Julian Dexel

Subcutaneous Emphysema of the Upper Extremity After Elbow Arthroscopy

Subcutaneous emphysema of the upper extremity is rare. Crepitation on physical examination and visible gas on radiographs raise the concern of gas gangrene due to gas-producing bacteria. Rapid establishment of a differential diagnosis is necessary to initiate proper treatment. We present a case of subcutaneous emphysema after elbow arthroscopy caused by a noninfectious genesis. A 59-year-old woman with loose bodies in her left elbow due to mild degenerative joint disease and restricted range of motion was offered an elbow arthroscopy with removal of loose bodies and arthrolysis. Postoperatively, the elbow was actively put alternatively in maximum extension and flexion. On the first postoperative day, rapidly ascending swelling and subcutaneous crepitation starting from the hand to the forearm were noted. There was no clinical evidence of infection. Radiographs showed subcutaneous air. Frequent blood tests and clinical evaluation ruled out a potentially life-threatening bacterial infection, and the signs resolved after 1 week without surgical treatment. Presumably, the intensive postoperative range-of-motion exercises led to a sucking in of air into the wound during each movement. This case illustrates that it is important to differentiate nonbacterial from bacterial causes of soft-tissue gas formation to initiate the appropriate treatment.

Similar stability and range of motion between cruciate-retaining and cruciate-substituting ultracongruent insert total knee arthroplasty

AbstractPurpose The use of an ultracongruent (UC) insert with a standard femoral component for substitution of the posterior cruciate ligament (PCL) is a bone-preserving and therefore interesting alternative to the established box and cam mechanism of posterior-stabilized total knee arthroplasty (TKA). Despite the regular use of these UC inserts, there is little evidence about stability and range of motion (ROM).Methods The aim of this study was to evaluate the stability and ROM in standard cruciate-retaining (CR) and cruciate-substituting UC inserts of the same TKA. In 39 patients, intraoperative measurements of stability and ROM were taken (1) before soft tissue release and bone cuts, (2) after implantation of a CR TKA and (3) after resection of the PCL and substitution with an UC insert. All measurements were taken using a navigation system.ResultsStability measurements demonstrated no differences between CR (PCL intact) and UC TKA (PCL resected), but significantly increased anteroposterior translation at 60° and 90° of knee flexion compared with the preoperative condition. ROM measurements demonstrated improvement of knee flexion from preoperatively mean 105° (SD 14.1°) to intraoperative 120.2° (SD 6.7°) with the CR and 121.0° (SD 7.5°) with the UC insert and 113.5° (SD 14.0°) at the 1-year follow-up.ConclusionThis study demonstrates similar stability of an UC insert compared with a standard CR insert. UC inserts are therefore a bone-preserving solution if the PCL needs to be substituted. ROM was not improved after resection of the PCL and substitution with the UC insert.Level of evidenceII.

Arthroskopie des Ellenbogens

ZusammenfassungIndikationen für die Ellenbogenarthroskopie sind die diagnostische Arthroskopie, die Entfernung freier Gelenkkörper, die Osteophytenabtragung, die Synovektomie, die Osteochondrosis dissecans und die Arthrolyse bei Kontrakturen des Ellenbogens.Die genaue Kenntnis der Anatomie und arthroskopische Erfahrung sind notwendig, um mit der engen Lagebeziehung der neurovaskulären Strukturen umzugehen. Damit die Operation schnell und komplikationsarm ausgeführt werden kann, sind eine korrekte Lagerung, die Markierung der Landmarken sowie die exakte Platzierung der Portale nötig.Der Anteil an Komplikationen ist verglichen mit den Knie- und Schulterarthroskopien häufiger, wobei geringfügige Komplikationen überwiegen. Die gefürchteten Nervenläsionen sind meistens transient, treten sie aber permanent auf, haben sie weitreichende Folgen für die Patienten.Die Ellenbogenarthroskopie hat sich zu einem sicheren und wichtigen Verfahren der Diagnostik und Therapie von Ellenbogenpathologien entwickelt.AbstractIndications for elbow arthroscopy include diagnostic arthroscopy, removal of loose bodies and osteophytes, synovectomy, treatment of osteochondrosis dissecans and capsular release in case of contracture. In particular, the anatomic vicinity of the neurovascular structures to the portals requires a thorough knowledge of elbow anatomy and some experience with the procedure. The exact positioning of the patient, identification of the landmarks and knowledge of the correct portal placement are necessary to perform a safe and effective operation and to avoid complications.The overall complication rate is higher as compared to knee- or shoulder arthroscopy with minor complications predominating. Nerve lesions are transient most of the time; however, being permanent they cause substantial problems for the patient. Overall, elbow arthroscopy has become a safe and reliable procedure for the diagnosis and therapy of elbow disorders.

A rare case of bilateral large osteolysis following cemented and cementless total knee arthroplasties

A 66-year old woman (BMI 36) presented for routine follow-up after undergoing total knee arthroplasty (TKA) in the right knee 12 years ago, and TKA in the left knee 4 years ago. The right TKA was a cementless cruciate-retaining prosthesis (Encore Medical Foundation Knee, femoral component porous coated CoCrMb alloy, tibial component Ti-alloy with 4 screws, PE insert 9 mm). The left TKA was a cemented cruciate-retaining prosthesis (Zimmer Natural Knee II, femoral component CoCrMb alloy, tibial baseplate component Ti-alloy, PE insert 9 mm). The patient reported only mild problems (knee score 88 points, function score 60 points). Radiographs and CT scans revealed extensive osteolysis at the proximal medial tibia of both knees (Figures 1 and ​and2).2). There was a mild varus malalignment (4°) of both legs. Rotational alignment measured on the CT scans showed a rotational mismatch between femoral and tibial components of 8° (femoral internal rotation) in the right knee and no mismatch (1° of femoral internal rotation) in the left knee. Figure 1. Anterioposterior and lateral radiograph and CT scans showing osteolysis of the distal right femur and the proximal tibia 12 years after implantation of a cemenless TKA. Figure 2. Anterioposterior and lateral radiograph and CT scans showing osteolysis of the distal left femur and the proximal tibia 4 years after implantation of a cemented TKA. Open biopsy was performed bilaterally to rule out a possible malignancy or infection. Microscopic histological examination revealed chronic inflammation and hisitocytic infiltrates in both knees. Polyethylene particles were observed within the cytoplasma of the histiocytes. There was no evidence of metal debris. All microbiological cultures were negative. During revision, both tibial baseplates were manually assessed as being well fixed to the lateral tibial bone stock, providing no evidence that baseplate loosening was the cause of the osteolysis. However, upon removal of the baseplates, the cortical bone at the proximal medial tibia was observed to be very thin and completely missing in some regions, as already revealed on the CT scans. Osteolytic defects were filled with autologous cancellous bone and augmented with bone cement, and both knees were implanted with a modular constrained TKA prosthesis.

TKA for Posttraumatic Osteoarthritis Is More Complex and Needs More Surgical Resources.

The purpose of this study was to evaluate the surgical effort of total knee arthroplasty (TKA) for posttraumatic osteoarthritis (PTOA) compared with primary osteoarthritis (OA). A total of 1841 TKAs were analyzed, including 170 patients with PTOA, that resulted from soft tissue trauma in 83 patients and fractures in 87 patients. Results showed that patients were significantly younger at the time of surgery in the posttraumatic group (62 vs 71 years; P<.001). Furthermore, fracture was associated with 3.7 years earlier need of TKA compared with soft tissue trauma. Operation time was significantly longer for both of the posttraumatic groups compared with OA (P<.001). Patients undergoing TKA after knee injuries are younger and surgical treatment is more challenging compared with TKA for OA. Extended operation time and implant systems with higher constraint and modular options are required. [Orthopedics. 2016; 39(3):S36-S40.].

Bilateral idiopathic osteonecrosis of the major tubercle of the humerus

AbstractBilateral osteonecrosis of the tuberculum majus has not been reported in the literature. A case of bilateral avascular necrosis of the tuberculum majus is presented associated with smoking and occasional alcohol consumption as risk factors, which was successfully treated with non-operative treatment. Level of evidence Case report, Level V.