected hip may become osteoarthritic and functionally disabling. Usually the literature is not in favor of total hip arthroplasty in young patients, and the reports are on patients older than 32 years of age. We present here a unique group of very young patients with early coxarthrosis caused by septic hip in childhood, with an average age of 19.14 years (range, 14–25) at the time of the arthroplasty. The Harris hip score improved from a preoperative mean of 58.43 to a postoperative mean of 94.14. The follow-up period ranged between 2 and 24 years, with an average of 8.14 years. We conclude that total hip arthroplasty in young people with early coxarthrosis caused by septic hip in childhood provides good functional results.

Magnetic resonance imaging of hydatid cyst in skeletal muscle

The typical MRI features of hydatid cyst in soft tissue/muscle are presented and discussed.

Trans-metatarsal amputation in patients with a diabetic foot: Reviewing 10 years experience

Considerable disagreement exists whether trans-metatarsal amputations are indicated in persons with diabetes. A previous study reported that statistically the success rate of Symes amputation in diabetic patients over 65 years of age resulted in a very poor results. The purpose of this study was to investigate the results of trans-metatarsal amputations, in patients with diabetes and to seek markers which could shed light upon the advantages/disadvantages of this procedure. The records of 46 patients covering a 10-year period (1996-2006) were used as a database. Twelve needed higher amputation level and another 10 needed a wound revision. All the patients that maintained the original amputation level walk without a need for a prosthesis and kept their previous abode. TMA in diabetic patients, although at a high risk for an extrasurgical procedure, once successful, the patient will regain his previous lifestyle.

Clinical tip: revision first metatarsophalangeal joint arthrodesis for sagittal plane malunion with an opening wedge osteotomy using a small fragment block plate.

Arthrodesis of the first metatarsophalangeal (MTP) joint is commonly used in the treatment of severe hallux rigidus,4 and recurrent hallux valgus,3,5 providing good results.1 It is important to position the proximal phalanx properly when performing an arthrodesis. Too much plantarflexion leads to overloading of the great toe, ulceration, interphalangeal joint osteoarthritis and difficulty executing the toe-off phase of stance. Patients tolerate excessive dorsiflexion poorly because of dorsal impingement and difficulty with footwear. Both, however, are recognized complications of first MTP joint arthrodesis. Techniques that can be used for revision of an excessively dorsiflexed arthrodesis include a dorsal opening wedge osteotomy packed with bone graft before fixation with a small fragment plate or crossed screws, a plantar closing wedge osteotomy, a crescentic osteotomy,2 or trapezoid osteotomy. All of these techniques require technical expertise to attain an appropriate MTP joint dorsiflexion angle. Dorsal opening wedge osteotomy fixed with a small fragment block plate is a technically less demanding procedure than other common techniques and reliably allows accurate reduction and stable fixation for revision of first MTP joint arthrodesis.

A young athlete with myositis ossificans of the neck presenting as a soft-tissue tumour.

Abstract Myositis ossificans is usually the result of direct injury to a muscle and is a self-limiting disease. It may present as a soft-tissue mass with a broad differential diagnosis, including highly malignant tumours, such as soft-tissue sarcomas. Many theories can be found concerning the aetiology of myositis ossificans, but minor or major traumas are considered to be the most common cause. A unique case of myositis ossificans of the neck in a 17-year-old professional, female, ground gymnast, who presented initially with a soft-tissue tumour, was treated successfully. The main differential diagnosis is presented along with typical radiographic features on conventional radiography, computerised tomography and magnetic resonance imaging, and typical pathological appearance, such as the pathognomonic “zoning phenomenon”. Myositis ossificans should be added to the differential diagnosis of every young patient who engages in sport and presents with a soft-tissue mass. Careful padding of the area and teaching the rolling technique to avoid repeated injuries to the neck can prevent recurrence.

Ankle tourniquet pain control in forefoot surgery: a randomized study.

Background: Forefoot surgery is often performed under regional anesthesia in awake patients, using tourniquet or Esmarch bandage to obtain a bloodless field. The purpose of this study was to examine the value and need for local tourniquet pain control using local subcutaneous analgesic mixture in patients undergoing forefoot surgery under ankle block anesthesia. Materials and Methods: We prospectively randomized 56 patients who underwent forefoot surgery under ankle block to receive either subcutaneous local anesthetic mixture under the tourniquet or no additional anesthetic. We checked for local tourniquet pain score (VAS 0 to 100) and skin condition during and after the procedure. Results: The tourniquet was quite tolerable in both groups, with an average VAS score of 7 to 21. No difference was observed between groups throughout most of the procedure. No correlation between VAS scores and procedure length or patients age or gender was found. Conclusion: An ankle tourniquet was well-tolerated by patients without need for local anesthetic beneath the cuff. Level of Evidence: II, Prospective Comparative Study