Jason Pui Yin Cheung

Magnetically controlled growing rods for severe spinal curvature in young children: a prospective case series

BACKGROUNDnScoliosis in skeletally immature children is often treated by implantation of a rod to straighten the spine. Rods can be distracted (lengthened) as the spine grows, but patients need many invasive operations under general anaesthesia. Such operations are costly and associated with negative psychosocial outcomes. We assessed the effectiveness and safety of a new magnetically controlled growing rod (MCGR) for non-invasive outpatient distractions.nnnMETHODSnWe implanted the MCGR in five patients, two of whom have now reached 24 months follow-up. Each patient underwent monthly outpatient distractions. We used radiography to measure the magnitude of the spinal curvature, rod distraction length, and spinal length. We assessed clinical outcome by measuring the degree of pain, function, mental health, satisfaction with treatment, and procedure-related complications.nnnFINDINGSnIn the two patients with 24 months follow-up, the mean degree of scoliosis, measured by Cobb angle, was 67° (SD 10°) before implantation and 29° (4°) at 24 months. Length of the instrumented segment of the spine increased by a mean of 1·9 mm (0·4 mm) with each distraction. Mean predicted versus actual rod distraction lengths were 2·3 mm (1·2 mm) versus 1·4 mm (0·7 mm) for patient 1, and 2·0 mm (0·2 mm) and 2·1 mm (0·7 mm) versus 1·9 mm (0·6 mm) and 1·7 mm (0·8 mm) for patient 2s right and left rods, respectively. Throughout follow-up, both patients had no pain, had good functional outcome, and were satisfied with the procedure. No MCGR-related complications were noted.nnnINTERPRETATIONnThe MCGR procedure can be safely and effectively used in outpatient settings, and minimises surgical scarring and psychological distress, improves quality of life, and is more cost-effective than is the traditional growing rod procedure. The technique could be used for non-invasive correction of abnormalities in other disorders.nnnFUNDINGnEllipse Technologies.

Mycobacterium marinum infection of the hand and wrist

Purpose. To review records of 166 patients who underwent treatment for Mycobacterium marinum tenosynovitis of the hand and wrist to identify factors associated with functional outcome. Methods. Records of 97 men and 69 women aged 13 to 85 (mean, 50) years who underwent treatment for suspected M marinum tenosynovitis of the hand and wrist were retrospectively reviewed. All underwent open biopsy; synovectomy was performed when florid synovitis was present. Rifampicin and ethambutol were usually prescribed. Clarithromycin, minocycline and/or levofloxacin were used as adjuvants if there was drug intolerance, allergy, or relapse. The duration of antibiotic treatment depended on the clinical recovery. Patients were followed up for one year after completion of drug treatment. Functional outcome was considered excellent for those with >195° total active motion (TAM) and >75% return of motion, good for those with 130° to 195° TAM and 50 to 75% return of motion, fair for those with 65° to 129° TAM and 25 to 49% return of motion, and poor for those with <65° TAM and <25% return of motion. Results. The mean delay in presentation was 4.9 (0.3–120) months. 93 of the patients presented with disabilities (fexion deformity or reduced range of motion), 64 of whom presented one month after injury. 37 (22%) of the patients had received intralesional steroids prior to admission, 30 of whom presented one month after injury. 32 (19%) patients were treated with antibiotics alone, whereas 134 (81%) patients underwent debridement in addition to antibiotic treatment. The mean duration of antibiotic treatment was 7.2 (range, 0–29) months. Of the 156 patients who completed the follow-up, functional outcome was satisfactory in 128 (82%) and unsatisfactory in 28 (17%). Steroid injections and late presentation led to worse functional outcome. Patients with unsatisfactory outcome were more likely to have received intralesional steroid injections (43% [16/37] vs. 10% [12/118], p<0.001, Pearson Chi squared test), have presented >2 months after injury (27% [21/79] vs. 9% [7/77], p=0.004, Pearson Chi squared test), and have undergone synovectomy (23% [28/124]) vs. 0% [0/32], p=0.001, Fishers exact test). Worse functional outcome correlated with late presentation (r=0.218) and the greater number of debridement procedures (r=0.453). Conclusion. Delayed antibiotic treatment of M marinum infections and steroid injections were associated with unsatisfactory outcome. Clinicians must have a high index of suspicion for this condition and avoid inappropriate management such as intralesional steroid injections. Public awareness to this condition should be raised.

REVIEW ON MALLET FINGER TREATMENT

Mallet finger is a common injury involving either an extensor tendon rupture at its insertion or an avulsion fracture involving the insertion of the terminal extensor tendon. It is usually caused by a forceful blow to the tip of the finger causing sudden flexion or a hyperextension injury. Fracture at the dorsal aspect of the base of the distal phalanx is commonly associated with palmar subluxation of the distal phalanx. Most mallet finger injuries are recommended to be treated with immobilisation of the distal interphalangeal joint in extension by splints. There is no consensus on the type of splint and the duration of use. Most studies have shown comparable results with different splints. Surgical fixation is still indicated in certain conditions such as open injuries, avulsion fracture involving at least one third of the articular surface with or without palmar subluxation of the distal phalanx and also failed splinting treatment.

Cervical spine complications after treatment of nasopharyngeal carcinoma.

PurposeRadiotherapy has been the mainstay treatment for nasopharyngeal carcinoma (NPC) and has achieved good disease control. However, irradiation is associated with potential complications such as osteoradionecrosis (ORN) and infection. There is sparse description in the literature of such complications and how they are best managed. The objectives of the study are: (1) to describe the complications at the cervical spine after surgical and radiotherapy treatment for NPC (2) to identify key principles in the diagnosis and treatment of these complications.MethodsA retrospective review of all patients with cervical spine complications after radiation treatment and surgery for NPC treated in a tertiary referral center, since 1990.ResultsFourteen patients with cervical spine ORN and infections were found with an average duration to diagnosis of 8.6xa0years. All 14 patients had mucosal and deep biopsies and none had tumor recurrence. Four patients had ORN, eight had osteomyelitis and two patients had both ORN and osteomyelitis.ConclusionsRadiotherapy complications usually have delayed and subtle presentations. ORN progresses slowly and can often be treated conservatively. Infections should be treated aggressively with surgical debridement and the results are generally good. Patients should be regularly followed-up with transoral examination to assess the integrity of the posterior pharyngeal wall and imaging to assess for ORN. Pharyngeal defects raise concern for cervical spine infections. Coverage of pharyngeal defects in these patients is important to prevent recurrent infection.

Cutout of proximal femoral nail antirotation resulting from blocking of the gliding mechanism during fracture collapse.

The proximal femoral nail antirotation had been successful in treating unstable trochanteric fractures. Previous studies have shown technical problems such as unsatisfactory fracture reduction, poor insertion technique, and poor blade position leading to complications such as cutout. We present a case of proximal femoral nail antirotation cutout resulting from the blocking of the gliding mechanism during fracture collapse by the lateral cortex. The trochanteric fracture had not healed on presentation and there was significant acetabulum protrusion of the device. Thus, a cemented total hip arthroplasty was required.

Mycobacterium marinum infection of the deep structures of the hand and wrist: 25 years of experience.

Mycobacterium marinum infection could have various presentations, from superficial skin infection to deep structure destruction. The prognosis is relatively poor when deep structure is involved as it is more destructive. The prognosis is even worse when operation is required. In the retrospective study of 136 patients who suffered this disease with deep structure involvement, their clinical presentations could be classified into benign and aggressive type. It was found that both types of presentation could be treated conservatively by medication alone. Benign presentations could be treated successfully with chemotherapy alone without complications. Patients with aggressive presentation were usually associated with worse prognosis as there were more complications regardless of the management option. Therefore, the clinical presentation not only had prognostic value but could also guide the treatment plan.

Unusual presentations of osteoarticular tuberculosis in two paediatric patients.

Tuberculosis is a universal mimicker and thus could be a differential diagnosis of any osteolytic lesion. Bone biopsy is crucial in these cases for culture and histological proof of tuberculous infection. This is a case report of two paediatric patients with unusual presentations of tuberculosis. One patient presented with knee pain and had imaged findings of an osteolytic lesion at the epiphysis. Interval scan showed spread of the lesion through the physis to the metaphyseal region. The second patient presented with hip pain and an osteolytic lesion of the acetabulum. He was subsequently found to have involvement of the brain and spine as well. Both patients were diagnosed with tuberculosis by bone biopsy for culture and pathological examination. They were treated successfully with antituberculous medications without chronic sequelae. These two patients showed that early recognition and prompt treatment are critical for management of tuberculosis to avoid chronic sequelae.

Multiple triggering in a girl with Ehlers-Danlos syndrome: Case report

We report a case of multiple triggering associated with Ehlers-Danlos syndrome. We postulate that the propensity for tendon degeneration in Ehlers-Danlos syndrome coupled with repetitive microtrauma might lead to fraying of the tendon fibers and, consequently, triggering. Indeed, in our case, debridement of the tendons rather than resection of A1 pulley resulted in a good long-term functional outcome 2 years after surgery.

Osteonecrosis and femoro-acetabular impingement: sequelae of developmental dysplasia of the hip.

A 2-year-old girl with developmental dysplasia of the right hip underwent open reduction and capsulorrhaphy via the anterior approach with hip spica casting in an internally rotated position. During her 26 years of follow-up, she was found to have osteonecrosis and subsequently cam-type femoro-acetabular impingement at 28 years of age. She was treated with surgical dislocation of the hip and osteochondroplasty to recreate the normal contour of the head and neck offset.

Fat embolism syndrome in a child with dystonia musculorum deformans.

A 16-year-old boy with dystonia musculorum deformans underwent an operation for removal of femoral implants and excision of the prominence at the greater trochanter of the left hip. He was found to have fat embolism syndrome at postoperative day 1 as evidenced by confusion, respiratory symptoms, chest radiograph changes, raised erythrocyte sedimentation rate, thrombocytopenia and fat in the urine and sputum.