Juan Pretell-Mazzini

Controversial topics in the management of displaced supracondylar humerus fractures in children

The aim of our study was to review the literature looking for the up to date information regarding these controversial topics. An electronic literature search was performed using the Medline/PubMed database. A closed reduction attempt should always be done first. It is more important to engage both columns as well as divergence of the pins no matter whatever configuration is applied. Time to surgery seems to be not an important factor to increase the risk of complications as well as open reduction rate. Usually neurological injuries present a spontaneous recovery. If there is absent pulse, we should follow the algorithm associated with the perfusion of the hand.

Clinical application of locked plating system in children. An orthopaedic view

In recent years, the locked plating system has gained favour in the treatment of certain fractures in adults; however, there is not much information regarding its use in children. We think there could be some advantages and applications such as: an alternative to external fixation, the bridge plating technique, unicortical screws, removal of hardware, metadiaphyseal fractures, periarticular fractures, poor quality bone, and allograft fixation. However, there are some disadvantages to keep in mind and the final decision for using it should be based on the osteosynthesis method principle the surgeon would like to apply. In this review article we discuss the up-to-date possible clinical applications and issues of this system.

HIV and Orthopaedics: Musculoskeletal Manifestations and Outcomes.

➤Advances in combined antiretroviral therapy (cART) in recent years have transformed HIV infection into a chronic disease when treatment is available, increasing a patients life expectancy and the chances that orthopaedic surgeons will encounter such patients in their clinical practice.➤Musculoskeletal manifestations in patients with HIV infection are common and sometimes are the initial presentation of the disease. Knowledge about neoplasms and associated conditions affecting muscle, bones, and joints is essential for successful management.➤Since the advent of cART, total joint arthroplasty has been shown to be a safe procedure; however, perioperative infection is still a small risk in patients with uncontrolled viral loads or CD4 counts of <400 cells/mm(3).➤With regard to trauma surgery, the rates of early and late infection around implants, as well as union rates, are comparable with those in the HIV-negative population; however, there is an increased risk of pulmonary, renal, and infectious or septic complications in the polytrauma setting.➤Factors such as CD4 count, nutritional status, cART therapy, viral load count, and other comorbidities (hemophilia, infection among intravenous drug users, etc.) should be considered when treating these patients in order to optimize their clinical outcomes.

Risk of bleeding associated with interventional musculoskeletal radiology procedures. A comprehensive review of the literature.

This review compiles the current literature on the bleeding risks in common musculoskeletal interventional procedures and attempts to provide guidance for practicing radiologists in making decisions regarding the periprocedural management of patients on antithrombotic therapy. The practitioner must weigh the risk of bleeding if therapy is continued against the possibility a thromboembolic occurring if anticoagulation therapy is withheld or reversed. Unfortunately, there is little empirical data to guide evidence-based decisions for many musculoskeletal interventions. However, a review of the literature shows that for low-risk procedures, such as arthrograms/arthrocenteses or muscle/tendon sheath injections, bleeding risks are sufficiently small that anticoagulants and antiplatelet therapies need not be withheld. Additionally, relatively higher-risk procedures, such as needle biopsies of bone and soft tissue, may be safely performed without holding antithrombotic therapy, provided pre-procedural INR is within therapeutic range. Thus, while a patient’s particular clinical circumstances should dictate optimal individualized management, anticoagulation alone is not a general contraindication to most interventional musculoskeletal radiology procedures.

Distal tibial fracture below a total knee arthroplasty: retrograde intramedullary nailing as an alternative method of treatment: a case report.

An 85-year-old woman with a history of insulin-dependent diabetes mellitus, hypertension, and chronic venous insufficiency with underlying venous stasis who sustained a fall in her house presented to the emergency room with a displaced distal diaphyseal tibial fracture and a stable total knee arthroplasty. At her third day of admission, an intramedullary nail was inserted in a retrograde fashion through the calcaneus and talus into her tibial shaft to stabilize the fracture; there were no postoperative complications. Three years after surgery, the patient remains pain-free, the fracture had united, and her functional status is the same as it was before the fracture. There are different options for solving these types of fractures. Nonoperative, external fixation, conventional or locking plates and antegrade and retrograde intramedullary nailing could be used; however, they should be weighed against the particular issues of the patient involved. We think that a retrograde nailing technique through the calcaneotalotibial axis could be an alternative method for these types of fractures in a fragile patient with important comorbidities with few complications and good functional outcome.

Secondary Patellar Resurfacing as a Rescue Procedure for Persistent Anterior Knee Pain After Primary Total Knee Arthroplasty: Do Our Patients Really Improve?

BACKGROUND Secondary patellar resurfacing (SPR) is a procedure that can be used in patients with persistent anterior knee pain (AKP) after a primary total knee arthroplasty. The aim of our study was to analyze the clinical and functional outcomes as well as the complications of this procedure and identify predictive factors for a favorable outcome. METHODS Forty-six patients who underwent SPR for persistent AKP after primary total knee arthroplasty were retrospectively studied. The patients mean age was 68 years (range, 36-86 years). The average follow-up time after SPR was 74 months (range, 24-197 months). Demographic data, Knee Society Score scale, range of motion, pain improvement (Visual Analogue Scale), overall satisfaction, and complications were recorded. The statistical analysis was performed using STATA tm/SE v10. RESULTS There was an improvement of the Knee Society scale (from 54 ± 11 to 64 ± 16 points; P < .05). However, in 59% of the cases, there was no pain improvement, and 65% of patients were not satisfied. Four patients showed complications, and in 2 cases, reoperation was necessary. We did not find any preoperative predictive factor for a favorable outcome after SPR. CONCLUSION Despite improvement of the Knee Society scale, many patients continue with AKP and are dissatisfied with this procedure; therefore, we do not recommend it in this clinical scenario.

Distal biceps brachii tendon repair complicated by a suture granuloma mimicking a soft-tissue sarcoma: a case report and review of the literature

The incidence of distal biceps brachii rupture is 1.2 per 100,000 persons per year; it most commonly occurs in the dominant elbow of men aged in their 40s. The repair, which includes several described techniques, is generally successful in restoring elbow strength, allowing for an early resumption of daily activities. Foreign-body granulomas have been extensively reported in the literature, occurring in a wide variety of operations and anatomic locations. Different surgical materials such as surgical sponges and silicone have been associated with the formation of this benign inflammatory lesion. Nonabsorbable sutures such as Ticron (Tyco, Waltham, MA, USA), FiberWire (Arthrex, Naples, FL, USA), and Ethibond (Ethicon, Somerville, NJ, USA), as in our case, used during tendon repairs can also elicit such a response. Though rare, these reactions can act as malignant neoplasms. However, no cases of suture granulomas after distal biceps brachii tendon repair presenting as a soft-tissue sarcoma (STS) have been reported.

Pediatric Maisonneuve: case report of a rare pattern of injury.

A 12-year-old boy presented to our emergency department complaining of pain and functional limitation on his right ankle after an indirect trauma. Plain radiographs were taken identifying a type II epiphysiolysis of the distal tibia and a proximal fibula fracture. An open reduction and internal fixation was performed without transyndesmal fixation. Maisonneuve fractures are an uncommon injury in the pediatric population. This fracture pattern has not been described by the Dias-Tachdjian classification. It is important to bear in mind that, based on the need for osteosynthesis for the epiphysiolysis, the treatment of these fractures in children usually differs from that in the adults as no transyndesmal screw fixation is required.

Local recurrence of soft-tissue sarcoma: issues in imaging surveillance strategy

Soft-tissue sarcomas pose diagnostic and therapeutic challenges to physicians, owing to the large number of subtypes, aggressive tumor biology, lack of consensus on management, and controversy surrounding interval and duration of surveillance scans. Advances in multidisciplinary management have improved the care of sarcoma patients, but controversy remains regarding strategies for surveillance following definitive local control. This review provides an updated, comprehensive overview of the current understanding of the risk of local recurrence of soft-tissue sarcoma, by examining the literature based on features such as histological type and grade, tumor size, and resection margin status, with the aim of helping clinicians, surgeons, and radiologists to develop a tailored approach to local imaging surveillance.

Intraosseous schwannomas involving the sacrum: Characteristic imaging findings and review of the literature

Background and purpose Sacral intraosseous schwannomas represent a rare subset of schwannomas. The existing literature detailing the radiographic appearance of intraosseous schwannomas is limited. The aim of this study is to formally characterize the radiological appearance of sacral intraosseous schwannomas to differentiate them from other lytic lesions. Materials and methods Imaging studies of 13 pathologically proven intraosseous schwannomas were reviewed from multiple institutions by fellowship-trained radiologists. A PubMed search was performed and identified four papers pertaining to the imaging characteristics of sacral intraosseous schwannomas. The results of these papers were compared to findings from our cases. Results All tumors had heterogeneous signals and were predominately solid but cystic components with fluid-fluid levels were present. The tumors caused a mass effect but none infiltrated the surrounding soft tissues. Post-contrast T1-weighted images revealed heterogeneous enhancement in all 13 tumors and four possessed non-enhancing cysts. A literature review identified 16 other cases of sacral intraosseous schwannomas forming a total of 29 cases examined. Conclusions Sacral intraosseous schwannomas should be considered in the differential diagnosis for both radiologists and pathologists when dealing with large expansile, lytic lesions, with well-defined sclerotic margins involving the sacrum. This is particularly important in middle-aged adults presenting with pathology centered around S2-3.