Sukit Saengnipanthkul

Pentalateral osteotomy for cubitus varus. Clinical experiences of a new technique

Several methods for the correction of cubitus varus have been described, but most reported series are small and show a high rate of complications. We report a six-year personal experience of 77 osteotomies by a new technique which provides rigid fixation and allows correction of both varus and rotation deformities. It also prevents lateral bulging at the level of the osteotomy. In 58 cases followed up for an average of 16 months, there were no serious complications, a satisfactory carrying angle and no significant loss of movement, giving 88% excellent or good results.

Treatment of de Quervain disease with triamcinolone injection with or without nimesulide. A randomized, double-blind, placebo-controlled trial.

BACKGROUND There is uncertainty as to whether supplemental oral nonsteroidal anti-inflammatory medication improves the effectiveness of steroid injections in the treatment of de Quervain disease. We tested the hypothesis that there are no significant differences in the success rates when this condition is treated with triamcinolone injection with or without supplemental oral nimesulide. METHODS In a randomized, double-blind trial, 160 patients with de Quervain disease received an injection of 10 mg of triamcinolone acetonide and either 200 mg of oral nimesulide for seven days (eighty patients) or placebo tablets for seven days (eighty patients). An independent, blinded evaluator assessed the primary outcomes (tenderness, pain, and the result on the Finkelstein test) at three weeks after injection. Adverse reactions were assessed, and probabilities of recurrence for both groups were compared. Factors possibly predictive of disease recurrence were also assessed. RESULTS The success rate after one injection was 67% in the nimesulide group and 68% in the placebo group. The overall success rates after single or multiple injections with a mean follow-up of 13.6 months were 95% for both groups. No significant differences were noted with respect to the success rates (p = 0.69) or pain scores after treatment (p = 0.11). The most common adverse reactions to triamcinolone injection and nimesulide were pain after injection and dyspepsia, respectively. The symptoms of de Quervain disease recurred in 33% of the patients in the nimesulide group and in 37% of those in the placebo group. The median time of recurrence was at the fifth month in the nimesulide group and at the fourth month in the placebo group. The recurrence of symptoms was significantly (p = 0.01) related to the presence of crepitation (relative risk, 2.13; 95% confidence interval, 1.19 to 3.80). CONCLUSIONS Supplemental oral administration of the nonsteroidal anti-inflammatory drug nimesulide does not improve the effectiveness of a single injection of triamcinolone acetonide in the treatment of de Quervain disease. Patients with crepitation in the first dorsal compartment during thumb extension or abduction are at increased risk for recurrence of this disease. LEVEL OF EVIDENCE Therapeutic study, Level I-1b (randomized controlled trial [no significant difference but narrow confidence intervals]).

Metastatic adenocarcinoma of the spine.

Eighty-six patients presenting with metastatic adenocarcinoma of the spine were retrospectively reviewed. Forty-nine patients had neurologic compromise: paraplegia developed in 23 patients and loss of anal or urethral sphincter control occurred in 17 patients. Anterior decompression was performed in 35 patients and posterior decompression in 14 patients. The rest of the patients were treated nonoperatively. Neurologic recovery in the operated cases was unsatisfactory. We found that this particular histologic type of spinal metastasis is highly invasive and aggressive. Survival analysis in 74 evaluable patients showed a median survival time of 76 days, which was not affected by the presence of multiple lesions or neurologic compromise. Surgical decompression had no positive impact on survival of the patients. Therefore, it is suggested that nonoperative treatment should be the guideline, and operative treatment should be offered only to carefully selected cases of metastatic adenocarcinoma of the spine.

Ultrasonography of pulled elbow

We used ultrasonography in ten children with pulled elbow to compare measurements of the radiocapitellar distance (RCD) on the affected and the unaffected sides. Similar measurements were made in a group of ten age-matched normal children. The mean RCD in pronation of the affected and normal sides in the patients with pulled elbows was 7.2 mm +/- 0.7 and 3.8 mm +/- 0.5, respectively (p < 0.0001). In the normal children the mean RCD in pronation was 4.5 mm +/- 0.5. We conclude that ultrasonography is of value for documenting pulled elbow in children.

Isolated Articular Melioidosis

Melioidosis is an infection caused by a gram-negative bacilli, Pseudomonas pseudomallei. This organism can cause fatal infection in domestic animals and are probably transmitted to humans by soil contamination of skin abrasions, ingestion, and inhalation. Melioidosis is being increasingly diagnosed in Western countries in other than its endemic areas of tropical and subtropical zones. In the past, only a few single case reports of articular melioidosis were published in English journals, and almost all were secondary to melioidosis of another organ. Accurate diagnosis of this infection is important because a high mortality rate is usually associated with the septicemic form. Nine cases of isolated articular involvement were diagnosed between 1984 and 1988 in Northeast Thailand. Symptoms were subtle and diagnosis required a high degree of suspicion. Diagnosis depended on bacteriologic methods including Grams stain, pus and blood cultures, and on an indirect hemagglutination titer of over 1:40. In addition to general measures for septic arthritis, antibiotic therapy using a combination of intravenous cotrimoxazole, doxycycline, and chloramphenicol was generally satisfactory. Second line drugs (i.e., more effective but also more expensive drugs that the authors administered when patients failed to respond to the first line drugs cotrimoxazole, doxycycline, and chloramphenicol) comprising intravenous ceftazidime and cotrimoxazole were administered in cases with an underlying disease. Comparison of the disease course before and during hospitalization as well as the total days of treatment between two small groups of patients with and without underlying disease revealed no statistically significant difference.

Simplified method for closed femoral nailing

We describe the method to simplify the procedure and shorten the operating time during closed femoral nailing. This includes early surgery, using a special reduction device, a marker to help interpretation of fracture alignment, limiting the surgical field to the trochanteric area with the thigh undraped to facilitate mobilization of the undraped C-arm, avoiding unnecessary intermediate reamers, less cortical reaming and a second team for distal locking when required. For 60 simple unlocked nailings and 15 locked nailings, the operation times were 40.4 and 58.7 min, respectively. These are much shorter than in previous reports.

Percutaneous release of the A1 pulley using a modified Kirschner wire: a cadaveric study

Purpose. To evaluate the outcome of percutaneous release of the A1 pulley in 40 cadaveric fingers using a modified Kirschner wire. Methods. A 2.5-mm-diameter Kirschner wire measuring >12 cm in length was used. One end of the wire was sharpened into a ‘J’ shape using a grinder. The J-shaped tip featured a blunt, elongated lower tip, a sharp J-shaped curve, and a blunt upper tip. Completeness of A1 pulley release and injuries to the A2 pulley, flexor tendon, and neurovascular structures were evaluated in 40 cadaveric fingers. Results. Complete release of the A1 pulley was achieved in 8 index, 7 middle, 8 ring, and 8 little fingers, whereas incomplete release of the distal part was noted in 2 index, 2 middle, 2 ring, and one little fingers; release was missed in one middle and one little fingers. Injury to the A2 pulley was noted in 2 index fingers; the injury was minimal and limited to the proximal 2 mm of the A2 pulley. There was no flexor tendon or digital nerve injury in any finger.

Differentiation of patented crystalline glucosamine sulfate from other glucosamine preparations will optimize osteoarthritis treatment.

Symptomatic slow‐acting drugs for osteoarthritis (SYSADOAs) are recommended for the medium‐ to long‐term management of knee osteoarthritis (OA) due to their abilities to control pain, improve function and delay joint structural changes. Among SYSADOAs, evidence is greatest for the patented crystalline glucosamine sulfate (pCGS) formulation (Mylan). Glucosamine is widely available as glucosamine sulfate (GS) and glucosamine hydrochloride (GH) preparations that vary substantially in molecular form, pharmaceutical formulation and dose regimen. Only pCGS is given as a highly bioavailable once‐daily dose (1500 mg), which consistently delivers the plasma levels of around 10 μmol/L required to inhibit interleukin‐1‐induced expression of genes involved in the pathophysiology of joint inflammation and tissue destruction. Careful consideration of the evidence base reveals that only pCGS reliably provides a moderate effect size on pain that is higher than paracetamol and equivalent to non‐steroidal anti‐inflammatory drugs (NSAIDs), while non‐crystalline GS and GH fail to reach statistical significance for pain reduction. Chronic administration of pCGS has disease‐modifying effects, with a reduction in need for total joint replacement lasting for 5 years after treatment cessation. Pharmacoeconomic studies of pCGS demonstrate long‐term reduction in additional pain analgesia and NSAIDs, with a 50% reduction in costs of other OA medication and healthcare consultations. Consequently, pCGS is the logical choice, with demonstrated medium‐term control of pain and lasting impact on disease progression. Physician and patient education on the differentiation of pCGS from other glucosamine formulations will help to improve treatment selection, increase treatment adherence, and optimize clinical benefit in OA.

Clinical diagnosis for metastatic adenocarcinoma of spine of unknown origin : a comparative study

The diagnostic values of the presence of Virchows node (VN) or rectal shelf (RS) in spinal metastasis from adeno-carcinoma of unknown origin were studied prospectively in 60 patients during 1986–1988. These were compared with 14 cases with other malignancies of the spine and 37 controls with nonneoplastic spinal lesions. The diagnosis was confirmed by histologic study in all malignant cases. The results were analyzed by diagnostic test analysis and McNemar X, testing. This yields 18.3–21.6%, 97.2–100%, and 92.8–100% sensitivity, specificity, and predictive value, respectively, for a positive test for VN and RS to differentiate significantly adenocarcinoma from other malignancies and control patients (P < 0.005). These findings may thus be considered as a simple and economic guide for physicians to determine the proper approach to patients with a spinal lesion suspected to be malignant.