Journal of Orthopaedic Surgery and Research - Latest Articles

Rupture of the ilio-psoas tendon after a total hip arthroplasty: an unusual cause of radio-lucency of the lesser trochanter simulating a malignancy

Aditya Maheshwari — 2010-02-05T00:00:00Z

Avulsion fracture or progressive radiolucency of lesser trochanter is considered a pathognomic finding in patients with malignancies. Although surgical release of the iliopsoas tendon may be required during a total hip arthroplasty (THA), there is no literature on spontaneous rupture of the ilio-psoas tendon after a THA causing significant functional impairment. We report here such a case, which developed progressive radiolucency of the lesser trochanter over six years after a THA, simulating a malignancy. The diagnosis was confirmed by MRI. Because of the chronic nature of the lesion, gross retraction of the tendon into the pelvis, and low demand of our patient, he was treated by physiotherapy and gait training. Injury to the ilio-psoas tendon can occur in various steps of the THA and extreme care should be taken to avoid this injury. Prevention during surgery is better, although there are no reports of repair in the THA setting. This condition should be considered in patients who present with progressive radioluceny of the lesser trochanter, especially in the setting of a hip/pelvic surgery. Awareness and earlier recognition of the signs and symptoms of this condition will aid in diagnosis and will direct appropriate management.

Long-term sequel of posterolateral rotatory instability of the elbow: a case report

Chun-Ying Cheng — 2010-01-27T00:00:00Z

The natural course of untreated posterior lateral rotatory instability of the elbow is unclear. A case of elbow arthrosis with progressing deformity and flexion contracture after an episode of elbow dislocation about 20 years ago presented the possibility the long term outcome of untreated posterior lateral rotatory instability of the elbow.

Lateral femoral traction pin entry: risk to the femoral artery and other medial neurovascular structures.

John Kwon — 2010-01-22T00:00:00Z

Background: Femoral skeletal traction assists in the reduction and transient stabilization of pelvic, acetabular, hip, and femoral fractures when splinting is ineffective. Traditional teaching has recommended a medial entry site for insertion of the traction pin in order to minimize injury to the femoral artery as it passes through Hunter's canal. The present anatomical study evaluates the risk to the femoral artery and other medial neurovascular structures using a lateral entry approach. Methods: Six embalmed cadavers (twelve femurs) were obtained for dissection. Steinman pins were drilled from lateral to medial at the level of the superior pole of the patella, at 2 cm, and at 4 cm proximal to this point. Medial superficial dissection was then performed to identify the saphenous nerve, the superior medial geniculate artery, the adductor hiatus, the tendinous insertion of the adductor magnus and the femoral artery. Measurements localizing these anatomic structures relative to the pins were obtained. Results: The femoral artery was relatively safe and was no closer than 29.6 mm (mean) from any of the three Steinman pins. The superior medial geniculate artery was the medial structure at most risk. Conclusions: Lateral femoral traction pin entry is a safe procedure with minimal risk to the saphenous nerve and femoral artery. Of the structures examined, only the superior medial geniculate artery is at a risk of iatrogenic injury due to its position. The incidence of such injury in clinical practice and its clinical significance is not known. Lateral insertion facilitates traction pin placement since it minimizes the need to move the contralateral extremity out of the way of the drilling equipment or the need to elevate or externally rotate the injured extremity relative to the contralateral extremity.

Anatomical, clinical and electrical observations in Piriformis Syndrome

Roger Jawish — 2010-01-21T00:00:00Z

IntroductionWe provided clinical and electrical descriptions of the piriformis syndrome, contributing to better understanding of the pathogenesis and further diagnostic criteria. Methods: Between 3550 patients complaining of sciatica, we concluded 26 cases of piriformis syndrome, 15 females, 11 males, mean age 35.37 year-old. We operated 9 patients, 2 to 19 years after the onset of symptoms, 5 had piriformis steroids injection. The H reflex was tested in 13 cases and MRI performed in all cases. Results: After a followup 1 to 11 years, for the 17 non operated patients, 3 patients responded to conservative treatment. 6 of the operated had an excellent result, 2 residual minor pain and one failed. 3 new anatomical observations were described with atypical compression of the sciatic nerve by the piriformis muscle.DiscussionThe H reflex of the peroneal nerve should be given more importance, because it demonstrated more specific sign, with six clinical criteria it contributed to improve the method of diagnosis. The cause of this particular syndrome does not only depend on the relation sciatic nerve-piriformis muscle, but the environmental conditions should be considered with the series of the anatomical anomalies to explain the real cause of this pain.

Spectrum of musculo-skeletal disorders in sickle cell disease in Lagos, Nigeria

Rufai Balogun — 2010-01-18T00:00:00Z

Background: Sickle cell anemia (SCA) is a common genetic disease in Nigeria. Past studies from West Africa focused on isolated aspects of its medical and surgical presentations. To the best of our knowledge, the musculo-skeletal presentations amongst Nigerians with SCA have not been documented in a single all encompassing study. This work aims to prospectively document the musculo-skeletal disease burden among SCA patients. Methods: In a prospective study of 318 consecutive patients with genotype-confirmed SCA at the Lagos University Teaching Hospital (LUTH), the musculo-skeletal pathologies, anatomic sites, grade of disease, age at presentation and management outcome were recorded over a one-year period. Data obtained were analyzed using Epi-Info software version 6.0. Data are presented as frequencies (%) and mean values (SD) as appropriate. Results: The HbSS genotype occurred in 296 (93.0%), while 22 (7.0%) were HbSC. 100 (31.4%) patients with average presenting haemoglobin concentration of 8.2 g/100ml in the study group, presented with 131 musculo-skeletal pathologies in 118 anatomic sites. Osteomyelitis 31 (31%) and septic arthritis 19 (19%) were most commonly observed in children less than 10 years. Skin ulcers and avascular necrosis (AVN) occurred predominantly in the older age groups, with frequencies of 13 (13.0%) and 26 (26.0%) respectively. 20 (71.5%) of diagnosed cases of AVN presented with radiological grade 4 disease. The lower limbs were involved in 84 (71.1%) of sites affected. Lesions involving the spine were rare 11 (0.9%). Multiple presentations occurred in 89 (28.0%) of patients; 62 (69.7%) of which were children below 10 years. Conclusions: Musculo-skeletal complications are common features of sickle cell anaemia seen in 31.4%. Infectious aetiologies predominate with long bones and joints of lower limbs more commonly affected by osteomyelitis and septic arthritis. Healthcare providers managing SCA should be aware of the potential morbidity and mortality of these conditions to ensure early diagnosis and adequate management.

Effects of low power laser irradiation on bone healing in animals: a meta-analysis

Siamak Bashardoust Tajali — 2010-01-04T00:00:00Z

Purpose: The meta-analysis was performed to identify animal research defining the effects of low power laser irradiation on biomechanical indicators of bone regeneration and the impact of dosage. Methods: We searched five electronic databases (MEDLINE, EMBASE, PubMed, CINAHL, and Cochrane Database of Randomised Clinical Trials) for studies in the area of laser and bone healing published from 1966 to October 2008. Included studies had to investigate fracture healing in any animal model, using any type of low power laser irradiation, and use at least one quantitative biomechanical measures of bone strength. There were 880 abstracts related to the laser irradiation and bone issues (healing, surgery and assessment). Five studies met our inclusion criteria and were critically appraised by two raters independently using a structured tool designed for rating the quality of animal research studies. After full text review, two articles were deemed ineligible for meta-analysis because of the type of injury method and biomechanical variables used, leaving three studies for meta-analysis. Maximum bone tolerance force before the point of bone fracture during the biomechanical test, 4 weeks after bone deficiency was our main biomechanical bone properties for the Meta analysis. Results: Studies indicate that low power laser irradiation can enhance biomechanical properties of bone during fracture healing in animal models. Maximum bone tolerance was statistically improved following low level laser irradiation (average random effect size 0.726, 95% CI 0.08 - 1.37, p 0.028). While conclusions are limited by the low number of studies, there is concordance across limited evidence that laser improves the strength of bone tissue during the healing process in animal models.

In vitro suppression of the MMP-3 gene in normal and cytokine-treated human chondrosarcoma using small interfering RNA

Korakot Nganvongpanit — 2009-12-24T00:00:00Z

Background: Matrix metalloproteinase (MMPs) synthesized and secreted from connective tissue cells have been thought to participate in degradation of the extracellular matrix. Increased MMPs activities that degrade proteoglycans have been measured in osteoarthritis cartilage. This study aims to suppress the expression of the MMP-3 gene in in vitro human chondrosarcoma using siRNA. Methods: Cells were categorized into four groups: control (G.1); transfection solution treated (G.2); negative control siRNA treated (G.3); and MMP-3 siRNA treated (G.4). All four groups were further subdivided into two groups - treated and non-treated with IL-1β- following culture for 48 and 72 h. We observed the effects of gene suppression according to cell morphology, glycosaminoglycan (GAG) and hyaluronan (HA) production, and gene expression by using real-time polymerase chain reaction (PCR). Results: In IL-1β treated cells the apoptosis rate in G.4 was found to be lower than in all other groups, while viability and mitotic rate were higher than in all other groups (p < 0.05). The production of GAG and HA in G.4 was significantly higher than the control group (p < 0.05). MMP-3 gene expression was downregulated significantly (p < 0.05). Conclusion: MMP-3 specific siRNA can inhibit the expression of MMP-3 in chondrosarcoma. This suggests that MMP-3 siRNA has the potential to be a useful preventive and therapeutic agent for osteoarthritis.

False aneurysm of the interosseous artery and anterior interosseous syndrome - an unusual complication of penetrating injury of the forearm: a case report

Ramon Pini — 2009-12-24T00:00:00Z

Background: Palsies involving the anterior interosseous nerve (AIN) comprise less than 1% of all upper extremity nerve palsies.ObjectivesThis case highlights the potential vascular and neurological hazards of minimal penetrating injury of the proximal forearm and emphasizes the phenomenon of delayed presentation of vascular injuries following seemingly obscure penetrating wounds.Case ReportWe report a case of a 22-year-old male admitted for a minimal penetrating trauma of the proximal forearm that, some days later, developed an anterior interosseous syndrome. A Duplex study performed immediately after the trauma was normal. Further radiologic investigations i.e. a computer-tomographic-angiography (CTA) revealed a false aneurysm of the proximal portion of the interosseous artery (IA). Endovascular management was proposed but a spontaneous rupture dictated surgical revision with simple excision. Complete neurological recovery was documented at 4 months postoperatively.Conclusions/SummaryAfter every penetrating injury of the proximal forearm we propose routinely a detailed neurological and vascular status and a CTA if Duplex evaluation is negative.

ACL reconstruction with unicondylar replacement in knee with functional instability and osteoarthritis

Srikrishna Krishnan — 2009-12-17T00:00:00Z

Severe symptomatic osteoarthritis in young and active patients with pre-existing deficiency of the anterior cruciate ligament and severe functionally instability is a difficult subgroup to manage. There is considerable debate regarding management of young patients with isolated unicompartment osteoarthritis and concomitant ACL deficiency. A retrospective analysis of was done in 9 patients with symptomatic osteoarthritis with ACL deficiencies and functional instability that were treated with unicompartment knee arthroplasty and ACL reconstruction between April 2002 and June 2005. The average arc of flexion was 119° (range 85° to 135°) preoperatively and 125° (range 105° to 140°). There were no signs of instability during the follow up of patients. No patients in this group were reoperated. In this small series we have shown that instability can be corrected and pain relieved by this combined procedure.

Minimal stress shielding around a Mallory-Head titanium femoral stem with proximal porous plasma-sprayed coating in total hip arthroplasty

Bradley Ellison — 2009-12-09T00:00:00Z

Background: As longevity of cementless femoral components enters the third decade, concerns arise with long-term effects of fixation mode on femoral bone morphology. We examined the long-term consequences on femoral remodeling following total hip arthroplasty with a porous plasma-sprayed tapered titanium stem. Methods: Clinical data and radiographs were reviewed from a single center for 97 randomly selected cases implanted with the Mallory-Head Porous femoral component during primary total hip arthroplasty. Measurements were taken from preoperative and long-term follow-up radiographs averaging 14 years postoperative. Average changes in the proximal, middle and diaphyseal zones were determined. Results: On anteroposterior radiographs, the proximal cortical thickness was unchanged medially and the lateral zone increased 1.3%. Middle cortical thickness increased 4.3% medially and 1.2% laterally. Distal cortical thickness increased 9.6% medially and 1.9% laterally. Using the anteroposterior radiographs, canal fill at 100 mm did not correlate with bony changes at any level (Spearman's rank correlation coefficient of -0.18, 0.05, and 0.00; p value = 0.09, 0.67, 0.97). On lateral radiographs, the proximal cortical thickness increased 1.5% medially and 0.98% laterally. Middle cortical thickness increased 2.4% medially and 1.3% laterally. Distal cortical thickness increased 3.5% medially and 2.1% laterally. From lateral radiographs, canal fill at 100 mm correlated with bony hypertrophy at the proximal, mid-level, and distal femur (Spearman's rank correlation coefficient of 0.85, 0.33, and 0.28, respectively; p value = 0.001, 0.016, and 0.01, respectively). Conclusion: Stress shielding is minimized with the Mallory-Head titanium tapered femoral stem with circumferential proximal plasma-sprayed coating in well-fixed and well-functioning total hip arthroplasty. Additionally, the majority of femora demonstrated increased cortical thickness in all zones around the stem prosthesis. Level of Evidence: Therapeutic Level III.