Tamir Pritsch

Meralgia paresthetica: A retrospective analysis of 79 patients evaluated and treated according to a standard algorithm

Background The efficacy of various treatment modalities in meralgia paresthetica (MP) is not established. We retrospectively evaluated the management of spontaneous MP (i.e. MP not secondary to trauma or surgery) according to a standard algorithm. Methods Initial management included oral medications, rest, and reduction of aggravating factors. Non-responders underwent a diagnostic local anesthetic nerve block test. Patients who responded with transient symptomatic relief were treated by local infiltration of corticosteroids. Surgical intervention was reserved for patients with positive nerve block test, who did not respond to nonoperative measures. Results A negative nerve block test ruled out the diagnosis of MP in 6/86 patients. Of 79 patients with MP, 21 responded to the initial nonoperative treatment and 48 patients responded to local corticosteroids. 3 of the remaining 10 patients underwent surgery (nerve transection 2, neurolysis 1). During an average of 3 (1–13) years of follow-up, symptoms consistent with MP did not recur in any of the 72 patients in whom symptoms had resolved after treatment. Interpretation The algorithm used proved to be useful in the management of spontaneous meralgia paresthetica.

A bleeding pseudoaneurysm of the lateral genicular artery after total knee arthroplasty--a case report.

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Detrimental Effect of Repeated and Single Subacromial Corticosteroid Injections on the Intact and Injured Rotator Cuff A Biomechanical and Imaging Study in Rats

Background: The effect of corticosteroids on tendons is poorly understood, and current data are insufficient and conflicting. Purpose: To evaluate the effects of corticosteroid injections on intact and injured rotator cuffs (RCs) through biomechanical and radiographic analyses in a rat model. Study Design: Controlled laboratory study. Methods: A total of 70 rats were assigned to 7 groups. Uninjured rats (no tear) received either a single saline injection, a single methylprednisolone acetate (MTA) injection, or triple MTA injections. Injured rats (unilateral supraspinatus injury) received either a single saline injection, triple saline injections, a single MTA injection, or triple MTA injections (injections were subacromial; repeat injections were administered weekly). Rats were sacrificed 1 week after final injection. Shoulders were harvested and grossly inspected, and the supraspinatus tendon was evaluated biomechanically. Bone density at the tendon insertion site on the greater tuberosity was assessed by micro–computed tomography. Results: Intact RCs exposed to triple MTA injections had significantly decreased maximal load and stiffness compared with the control group (14.43 vs 21.25 N and 8.21 vs 16.6 N/mm, respectively; P < .05). Injured RCs exposed to steroid treatment had significantly lower maximal load (single saline: 10.91 N, single steroid: 8.43 N [P < .05]; triple control: 15.77 N, triple steroid: 11.65 N [P < .05]) compared with the control at 3 weeks. Greater tuberosity volume density and connectivity density were significantly lower in undamaged rats after triple MTA injection (P < .05). Conclusion: The study results clearly showed that repeated doses of corticosteroids significantly weaken rat RC and negatively affect bone quality in addition to possibly causing deterioration of the osteotendinous junction. However, data retrieved from animals must be scrupulously analyzed before extrapolation to humans. As such, the potential benefits and harms of subacromial corticosteroid treatment must be considered before administration. Clinical Relevance: The potential benefit and detrimental effects of corticosteroid injection should be thoroughly considered before it is administered subacromially in patients with RC injuries.

Late recurrent hemarthrosis following knee arthroplasty associated with epithelioid angiosarcoma of bone.

We report a case of recurrent hemarthrosis 1 year following total knee arthroplasty in a patient with no bleeding diathesis, the hemarthrosis was found to be related to, and led to the diagnosis of high grade sarcoma of the proximal tibia. Twenty five years earlier, he sustained a lateral tibial plateau fracture and was treated with open reduction and plating. Sarcoma developing in association with a metallic orthopedic prosthesis or hardware is an uncommon, but well-recognized complication. Sarcomas that occur adjacent to orthopaedic prostheses or hardware are of varied types, but are usually osteosarcoma or malignant fibrous histiocytoma.

Favorable radiographic outcomes using the expandable proximal femoral nail in the treatment of hip fractures – A randomized controlled trial

AIM To compare the functional and radiographic results of dynamic hip screw (DHS) and expandable proximal femoral nail (EPFN) in the treatment of extracapsular hip fractures. METHODS A randomized controlled trial of sixty hip fracture patients. Outcomes included mortality, residency, independence, mobility, function and radiographic results at a minimum of 1 year. RESULTS Twenty-nine EPFN patients demonstrated fewer cases of shaft medialization or femoral offset shortening compared to the 31 DHS patients. Mortality, complications and functional outcomes were similar. CONCLUSION EPFN provides stable fixation of pertrochanteric hip fractures and prevents neck shortening that is commonly observed after DHS fixation.

Unilateral Congenital Terminal Finger Absences: A Condition That Differs From Symbrachydactyly

PURPOSE To describe a type of nonhereditary unilateral transverse deficiency, which we have named hypodactyly, that is distinct from symbrachydactyly or amniotic disruption sequence. METHODS We identified 19 patients with unilateral congenital anomalies consisting of absent or short bulbous fingers that lack terminal ectodermal elements. Medical records and radiographs were retrospectively reviewed and contrasted with the typical findings of symbrachydactyly and amniotic disruption sequence. RESULTS No associated syndromes or potentially causative diagnoses were identified in the hypodactyly patients. The digital absences were of a truncated pattern with thickened, tubular soft tissue coverage. Radiographs revealed a pattern of severity progression that is different from that of symbrachydactyly. Distal phalanges were the bony elements absent most frequently, followed sequentially by the middle phalanx and proximal phalanx. In all cases, metacarpals were present. Unlike symbrachydactyly, the ulnar 2 digits were more involved than the index and long fingers, and the thumb was the least involved digit. CONCLUSIONS Hypodactyly appears to be a congenital hand anomaly that is clinically and radiographically different from symbrachydactyly or amniotic disruption sequence and is presumed to be caused by a distinct pathomechanism. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic IV.

Tenodesis for Restoration of Distal Interphalangeal Joint Flexion in Unrepairable Flexor Digitorum Profundus Injuries

PURPOSE To describe in a cadaveric model a tenodesis procedure for restoring distal interphalangeal joint flexion in patients with unrepairable isolated flexor digitorum profundus (FDP) injuries. METHODS In 16 fresh-frozen cadaveric fingers, the FDP tendon was transected 1 cm proximal to its insertion to simulate an isolated zone I laceration. The injury was reconstructed using a palmaris longus tendon graft to create a mechanical linkage between the interphalangeal joints, which restored coordinated interphalangeal joint flexion. Joint motion and the force required to flex and extend the fingers were tested before and after the tenodesis. RESULTS After FDP zone I laceration, distal interphalangeal joint flexion with load applied to the flexor digitorum superficialis tendon averaged 2°. The FDP flexion increased to a mean of 57° after the tenodesis. The sum of metacarpophalangeal, proximal interphalangeal and distal interphalangeal joint flexion averaged 186° before the tenodesis and increased to 233° after the tenodesis. The force required to achieve fingertip to palm contact and the force required to fully extend the proximal interphalangeal joint were not altered. CONCLUSIONS In this cadaveric model, this tenodesis successfully restored coordinated interphalangeal joint flexion after a simulated zone I FDP laceration with improvements in distal interphalangeal joint flexion and composite finger flexion. Critical factors such as the effects of inflammation, edema, soft tissue healing, and scar formation could not be evaluated and would likely affect the outcomes of this procedure. The in vivo results of this procedure are not known. CLINICAL RELEVANCE The potential use of this tenodesis for treating unrepairable isolated zone I FDP injuries was demonstrated in a cadaveric model. Further investigation of the outcomes and complications in vivo would be required before routine clinical use.

Adult Closed Distal Radius Fracture Reduction: Does Fluoroscopy Improve Alignment and Reduce Indications for Surgery?

Background: This study compared the radiological outcomes of adult closed distal radius fractures (DRFs) reduction with and without fluoroscopy. We hypothesized that fluoroscopy-assisted reduction would not improve radiographic alignment or decrease the need for surgery. Methods: Hospital medical records and radiographic images of all patients who presented with DRFs between April to June 2009 and April to June 2013 were reviewed. All patients underwent closed reduction and immobilization with or without fluoroscopic assistance. Reduction attempts were noted and pre- and postreduction posteroanterior and lateral radiographs were reviewed for fracture stability. Results: Eighty-four patients underwent reduction without fluoroscopy (group 1), and 90 patients underwent reduction with the aid of fluoroscopy (group 2). According to accepted radiographic guidelines, nonsurgical treatment was indicated for 62% of patients in group 1 and 56% of patients in group 2 (P = .44). In addition, no significant difference between the groups was observed in any postreduction radiographic parameters (P > .53) or postreduction alignment of unstable fractures (P = .47). Conclusions: Reduction without the use of fluoroscopy demonstrated noninferiority when compared with fluoroscopy-assisted reduction in the emergency department for closed adult DRFs.

Bilateral Heel Panniculitis Presenting as Calcaneal Osteomyelitis

Panniculitis is an inflammatory process of the subcutaneous adipose layer (panniculos adiposus). It is frequently a sign of systemic disease with a wide range of clinical presentations. The histopathological findings are diverse, making diagnoses difficult. We present a case of heel panniculitis, initially misdiagnosed as calcaneal osteomyelitis. Our intention is to make physicians, treating these type of patients, aware of the possibility of this rare disease, especially in situations when conventional therapy is not successful. A 66-year-old woman was admitted to the hospital with the initial diagnosis of suspected calcaneal osteomyelitis of her right heel, presumably due to a foreign body penetration a few months prior. Initial treatment with intravenous antibiotics was unsuccessful. When significant fluctuation developed, she underwent incision and drainage of her right heel. Postoperatively, her right heel condition did not improve and similar phenomena appeared on her left side. She continued to deteriorate up to the point when panniculitis was diagnosed and corticosteroid treatment was initiated. Her condition rapidly improved after this treatment.

Tailored tibial tubercle transfer for patellofemoral malalignment: analysis of clinical outcomes: Reply to the comments by S. Koëter and A. Wymenga

The purpose of this study was to describe the surgical technique, and evaluate and analyze the clinical outcomes of patients who underwent tibial tubercle realignment in our institution. Reported results of tibial tubercle transfer for patellofemoral malalignment vary considerably. Most authors rely mainly on the passive intraoperative patellar tracking test in determining the new location of the tibial tubercle. Conversely, the senior author relocates the tibial tubercle based on the intraoperative active and passive patellar tracking tests and the condition of the patellar articular surface. The medical records of 66 consecutive patients who underwent 80 tibial tubercle relocation procedures due to patellar instability or patellofemoral pain and maltracking were reviewed. Fifty-five patients with 69 operated knees participated in designated follow-ups which were conducted according to a predesigned protocol. The median follow-up was 6.2 years (range 2-13 years). Clinical outcomes significantly improved compared to the preoperative state; 72.5% of operated knees demonstrated good-to-excellent results according to the Lysholm and Karlsson scores, and physical findings supported the positive effect of the procedure. A statistically significant positive correlation was found between clinical outcomes and male gender, the absence of moderate to severe patellar chondral damage, and instability as the dominant preoperative symptom. Postoperative complication rate was low and patients with longer postoperative follow-ups demonstrated better clinical outcomes. The presented method of tibial tubercle transfer provided a good long-lasting surgical solution for patients with patellar instability and patients with patellar maltracking and anterior knee pain. Good prognostic factors included male gender, clinical patellar instability as the dominant preoperative symptom and intact patellar articular cartilage.