Karuppaiah Karthik

Severe ulnar nerve entrapment at the elbow: functional outcome after minimally invasive in situ decompression

The role of in situ decompression in patients with severe ulnar nerve compression is still controversial. Thirty patients with severe ulnar nerve compression confirmed clinically and electrophysiologically underwent simple decompression. The mean age of the patients was 58 (range 26–87) years. Through incisions ≤4 cm the nerves were fully visualized and decompressed. Outcome was measured prospectively using Modified Bishop’s score (BS), grip and pinch strengths and two-point discrimination (2PD). Significant improvement in power (p = 0.01) and pinch grip (p = 0.001) was noted at 1 year. The grip strength continued to improve up to 1 year. According to the BS, 24 patients (80%) had good to excellent results at 1 year. Minimally invasive in situ decompression is technically simple, safe and gives good results in patients with severe nerve compression. The BS and 2PD were more reliable than grip strength in assessing these patients at follow-up.

Role of intraoperative 3D C-arm-based navigation in percutaneous excision of osteoid osteoma of long bones in children.

Failures of treatment of osteoid osteoma (OO) are related to errors in exact localization and incomplete excision of the nidus. We report the successful percutaneous excision of OO in five patients (upper end of femur – 3, tibia – 2). All patients had a minimally invasive reflective array fixed to the same bone followed by registration of anatomy by Iso-C three-dimensional (3D) C-arm. A tool navigator was used to plan the keyhole incision then a sleeve was introduced which allowed the usage of burr and curette to remove the tumor. After excision, the 3D C-arm was again used intraoperatively to confirm the complete eradication of the nidus. Adequate material for histology was obtained in four patients that confirmed the diagnosis of OO. In one child postexcision scans were successful in identifying incomplete removal requiring further excision of the nidus. All patients achieved excellent pain relief and were asymptomatic at an average follow-up of 3.2 years. 3D C-arm-based navigation offers the advantage of excellent localization, percutaneous excision, and intraoperative confirmation of adequate excision.

Robotic surgery in trauma and orthopaedics: a systematic review

The use of robots in orthopaedic surgery is an emerging field that is gaining momentum. It has the potential for significant improvements in surgical planning, accuracy of component implantation and patient safety. Advocates of robot-assisted systems describe better patient outcomes through improved pre-operative planning and enhanced execution of surgery. However, costs, limited availability, a lack of evidence regarding the efficiency and safety of such systems and an absence of long-term high-impact studies have restricted the widespread implementation of these systems. We have reviewed the literature on the efficacy, safety and current understanding of the use of robotics in orthopaedics.

Unstable trochanteric fractures in elderly osteoporotic patients: role of primary hemiarthroplasty.

Objective Unstable intertrochanteric fractures in osteoporotic patients are difficult to treat. Fixation failure often leads to prolonged morbidity and poor functional outcomes. The objective of the present study was to investigate primary replacement as a suitable option that could minimize complications in selected patients. Methods From January 2004 to March 2007, 28 elderly osteoporotic patients with unstable intertrochanteric fractures were included in this study. Their fractures were classified according to the AO/OTA classification (8 patients, 31A2.2; 17 patients, 31A2.3 and 3 patients, 31A3.3) and their osteoporosis was confirmed by bone densitometry. Hemiarthroplasty was performed in all patients and the outcomes analyzed using the Harris hip score system. Results Of the 28 patients, 19 were women and the mean age was 79 years (range, 52–95 years). At a mean follow up of 4.2 years (range, 3–6 years), there were 17 excellent, 7 good, 2 fair and 2 poor results according to the Harris hip score system. Conclusion In elderly osteoporotic patients with unstable intertrochanteric fractures, hemiarthroplasty is a reliable alternative to internal fixation. The functional outcome has been encouraging and we suggest it as a method of treatment in this group of patients.Unstable intertrochanteric fractures in osteoporotic patients are difficult to treat. Fixation failure often leads to prolonged morbidity and poor functional outcomes. The objective of the present study was to investigate primary replacement as a suitable option that could minimize complications in selected patients.

Extensor Pollicis Brevis tendon damage presenting as de Quervain’s disease following kettlebell training

Kettlebell exercises are more efficient for an athlete to increase his or her muscle strength. However it carries the risk of injury especially in the beginners. A 39 year old gentleman came to our clinic with radial sided wrist pain following kettlebell exercises. Clinically patient had swelling and tenderness over the tendons in the first dorsal wrist compartment, besides Finklesten test was positive. Patient had a decreased excursion of the thumb when compared to the opposite side. Ultrasound/MRI scan revealed asymmetric thickening of the 1st compartment extensors extending from the base of the thumb to the wrist joint. Besides injury to the Extensor Pollicis Brevis (EPB) tendon by repetitive impact from kettlebell, leading to its split was identified. Detailed history showed that the injury might be due to off-centre handle holding during triceps strengthening exercises. Our report stresses the fact that kettlebell users should be taught about problems of off-center handle holding to avoid wrist injuries. Also, in Kettlebell users with De Quervains disease clinical and radiological evaluation should be done before steroid injection as this might lead to complete tendon rupture.

Incongruent reduction following post-traumatic hip dislocations as an indicator of intra-articular loose bodies: A prospective study of 117 dislocations.

BACKGROUND Intra-articular loose bodies following simple dislocations can lead to early degeneration. Nonconcentric reduction may indicate retained loose bodies and offer a method to identify patients requiring exploration so that this undesirable outcome can be avoided. MATERIALS AND METHODS One hundred and seventeen consecutive simple dislocations of the hip presenting to the hospital from January 2000 to June 2006 were assessed for congruency after reduction by fluoroscopic assessment of passive motion in the operating room as well as with good quality radiographs. Computerized tomography (CT) scan with 2-mm cuts was done for confirmation of reduction and to identify the anatomy of loose bodies. Patients with nonconcentric reduction underwent open exploration to identify the etiology of the dislocation and for removal of loose bodies. Thomson and Epstein clinical and radiological criteria were used to assess the outcome. RESULTS Twelve of the one hundred and seventeen (10%) dislocations had incongruent reduction, which was identified by the break in Shentons line and increase in medial joint space in seven patients, increase in the superior joint space in three patients, or increase in the joint space as a whole in two patients. CT scan identified the origin of the osteocartilaginous fragment as being from the acetabulum in six patients, the femoral head in four, and from both in one. One patient had an inverted posterior labrum. Following debridement, congruent reduction was achieved in all patients. At an average follow-up of 5 years (range: 2 years 5 months to 8 years), the outcome as evaluated by Thompson and Epstein clinical criteria was excellent in eleven cases and good in one case; the radiological outcome was excellent in eight cases and good in four cases. CONCLUSIONS Intra-articular loose bodies were identified by nonconcentric reduction in 12 out of 117 patients with simple hip dislocation. Careful evaluation by fluoroscopy and good quality radiographs are indicated following reduction of hip dislocations.

Corrective osteotomy for malunited metacarpal fractures: Long-term results of a novel technique

Symptomatic malunited metacarpal fractures can significantly affect hand function. We retrospectively reviewed the results of our technique of corrective osteotomy in 14 malunited metacarpal fractures (12 patients) with an average age of 30 years (range 18–49) from January 2005 to December 2011. The dominant hand was involved in nine patients and all except one were male. The malunited metacarpals demonstrated mean dorsal apex angulation of 43° (range 33°–72°) with apparent metacarpal shortening. All except three cases had rotational deformity. All patients underwent surgical correction of the deformity using our described technique of closing wedge osteotomy using temporary intramedullary K-wire and plate fixation. At a mean follow-up of 46 months (range 12–78), the DASH scores improved significantly (p < 0.001). All our patients scored ‘excellent’ according to the Büchler criteria and at final follow-up had returned to pre-injury work and sports activities. Our technique is safe, easily performed and can be adapted to correct a range of deformities. Level of evidence: Level IV

Scapular spine stress fractures: To fix or not to fix, our experience in a patient with bilateral fractures and review of the literature

We report a case of bilateral scapular spine stress fracture, treated conservatively on one side and operatively on the other side. Besides, we performed a literature review to establish management options. A 61-year-old right-handed gentleman came to our clinic with acute on chronic deterioration of shoulder pain and loss of arm function. Clinical assessment and investigations revealed long-standing bilateral rotator cuff tear and scapular spine stress fractures. The fracture on the right side united with conservative management for 2 months. However, his left side remained symptomatic with pain, abnormal mobility and no radiological evidence of union. The fracture progressed to union after fixation and bone grafting. At the final follow-up at 2 years, the patient was asymptomatic with regards to the fractures with Oxford Shoulder Score (OSS)-30 and Disabilities of the Arm, Shoulder and Hand (DASH)-30.8. Fracture union either by conservative or operative treatment is associated with good functional outcome and is supported by our review.

Solitary enchondroma presenting with an intra-articular comminuted fracture treated with ligamentaxis and percutaneous curettage

A 35-year-old right-handed professional flautist presented with pain in the right ring finger after minor trauma. There was tenderness and swelling of the proximal interphalangeal (PIP) joint and reduced movement. Radiographs showed an eccentric lytic lesion in the middle phalanx characteristic of an enchondroma with a pathological fracture extending into the PIP joint (Figure 1). The fracture had intra-articular comminution with loss of joint congruity and collapse of the lesion, leading to radial deviation of the digit. Precise realignment of the digit and restoration of good movement were important treatment goals because of her profession. Treatment was planned in two stages. The first was to restore alignment, allow early movement and wait for healing of the pathological fracture. It was assumed that secondary bone grafting might be necessary. Initial surgery was by the application of a Ligamentotaxor (AREX, Palaiseau, France) under axillary block using two wires, one in the proximal phalanx at the centre of rotation of PIP joint, parallel to the articular surface, and another in the middle phalanx shaft. The middle phalanx was distracted to restore length, alignment and joint congruity (Figure 1). To stimulate bone healing a 19 gauge needle was inserted through the thin ulnar wall and used to curette the cavity. Post-operatively the patient was allowed to mobilize the finger as tolerated. Six weeks later the cavity had filled with new bone, obviating the need for further bone grafting, and the fixator was removed (Figure 1). After hand therapy she returned to her profession at 3 months. At the final 1-year follow-up the range of movement was from 10°–90° and the radiographs showed complete filling of the cavity with bone and a congruent articular surface (Figure 2). Treatment of a pathological fracture though a benign cyst or tumour in the middle phalanx depends on its size, location and displacement (Jacobson and Ruff, 2011). The treatment options vary from simple observation to curettage and filling the gap with bone graft or bone cement (Jacobson and Ruff, 2011). Simple curettage without bone grafting has shown promising results in enchondromas (Goto et al., 2002; Hasselgren et al., 1991). In this patient, early grafting was contraindicated owing to the intra-articular comminution. Also we wanted to restore alignment and mobilize as soon as possible and to avoid open procedures, which may produce stiffness. A dynamic external fixator has been used for unstable fractures at the PIP joint to preserve joint congruity and to prevent stiffness (Ruland et al., 2008). The use of such a fixator allowed early mobilization in this particular situation. Although the clinical and radiological diagnosis was an enchondroma, there was no confirmation by biopsy since it healed so rapidly and we were unable to extract any tissue or fluid though the needle. The curettage using the needle appeared to have the advantage of stimulating bone ingrowth with minimal intervention, without the risk of open Figure 1. (Left) The AP and lateral radiographs showing a communited, intra-articular pathological fracture with radial deviation owing to collapse of the cavity. (Middle) Immediate post-operative radiograph with a congruent joint. (Right) At 6 weeks the cavity was filled with new bone.

Intraoperative Life Threatening Acute Lung Injury Due to Multiple Septic Pulmonary Emboli during Transpedicular Biopsy and Kyphoplasty

A 55-year-old gentleman was presented to our clinic two months after a trivial fall with persistent pain, gibbus at the thoraco-lumbar junction and intact neurology. Radiological and laboratory investigations suggested osteoporotic fracture or metastasis. Due to unremitting pain, a plan was made to do transpedicular biopsy and kyphoplasty. Biopsy needles were inserted into both pedicles and an attempt at aspiration was made. Since the aspirate was dry, 5 to 6 mL of saline was injected through one needle and an attempt at aspiration was made through the other. Three-millilitres of sero-sanguineous material mixed with pus came out and kyphoplasty was deferred. After extubation, the patient developed severe bronchospasm and was transferred to the intensive care unit. Investigations confirmed multiple septic pulmonary emboli and the patient recovered completely after treatment. This report highlights that confirmation of the diagnosis is essential before performing any procedure that increases the intravertebral pressure and the place should have appropriate facilities to manage complications.