Anatomical variation of abductor pollicis longus in Indian population: A cadaveric study

BACKGROUND

Many authors have reported the anatomical variation of abductor pollicis longus (APL) around the wrist and its association with de Quervain tenosynovitis (DQT), first carpo-metacarpal arthritis, and trapezio-metacarpal subluxation. From Indian subcontinent, there is only one original article and a few case reports on the variability of APL tendon insertion.

MATERIALS AND METHODS

Fifty formaldehyde preserved cadaveric wrists were dissected to look for the anatomical variation of APL in the Indian population.

RESULTS

The APL was found with single tendon in 2, double in 31, triple in 8, and quadruple in 8 extremities. A maximum of 6 tendon-slips were found in one cadaveric wrist. In all hands, the APL had at least one attachment to first metacarpal bone and in 46 hands (92%), there was second insertion to the trapezium bone. Of all tendon-slips of APL (n = 126), 44% of tendons (68 tendons) were inserted into the base of the first metacarpal bone. This was followed by the insertion into the trapezium in 42% tendons (52 tendons).

CONCLUSION

Bi-tendinous APL is commonly observed on the dorsal compartment of the wrist in Indian population and these tendon-slips are commonly attached to the first metacarpal base and trapezium. This variation must be understood by the Indian Orthopedic surgeons as the response to treatment of DQT and reason for first carpo-metacarpal arthritis can be dependent on this anatomical variation.

Nonunions and malunions of the pelvis

INTRODUCTION

Neglected pelvic fractures manifesting as pelvic nonunion or malunion are usually due to inadequate initial fixation or negligence of the injury because of increased attention towards other associated life-threatening conditions. The management of such injuries is complex. A systematic review was conducted to spot the clinical manifestations, evaluation, management and outcome of pelvic nonunion and malunion.

MATERIALS AND METHODS

Two databases ("Pubmed" and "Google scholar") were searched to look for relevant literature on pelvic non-union and malunion.  The search was limited to 'English language' and 'Human being'.

RESULTS

A total of 500 articles found, of which 10 articles were only reviewed which met the inclusion criteria. These articles discussed the clinical management and treatment of pelvic malunion and non-union following trauma without associated acetabular injury.

CONCLUSION

The usual presentations of pelvic non-union and malunion are pain, deformity, gait abnormality or instability. A detailed preoperative evaluation is essential as a majority of them have associated hip and spine injury which may be the cause of symptoms. Radiographs and 3D CT scans have helped surgeons in deciding the best way of management. The surgeries are usually complex and may need multiple-staged procedures. Soft tissue release, multiple osteotomies to achieve anatomical or near-anatomical reduction, augmentation of healing process using bone graft and stabilizing the nonunion/ osteotomy site using plates/screws/rods is the basic principle of surgery. Per-operative use of somato-sensory evoked potential evaluation helps the surgeon in preventing iatrogenic nerve injury. Despite these precautions and surgeries, most of the patients do not regain their preinjury functional activity.

Management of neglected acetabular fractures

Management of neglected acetabular fractures is a difficult task. Osteosynthesis in such cases may not be an ideal solution because of the femoral head damage due to pressure by the fractured acetabular edge, avascular necrosis, difficulty in mobilizing the fragments due to callus formation, difficulty in indirect reduction of the fracture fragments and macerated acetabular fragments all contributing to inadequate fracture reduction. Majority of such fractures are now treated with total hip replacement. While treating such fractures with THR, problems associated with neglected acetabular fractures such as fracture non-union, hip dislocation, protrusio, cavitary bone defect or peripheral bone defect must be considered. 3D computed tomography scan provides a clear view about the acetabular and periacetabular bony anatomy. Impaction grafting and antiprotrusio cage or ring with a cemented acetabular cup can address most of the hip protrusio and cavitary bone defects. Segmental bone defect needs cortical strut-bone graft fixation and subsequent implantation of a cemented or uncemented acetabular cup implantation. Fracture non-union needs approximate reduction and fixation with plates followed by bone grafting and implantation of an acetabular cup. Despite these efforts, the outcome of THR in neglected acetabular fracture is considerable worse than after conventional hip replacement.

Combined acromioclavicular joint dislocation and coracoid avulsion in an adult

Avulsion fracture of coracoid process with acromioclavicular joint dislocation is extremely rare. We report a case of coracoid avulsion with acromioclavicular disruption in a 24-year-old man who sustained injuries in a road traffic accident. Although acromioclavicular (AC) dislocation was obvious from an initial radiograph, coracoid avulsion was picked up in a CT scan. Open reduction and internal fixations of the coracoid with a 4 mm cannulated screw, an AC joint with two K-wires and an anchor suture, resulted in rapid recovery. The patient had complete range of shoulder movements at the end of 3 months and he resumed his professional activities. After 1 year, he had normal shoulder movement without any functional limitations.

WHOQOL-BREF Hindi questionnaire: Quality of life assessment in acetabular fracture patients

BACKGROUND

The incidence of acetabular fractures in India has increased over the past years but so has the operating skills of pelvi-acetabular trauma surgeons. The outcomes of surgical management need to be assessed so as to be able to devise proper treatment plan and execute the same during and after surgery, which in turn requires assessment of quality of life indices as well as functional scores. While there are studies assessing Harris Hip scores (HHS) and world health organization quality of life BREF (WHOQOL BREF) in the western population there is no study which assesses the same in Indian population. We designed this study to evaluate and define reference values for use of WHOQOL BREF Hindi scores in QOL Assessment in patients with acetabular fractures and to assess the relationship between it and HHS.

MATERIALS AND METHODS

118 patients with acetabular fractures who were treated surgically were included in this retrospective study. Assessment of reduction quality (Matta's radiological criteria), clinical outcome (HHS) and functional outcome (WHOQOL-BREF score) were done. The affect of age, gender, fracture displacement, hip dislocation, delay in surgery and associated injury on the clinical and functional outcome was evaluated.

RESULTS

The mean HHS was 90.65 (42-100) which showed an overall good to excellent outcome in 78.8% cases. WHOQOL-BREF Hindi score of domain-one was 63.06 ± 20.31 (13-94), of domain-two was 58.22 ± 19.57 (13-100), of domain-three was 70.49 ± 17.92 (13-100) and of domain-four was 64.48 ± 18.46 (13-100), which showed significant functional deficit in domain-one (P = 0.0001) and domain-two (P = 0.0001) but not in domain-three (P = 0.458) and domain-four (P = 0.722) when compared to score of general healthy population. The domain scores of general population norms were achieved in 59.3%, 61.9%, 69.5% and 66.1% cases in domain one, two, three and four respectively.

CONCLUSIONS

Based on these results one can conclude that WHOQOL-Hindi questionnaire is good enough for assessment of QOL in addition to clinical measures in acetabular fracture patients.

Endocrine alterations in HIV-infected patients

AIMS AND OBJECTIVES

To study the frequency of thyroid, adrenal and gonadal dysfunction in newly diagnosed HIV-infected patients and to correlate them at different levels of CD4 cell counts.

MATERIALS AND METHODS

Forty-three HIV-positive cases were included in the study group. Cases were divided into three groups on the basis of CD4 cell count. Serum free T3, free T4, TSH, Cortisol, FSH, LH, testosterone and estradiol were estimated by the radioimmunoassay method. Hormone levels between cases were compared and their correlation with CD4 count was analyzed.

RESULTS

Prevalence of gonadal dysfunction (88.3%) was the most common endocrine dysfunction followed by thyroid (60.4%) and adrenal dysfunction (27.9%). Secondary hypogonadism (68.4%) was more common than primary (31.6%). Low T3 syndrome, that is, isolated low free T3, was the most common (25.6%) thyroid dysfunction followed by secondary hypothyroidism (16.2%) and subclinical hypothyroidism (11.6%). Adrenal excess (16.3%) was more common than adrenal insufficiency (11.6%). The difference in hormonal dysfunction between male and female was statistically insignificant (P > 0.05). 27.9% of patients had multiple hormone deficiency. There was negligible or no correlation between CD4 count and serum hormone level.

CONCLUSION

In our study, endocrine dysfunction was quite common among HIV-infected patients but there was no correlation between hormone levels and CD4 count. Endocrine dysfunctions and role of hormone replacement therapy in HIV-infected patient needs to be substantiated by large longitudinal study, so that it will help to reduce morbidity, improve quality of life.

Management of femoral head osteonecrosis: Current concepts

Osteonecrosis of femoral head (ONFH) is a disabling condition of young individuals with ill-defined etiology and pathogenesis. Remains untreated, about 70-80% of the patients progress to secondary hip arthritis. Both operative and nonoperative treatments have been described with variable success rate. Early diagnosis and treatment is the key for success in preserving the hip joint. Once femoral head collapses (>2 mm) or if there is secondary degeneration, hip conservation procedures become ineffective and arthroplasty remains the only better option. We reviewed 157 studies that evaluate different treatment modalities of ONFH and then a final consensus on treatment was made.

Psychogenic limp in a child: are we aware of it?

A 10-year-old child presented with a limp for 9 months. The child was keeping his right knee extended and foot in the equinus position. The child had been investigated by numerous laboratory investigations and imaging procedures during the initial 9 months, but no organic cause was found. Without any conclusive diagnosis, the child was being managed by physical therapy. During examination in our clinic, the variable contraction of the quadriceps muscle raised the possibility of a psychiatric disorder. A psychiatrist's opinion was sought and the child was found to have dissociative motor disorder. His conflict was identified and treated by cognitive behavioral therapy. The child walked normally after 1 week. A psychogenic limp is often not suspected by the orthopedic surgeon in the evaluation of a limp. The involvement of a psychiatrist in this evaluation may be helpful to identify the condition easily and even at the first instance.

Tuberculous altantoaxial subluxation: a case report with review of literature

Involvement of upper cervical and craniovertebral junction is rare but might lead to lethal consequences if the diagnosis is delayed. We present a case of atlantoaxial joint tuberculosis, resulting in gross instability of the joint. The patient was treated with antitubercular medication combined with posterior decompression and transarticular screw fixation. Patient improved neurologically, and clinical and radiological improvements were maintained at the latest follow-up of 2 years.

Predictors of postoperative outcome for acetabular fractures

BACKGROUND

The outcomes of surgically treated acetabular fractures are dependent on many factors. The purpose of this retrospective study is to evaluate these factors in a group of patients operated on by a single surgeon in one institute.

METHODS

One hundred and eighteen patients, treated surgically for their displaced acetabular fracture and who had completed two years follow-up, were evaluated clinically with Modified Postel Merle d'Aubigné score and radiologically with Matta's radiological outcome grading. The effect of age (≤ 55 or >55 years), gender, fracture displacement (≤ 20mm or >20mm), hip dislocation, delay in surgery (≤ 2 weeks or >2 weeks), associated injury and length of follow-up (≤ 5 years or >5 years) on the functional outcome was evaluated.

RESULTS

There were 99 (83.9%) males and 19 (16.1%) females with mean age of 38.75 years (16 to 65 years). The mean duration of follow-up was 3.95 years (range 2 to 14 years). The mean Modified Postel Merle d'Aubigné score was 15.7 ± 2.2 (range, 8 to 18). The clinical outcome was excellent in 27 (22.9%), good in 52 (44.2%), fair in 20 (16.9%), and poor in 19 (16.1%, 10 patients who underwent THR for secondary arthritis were considered as poor outcome) patients. The Modified Postel Merle d'Aubigné score was significantly affected by quality of reduction (P=0.0001), presence of associated injuries (P=0.0001), initial fracture displacement of >20mm (P=0.018), joint dislocation (P=0.015) and delay in surgery (P=0.001). However, age, gender, fracture type and length of follow-up did not have any effects on the clinical outcome.

CONCLUSION

Poor reduction, associated injuries, fracture displacement of >20mm, joint dislocation and late surgery definitely carry poor prognosis in predicting the outcome of surgically treated acetabular fractures.

Modified valgus osteotomy of the femoral neck for late presenting femoral neck stress fractures in military recruits

Neglected or late presenting femoral neck stress fractures are often associated with varus deformity, with potential risks of nonunion and osteonecrosis. We proposed a surgical technique whereby a wedge osteotomy was performed at the basal part of the neck, on the tensile surface, keeping the inferomedial femoral neck as a hinge. The femoral shaft was abducted to close the osteotomy site and it was fixed with three cannulated cancellous screws. Three military recruits who presented with neglected femoral neck stress fracture with varus deformity were operated on with the proposed modified femoral neck valgus osteotomy. All the fractures united without any complications and the patients resumed their professional activity.

Correlation between the forearm plus little finger length and the femoral length

PURPOSE. To assess the correlation between the forearm plus little finger length and the femoral length in 100 volunteers. METHODS. The forearm plus little finger length and the ipsilateral femoral length of 68 male and 32 female volunteers aged 19 to 55 (mean, 35.8) years were measured using a measuring tape. The forearm plus litter finger length was measured from the tip of the olecranon to the tip of the little finger, whereas the femoral length was measured from the tip of the greater trochanter to the level of proximal pole of the patella over the outer aspect of thigh. Two observers made the measurements on 2 separate occasions. Intra- and inter-observer variations were calculated. A value of 0.75 or greater indicated excellent agreement. RESULTS. The mean forearm plus little finger length and femoral length were 39.87 (SD, 2.73) and 39.85 (SD, 2.44) cm, respectively. The mean difference between these 2 measurements was 0.028 (95% CI, -0.109 to 0.165) cm. The correlation between these 2 measurements was 0.861 (p<0.001). Patient age, sex, and body mass index did not affect this correlation. The intra- and inter-observer reliability was excellent. CONCLUSION. The forearm plus little finger length correlated with the femoral length. This method is simple, radiation-free, and can be applied in day-today practice.

Local distal radius bone graft versus iliac crest bone graft for scaphoid nonunion: a comparative study

The aim of the study is to find whether there is any superiority of the iliac crest bone graft over the distal radius bone graft, in surgery of nonunion of scaphoid fractures. This is a prospective randomized controlled trial comparing 50 patients treated with internal fixation and distal radius bone graft (group 1) and 50 patients in whom iliac crest bone graft was used instead (group 2). The patients donor site pain in the postoperative period was assessed using visual analogue scale. At each follow-up, each patient was evaluated using Quick DASH score and Mayo's scoring system. Minimum follow-up was 3 years. Mean value of visual analogue scale for pain was 7.1 for group 2 and 4.2 for group 1. There was no statistically significant difference between the two groups in terms of range of wrist joint motion, functional scores, union rate and fracture reduction. There is no advantage of the iliac crest over the distal radius graft to justify its greater morbidity.

Clinical and radiological outcome of percutaneous plating in extra-articular proximal tibia fractures: a prospective study

BACKGROUND

Despite various techniques of fixation, proximal tibia fractures are associated with poor outcome and increased rates of complications. Minimal access and rigid fixation are the keys for optimal outcome in such fractures. Therefore, this study was designed to look for the clinical and radiological outcomes of percutaneous locked plating (PLP) in extra-articular proximal tibia fracture.

METHODS

Between April 2008 and September 2010, 47 consecutive patients with 49 proximal third extra-articular tibial fractures (29 closed and 20 open injuries) underwent PLP. The patients were followed up at 6 weeks, 3 months, 6 months and 1 year. The union rate and complications of this fixation were evaluated. The clinico-radiological outcomes were assessed at 1 year of surgery.

RESULTS

Four patients had infection in the postoperative period which needed repeated debridement, gentamycin bead application and prolonged antibiotic therapy. Three of these infective cases ended up with nonunion and needed cancellous bone grafting. All the remaining fractures united. The average time for union was 20 weeks in closed and type I open fracture and 25 weeks in type II and III fractures. No neurovascular injury, hardware failure or loss of fixation was documented till the last follow-up. The mean range of knee joint movement was 119°. The average lower extremity functional score (LEFS) was 59 (74%). There were 10 cases of malunion (20.14%), with six varus/valgus and five procurvatum/recurvatum (one having both sagittal and coronal malunion) angulations. There were no statistical differences between patients with malunion and normal alignment with regard to knee range of motion and LEFS.

CONCLUSION

Minimally invasive osteosynthesis using PLP in extra-articular proximal tibia fractures showed a promising result with minimal complications.

Role of interleukin-6 as an early marker of fat embolism syndrome: a clinical study

BACKGROUND

A few animal studies have shown that IL-6 can serve as an early marker of fat embolism syndrome. The degree to which this is true in human trauma victims is unknown.

QUESTIONS/PURPOSES

In this clinical study, we sought to determine (1) whether elevated serum IL-6 levels at 6, 12, and 24 hours in patients with skeletal trauma were associated with the development of fat embolism syndrome (FES) within 72 hours after injury, and (2) at what time after trauma peak IL-6 levels are observed.

METHODS

Forty-eight patients between 16 and 40 years old who presented to our tertiary trauma center within 6 hours of injury with long bone and/or pelvic fractures were included in this study. Serum IL-6 levels were measured at 6, 12, and 24 hours after injury. The patients were observed clinically and monitored for 72 hours for development of FES symptoms. Gurd's criteria were used to diagnose FES.

RESULTS

Elevated serum IL-6 levels 12 hours after trauma correlated with an increased likelihood of having FES develop; no significant relationship was observed between IL-6 levels at 6 or 24 hours and the development of FES. Patients with FES had a mean IL-6 level of 131 pg/mL, whereas those without FES had a mean IL-6 level of 72 pg/mL. Peak IL-6 levels were observed at 12 hours.

CONCLUSIONS

An elevated serum IL-6 level may be useful as an early marker of FES in patients with isolated skeletal trauma.

LEVEL OF EVIDENCE

Level II, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

Neglected Hoffa fracture in a child

The clinical presentations and surgical outcome of a 4-month-old Hoffa fracture in a 12-year-old child are reported. The child presented with chronic pain, swelling and instability in the right knee joint. Lateral radiograph showed a small bone fragment on the posterior condyle, which raised the possibility of a fracture. Computed tomographic scan and MRI clearly delineated the coronal plane fracture of the lateral femoral condyle that had spared the physeal cartilage. The fracture was accessed through the posterolateral approach to the knee; the fragment was anatomically reduced and fixed with two partially threaded cancellous screws. Radiographic union was observed after 3 months, and after 2 years of follow-up, the child had excellent functional outcome.

Femoral head chondrosarcoma causing femoroacetabular impingement in an adult professional football player

Femoroacetabular impingement (FAI) is often diagnosed as a cause of hip pain in athletes. Benign tumorous conditions presenting with FAI symptoms have been described in the literature, but there is no mention of any malignant lesion causing impingement. We report the case of a femur head chondrosarcoma in a 23-year-old professional football player who presented with FAI symptoms. Magnetic resonance imaging of the hip showed a bumpy outgrowth (hyperintense T2-weighted signal) from the anteroinferior portion of the femoral head without any signal changes in the rest of the head or in the hip joint. Clinical, laboratory, and radiologic findings remained inconclusive regarding a specific diagnosis. The lesion was excised through an anterior approach to the hip. Histologic evaluation of the specimen revealed an undifferentiated chondrosarcoma. Six months after surgery, the patient, completely free of pain and impingement symptoms, resumed his sports activity. At 3-year follow-up, there was no limitation in activity, and there was no evidence of tumor recurrence. Although rare, bony malignant conditions of the hip can present with FAI symptoms and a complete radiologic evaluation is warranted prior to any surgical intervention.

Four quadrant parallel peripheral screw fixation for displaced femoral neck fractures in elderly patients

BACKGROUND

The treatment options for displaced femoral neck fracture in elderly are screw fixation, hemiarthroplasty and total hip arthroplasty based primarily on age of the patient. The issues in screw fixation are ideal patient selection, optimal number of screws, optimal screw configuration and positioning inside the head and neck of femur. The problems of screw fixation may be loss of fixation, joint penetration, avascular necrosis of femoral head, nonunion, prolonged rehabilitation period and the need for second surgery in failed cases. We hereby present results of a modified screw fixation technique in femoral neck fractures in patients ≥50 years of age.

MATERIALS AND METHODS

Patients ≥50 years of age (range 50-73 years) who sustained displaced femoral neck fracture and fulfilled the inclusion criteria were enrolled in this prospective study. They were treated with closed reduction under image intensifier control and cannulated cancellous screw fixation. Accurate anatomical reduction was not aimed and a cross sectional contact area of >75% without varus was accepted as good reduction. Four screws were positioned in four quadrants of femoral head and neck, as parallel and as peripheral as possible. Radiological and functional results were evaluated periodically. Sixty four patients who could complete a minimum followup of two years were analyzed.

RESULTS

Radiologically, all fractures healed after mean duration of 10 weeks (range 8-12 weeks). There was no avascular necrosis. Nonanatomical healing was observed in 45 cases (70%). All patients except one had excellent functional outcome and could do cross-legged sitting and squatting. Chondrolysis with progressive head resorption was seen in one case, which was converted to total hip arthroplasty.

CONCLUSION

Closed reduction and cannulated cancellous screw fixation gives satisfactory functional results in large group of elderly patients. The four quadrant parallel peripheral (FQPP) screw fixation technique gives good stability, allows controlled collapse, avoids fixation failure and achieves predictable bone healing in displaced femoral neck fracture in patients ≥50 years of age.