Neglected volar subluxation of the metacarpophalangeal joint of the thumb: A case report

We present an 30 year-old female patient with a volar subluxation of the metacarpophalangeal joint of the thumb.Dislocation  of the metacarpophalangeal joint is rare ; volar subluxation is much more rare. Open reduction was performed through a dorsal incision because of the soft tissue interposition. Ultimately, doctors in the emergency department should pay attention to volar MCPJ subluxation and it is important to assess collateral ligament stability after closed reduction.

Effect of FMD vaccination schedule of dams on the level and duration of maternally derived antibodies

Vaccination against Foot and Mouth Disease (FMD) in pregnant cows is crucial to produce greater immunity in new born calves, especially in late gestation, as this directly affects neonatal immunity. Therefore, we aimed to investigate how late gestation FMD vaccination of pregnant cows affects the maternally derived antibodies in their offspring. Pregnant cows were vaccinated with and without booster vaccination during the 3rd months (early gestation vaccination, EGV) or the 6.5th months (late gestation vaccination, LGV). Their offspring were investigated for passive immunity transfer, maternal antibody duration, and the first vaccination age of calves (when the maternal antibody has waned sufficiently to allow the first vaccination). Antibody titers were analyzed by a virus neutralization test (VNT). A digital Brix refractometer (% Brix) was used to estimate passive antibody transfer efficiency measuring total protein (TP) content of calf blood sera and also colostrum IgG content. Two linear mixed effects models were fitted: one for the antibody titer values of the dams, and the other for the antibody titer values of calves before the vaccination. A marginal fixed effects model was also fitted to explore the effects of the dam titers on the antibody titers of the calves after their vaccinations. As a result, the average neutralizing antibody titers did not differ between the EGV and LGV groups nor were any differences detected between dams that received a booster and those that were not boosted. However, the LGV calves' mean maternally derived antibody titers were significantly higher (p-values = 0.0001 for both groups) and the duration was longer than that of the EGV calves (120 days in LGV, 60 days in EGV, p < 0.05). Since no statistical difference was found between the titers of either group of dams at the beginning of the experiment and parturition, it does not appear that the higher VN titers in LGV calves compared to titers in EGV are directly related to the circulating antibody levels in the dams. Furthermore, the TP value (% Brix) of calf blood sera was higher than>8.4% in both calf groups (9.3 ± 0.33 in LGV and 8.6 ± 0.40 in EGV, p > 0.05) indicating that passive immunity transfer had occurred for both groups. In addition, we found that the % Brix mean colostrum IgG content of the LGV (25.8 ± 1.30) was higher than the EGV (21.8 ± 0.58) dams (p < 0.01) and a significant positive correlation found between the colostrum density of LGV dams and TP (% Brix) value of their offspring (r = 0.73, p < 0.01). Our results show that vaccination during the late gestation period increased the colostrum IgG content of dams of LGV in addition to the maternally derived antibody duration and potentially provided greater protection of the offspring.

Treatment of osteonecrosis of the femoral head with free vascularized fibular grafting: results of 7.6-year follow-up

OBJECTIVE

The aim of this study was to determine long-term follow-up results of patients with femoral head osteonecrosis who were treated with free vascularized fibular grafting (FVFG).

METHODS

The results of 28 hips of 21 patients (16 male, 5 female) who underwent FVFG for treatment of osteonecrosis of the femoral head were retrospectively reviewed. Mean age of patients at time of surgery was 30.7 years (range: 15-53 years). Mean follow-up duration was 7.6 years (range: 5-9.2 years).

RESULTS

During follow-up, 1 patient died because of leukemia, and 1 patient was lost. The remaining 26 hips of 19 patients were evaluated. According to Ficat classification, at time of surgery, 17 hips were grade II, and 9 hips were grade III, 3 hips underwent total hip arthroplasty. Postoperative Harris Hip Score (HHS) in grade II disease was excellent in 12 patients, good in 3 patients, and fair in 1 patient. In grade III disease, 1 patient was excellent, 5 patients were good, and 1 patient was fair. There was a significant increase in HHS scores from preoperatively to postoperatively (61±9.7 vs 84±17.8, p<0.001).

CONCLUSION

FVFG yields extremely good results, particularly in pre-collapse stages of the disease in young patients. The operation time does not markedly increase if the surgical team is knowledgeable of the procedure and the residual fibular defect of the donor site does not impair functions of daily living.

Treatment of osteonecrosis of the femoral head with free vascularized fibular grafting: Results of 7.6-year follow-up

Objectives

The aim of this study was to determine long term follow up of the patients who had femoral head osteonecrosis and had been treated with free vascularized fibular grafting.

Patients and methods

We retrospectively reviewed 28 hips of 21 patients who had undergone free vascularized fibular grafting for the treatment of osteonecrosis of femoral head. There were 16 male and 5 female patients. The mean age of the patients at the time of surgery was 30.7 years (between 15 and 53 years). The mean follow-up time was 7.6 years (between 5 years and 9.2 years).

Results

During follow-up, one patient died because of leukemia, and one patient was lost. The remaining 26 hips of 19 patients were evaluated. According to the Ficat classification, at the time of surgery, 17 hips were in grade 2 and 9 hips were in grade 3. The post-operative Harris hip scores in grade II disease were excellent in 12 patients, good in 3 patients, and fair in 1 patient. In grade III disease, 1 patient was excellent, 5 patients were good, and 1 patient was fair. There was a significant increase in HHS scores (61 ± 9.7 vs 84 ± 17.8, p < 0.001).

Conclusion

Free vascularized fibular grafting yields extremely good results, particularly in pre-collapse stages of disease in young patients. The operation time does not mark increased if the surgical team is “familiar” with the procedure, and the residual fibular defect of the donor site does not impair the functions of daily living.

Level of Evidence

Level IV, Therapeutic study.

Firearm bullet settling into the lumbar spinal canal without causing neurological deficit: A report of two cases

BACKGROUND

Uncertainty still exists regarding the treatment of the patients presenting with gunshot wounds to the spine. Neurological insults, cerebrospinal fluid fistula, infection, lead or copper toxicity, migration of bullets, and spinal instability are included among the common challenging issues.

CASE DESCRIPTION

An 18-year-old woman was admitted with low back pain following a gunshot injury five days ago. She was neurologically intact. Radiological examinations showed that a bullet was settled in L4-5 disc space. The bullet was removed with a unilateral L4-5 partial hemilaminectomy and discectomy from the left side. The second case was of a 29-year-old man admitted with radiating leg pain on the right side following a gunshot injury from his left side of lower back four months ago. He had only positive straight leg raising test. Radiological studies showed two bullets, one was in the psoas muscle on the left side and the other was in spinal canal that had caused a burst fracture of the L5 vertebra. Following L5 laminectomy and bilateral L5-S1 facetectomy, the bullet was removed from the spinal canal and L5-S1 transpedicular posterior stabilization was performed. The postoperative period of both patients was unremarkable.

CONCLUSION

Bullet settling into the lumbar spinal canal without causing neurological deficit may require surgical intervention. Removal of bullets provided not only pain relief in both the cases but also prevented future complications such as migration of the bullets, plumbism, and neuropathic pain and instability.

Distraction lengthening of the proximal phalanx in distal thumb amputations

OBJECTIVE

Thumb amputation is a major cause of hand dysfunction, and the treatment for distal thumb amputations remains controversial. Although finger reconstruction methods using distraction lengthening are known to restore finger length and function, we found no reports in the literature regarding phalangeal lengthening in thumb amputations. We aimed to evaluate proximal phalangeal lengthening in thumb amputations at or near the interphalangeal (IP) joint.

METHODS

We retrospectively evaluated patients who had undergone distraction lengthening of the proximal phalanx of the thumb. All patients underwent osteotomy, either during the initial procedure or as a second-stage procedure. Distraction began 10 days after osteotomy with the use of an external fixator that remained in place until ossification of the gap occurred without bone grafting. Patients were evaluated using the QuickDASH score.

RESULTS

Fourteen patients with a mean age of 27 years and a mean follow-up period of 7 years were enrolled. The mean phalangeal lengthening achieved was 20 mm. Ossification occurred at all distraction sites, and the fixators were maintained for a mean of 85 days. The mean healing index was 42.5 days/cm. All 14 patients achieved the desired amount of phalangeal lengthening without major complications such as nonunion, premature union, or gross infection.

CONCLUSION

For reconstruction in cases of distal thumb amputations, distraction lengthening of the proximal phalanx can be used to improve absolute length, web space, and grip distance. The technique is safe and effective, improves functionality/cosmesis, and offers a low complication risk.

Annual trends in antibiotic resistance of nosocomial Acinetobacter baumannii strains and the effect of synergistic antibiotic combinations

Acinetobacter baumannii is becoming increasingly resistant to antibiotics often requiring combination therapy. Annual changes of resistance to selected antimicrobials of 150 A. baumannii strains, isolated as nosocomial pathogens between 1994 and 2000 were investigated. The synergistic effects of antimicrobials were studied using a microdilution checkerboard technique in eight selected isolates resistant to third-generation cephalosporins and beta-lactam/beta-lactamase inhibitor combinations and to at least one aminoglycoside. Rates of resistance of cefepime, ceftazidime, ampicillin/sulbactam, amikacin and ciprofloxacin (before 1996 and between 1996-2000) were 29.7% - 72.6, 37.8% - 81.4%, 35.1% - 72.6%, 8.1% - 56.6%, 5.4% - 46.0% respectively (p < 0.001 for each one). Synergy was observed in at least one of the combinations of antibiotics from seven of eight isolates (87%), no antagonism was detected with any combination. Ceftazidime-amikacin (50%) and ampicillin/sulbactam-tobramycin (50%) were the most effective combinations. Due to the effectiveness of sulbactams to Acinetobacter, ampicillin/sulbactam-tobramycin combination is recommended as the first line of choice.