John M. Kirkos

Late treatment of brachial plexus palsy secondary to birth injuries : Rotational osteotomy of the proximal part of the humerus

We retrospectively reviewed the results of rotational osteotomy that had been performed distal to the surgical neck of the humerus in twenty-two patients who had sustained an injury of the brachial plexus at birth. Eighteen patients had a lesion of the superior trunk of the brachial plexus (the fifth and sixth cervical nerve roots), and four had involvement of the entire brachial plexus. The patients ranged in age from four to seventeen years old (average age, ten years and three months old) at the time of the operation. The average duration of follow-up was fourteen years (range, two to thirty-one years). Preoperatively, the patients had been unable to perform self-care activities, such as grooming, feeding, and washing themselves, because of limited active external rotation or fixed internal rotation of the shoulder. All patients had decreased strength of the lateral rotator and abductor muscles and normal strength of the subscapularis and pectoralis major muscles. Radiographs showed some flattening of the humeral head, and four patients had posterior subluxation of the humeral head. A lateral rotational osteotomy of the proximal part of the humerus was performed between the insertions of the subscapularis and pectoralis major muscles. The site of the osteotomy was stabilized with catgut sutures in the periosteum in ten patients and with one or two staples in twelve. The extremity was immobilized in a plaster shoulder-spica cast for six weeks. At the latest follow-up evaluation, the average increase in active abduction was 27 degrees (range, 0 to 60 degrees) and the average increase in the arc of rotation was 25 degrees (range, 5 to 85 degrees). Supination of the forearm also had increased commensurate with the increase in external rotation. The appearance of the extremity had improved as well.

Efficacy of Steroid and Nonsteroid Caudal Epidural Injections for Low Back Pain and Sciatica: A Prospective, Randomized, Double-blind Clinical Trial

Study Design. Prospective, double-blind, randomized, case-control study. Objective. To evaluate the efficacy of caudal epidural injections (CEI) containing steroid versus nonsteroid preparations when treating patients suffering from low back pain (LBP) and sciatica. Summary of Background Data. Literature seems to be deprived of well-designed randomized, controlled studies that evaluate the effectiveness of CEI in the treatment of chronic LBP; hence the value of CEI remains still the subject of controversy. Methods. Patients suffering from severe chronic LBP and sciatica were randomly allocated into 2 groups. Steroid-group’s patients (n = 93) underwent CEI containing 12 mL of xylocaine 2% and 1 mL of betamethasone dipropionate and betamethasone phosphate (2 + 5) mg/dL. Water for Injection (WFI)-group’s patients (n = 90) underwent CEI containing 12 mL of xylocaine 2% and 8 mL of WFI. Both groups were statistically comparable as far as their demographic data and the cause and duration of symptoms were concerned. Patients answered the Oswestry Disability Index questionnaire and underwent physical examination, before and at 1 week, 1 month, 6 months, and 1 year following the CEI. Results. Symptoms improved in 132 patients (72.1%) following CEI. The mean Oswestry Disability Index questionnaire score of steroid-group’s patients was statistically significant lower than that of the WFI-group at all postinjection re-evaluations. Patients receiving steroid CEI experienced faster relief during the first postinjection week. The Straight Leg Rising test improved in both groups following CEI; this improvement was faster among steroid-group’s patients. Fifty-one patients (27.8%), noticed no improvement 1 week post-CEI and underwent a second CEI (with the same preparation) 7 to 14 days later. Nineteen of them reported improvement; 32 (steroid-group:13, WFI-group:19) did not respond well and underwent operative decompression (n = 15) or spinal fusion (n = 17). Conclusion. CEI containing local anesthetic and steroids or WFI seems to be effective when treating patients with LBP and sciatica. CEI containing steroid preparations demonstrated better and faster efficacy.

Brachial plexus palsy secondary to birth injuries: LONG-TERM RESULTS OF ANTERIOR RELEASE AND TENDON TRANSFERS AROUND THE SHOULDER

We describe the long-term results in ten patients with obstetric brachial plexus palsy of anterior shoulder release combined with transfer of teres major and latissimus dorsi posteriorly and laterally to allow them to act as external rotators. Eight patients had a lesion of the superior trunk and two some involvement of the entire brachial plexus. The mean age at operation was six years, and the mean follow-up was 30 years. Before operation, the patients were unable actively to rotate the arm externally beyond neutral, although this movement was passively normal. All showed decreased strength of the external rotator, but had normal strength of the internal rotator muscles. Radiologically, no severe bony changes were seen in the glenohumeral joint. No clinically detectable improvement of active abduction was noted in any patient. The mean active external rotation after operation was 36.5°. This was maintained for a mean of ten years, and then deteriorated in eight patients. At the latest follow-up the mean active external rotation was 10.5°. The early satisfactory results of the procedure were not maintained. In the long term there was loss of active external rotation, possibly because of gradual degeneration of the transferred muscles, contracture of the surrounding soft tissues and degenerative changes in the glenohumeral joint.

Histomorphologic Study of Discoid Meniscus

PURPOSE The purpose of this study was to investigate the matrix collagen network of the discoid lateral meniscus in comparison with normal lateral meniscus. METHODS Discoid meniscus samples obtained arthroscopically from 10 patients with a diagnosis of intact complete-type discoid lateral meniscus by a technique of excision in 1 piece were examined histomorphologically regarding the integrity of both main collagen fiber systems, radial and circular, because they have been described in the structure of normal knee meniscus. As a control group, intact lateral menisci excised during knee arthroplasty procedures were used. RESULTS Histomorphologic scoring showed statistically significant disorganization of the circular collagen network in the discoid meniscus group compared with the normal meniscus group, especially along the posterior third of the specimen (P < .001). In addition, a heterogeneous course of the circumferentially arranged collagen fibers was shown in the discoid meniscus structure. CONCLUSIONS Findings of discontinuity and inhomogeneity of the circumferential collagen network in the discoid meniscus in comparison with normal meniscus indicate that the discoid lesion represents a structural lesion rather than a morphologic variant. CLINICAL RELEVANCE Disorganization of the circular collagen fiber system in the discoid meniscus matrix may contribute to the pathogenesis of the high tear and degenerative lesion rate observed among menisci with discoid configuration.

Thoracic cord compression caused by disk herniation in Scheuermann’s disease: A case report and review of the literature

We present the case of a 14-year-old male with Scheuermann’s disease and significant neurological deficit due to thoracic disk herniation at the apex of kyphosis. He was treated with an anterior decompression, anterior and posterior fusion in the same setting using plate, cage and a segmental instrumentation system. The patient had an excellent outcome with complete neurological recovery.

Posteromedial dislocation of the elbow with lateral condyle fracture in children.

Posteromedial dislocation of the elbow in children is an extremely rare injury. The current study describes four boys with posteromedial dislocation of the elbow associated with a displaced fracture of the lateral humeral condyle. The patients ranged in age from 6 to 12 years (average age, 9 years 6 months). Closed reduction of the elbow dislocation and open reduction of the lateral humeral condyle fracture with fixation by Kirschner wires by a lateral approach was done in each patient. This was followed by 4 weeks immobilization wearing a long-arm cast. There were three excellent results and one good result. Healing and return of normal function occurred in all but one patient who had minor loss of full extension. Average duration of followup was 7 years 6 months (range, 3–13 years). Dislocation of the elbow associated with a displaced fracture of the lateral humeral condyle can be treated by closed reduction of the elbow dislocation and open anatomic reduction and fixation of the lateral condyle fracture with good results.

Surgical treatment of unstable diaphyseal both-bone forearm fractures in children with single fixation of the radius

We retrospectively reviewed the result from 50 children (5 to 14 years; mean age 11 years) with unstable diaphyseal forearm fractures involving both the radius and ulna, for which closed reduction has been unsuccessful, and so were treated with open reduction and internal fixation of the radius only. The rationale of this treatment is to stabilize the radius as it is this bone which has the more complicated function of the two forearm bones. After anatomical reduction and fixation of the radius the ulnar fracture had a better alignment. In this series the functional and the anatomical results in all children at a mean follow up of 4 years (range 1 to 10 years) were excellent.

Management of traumatic sacral fractures: A retrospective case-series study and review of the literature

BACKGROUND Being the result of high-energy trauma in most cases, traumatic sacral fractures are rare, difficult to recognise and frequently misdiagnosed. Furthermore they may lead to vascular injuries, mechanical instability, neurological impairment and increased morbidity. As a result, patients with traumatic sacral fractures may suffer major socio-economic consequences. OBJECTIVE This retrospective case-series study evaluated the functional, neurological, mental and emotional status of patients who had suffered traumatic sacral fractures and either followed conservative or underwent operative treatment at our department. PATIENTS AND METHODS We evaluated the clinical and radiographic results of all patients who had suffered traumatic sacral fractures between December 2003 and June 2007. The case-notes of all patients were reviewed, all co-existing injuries were registered and an ISS was calculated for each patient. At the latest follow-up visit, all patients completed the Short Form-36 questionnaire as well. RESULTS Sixteen patients (eleven male, five female) were included in this study. At the time of initial admission, the mean age of the patients was 30 years (range: 14-53) and the mean ISS was 33.2 points (range: 21-59). The mean follow-up period was 24.1 months (range: 13-40). Six patients were treated operatively (four patients diagnosed with some type of neurological impairment at their initial physical examination and two patients due to pelvic instability). The mean ISS of the patients who were treated operatively was 41.1 points (range: 21-59), whereas of those who were treated conservatively was 28.5 points (range: 21-45). No patient had any neurological deficit at his/her latest re-evaluation. Patients who were treated conservatively achieved the best scores in every domain of the SF-36 questionnaire, when compared with those who were treated operatively. CONCLUSION The diagnosis and management of sacral fractures may pose several dilemmas in everydays clinical praxis. Patients suffering from traumatic sacral fractures who were treated conservatively seem to have better functional and mental/emotional outcomes, probably because their injuries were less severe than those of the patients who were treated conservatively.

Recurrent Spontaneous Hemarthrosis After Total Knee Arthroplasty Successfully Treated with Synoviorthesis

A case of spontaneous recurrent hemarthrosis--due to developed hypertrophied synovium--after total knee arthroplasty is reported. The patient was successfully treated with radiosynovectomy. The first hemorrhage occurred 18 months after the total knee arthroplasty. Several similar episodes followed over a period of 4 years. Because conservative treatment failed to control the bleeding, an arthroscopic lavage was performed, which revealed the existence of proliferative synovium. A significant part of the hypertrophic tissue was excised with the use of a thermocoagulator. However, 1 month later, another episode of hemarthrosis occurred. As a final step before reoperation, the patient was treated with intra-articular injection of ytrium 90. Eighteen months later, she remains symptom-free, is very satisfied with the result, and reports no new episode of hemarthrosis.

The role of pantalar arthrodesis in the treatment of paralytic foot deformities. A long-term follow-up study.

BACKGROUND Pantalar arthrodesis is considered by many to be the final operative option before amputation for the treatment of paralytic foot deformities. The aim of the present study was to evaluate the long-term results of pantalar arthrodesis with regard to its impact on the adjacent joints and the walking ability of patients with paralytic foot deformities. METHODS Twenty-four patients (seventeen men and seven women) who underwent a one-stage pantalar arthrodesis between 1953 and 1973 for the treatment of sequelae of poliomyelitis were reevaluated. All patients underwent a physical and radiographic examination, and all completed the Short Form-36 questionnaire and a pantalar arthrodesis-specific questionnaire. RESULTS The average age of the patients was twenty years at the time of the operation and 57.2 years at the time of the latest evaluation. The average duration of follow-up was 37.2 years. Eleven patients had development of immediate postoperative complications, including wound-healing problems (nine) and infections (two). The long-term results, however, were good (mean Short Form-36 scores, 73 of 100 points [overall], 51.5 points [physical functioning], and >70 points [all other domains]). Sixteen patients experienced repeated episodes of ipsilateral knee pain; most (fifteen) of these patients experienced a gradual onset of this pain, starting at an average of 20.8 years (range, fifteen to thirty years) postoperatively. The position of the fused ankle did not appear to have a significant impact on the development of ipsilateral knee pain or the time interval between the pantalar arthrodesis and the onset of ipsilateral knee pain. CONCLUSIONS Pantalar arthrodesis effectively stabilizes the ankle, hindfoot, and midfoot in patients with severe paralytic deformities. Even though most patients can be expected to have development of osteoarthritis of the ipsilateral knee, it seems that a successfully performed pantalar arthrodesis in carefully selected cases is a reliable operative option offering a strong and stable foot that will function well for many years.