Comparison between suprapatellar and parapatellar approaches for intramedullary nailing of the tibia. Cadaveric study

Intramedullary nailing is one viable option for treating fractures of the tibia with a short, proximal segment. For a procedure being carried out with the knee in a semi-extended position, either a suprapatellar or parapatellar approach may be used. The objective of this study is to demonstrate whether the entry point for tibia nails is obtainable through suprapatellar or parapatellar approaches and to evaluate the most frequent injuries of the knee with these two approaches.Materials and methodsPaired legs from 10 fresh frozen cadavers were used. An arthroscopy was performed in each knee, documenting the status of the knee prior to the insertion of the tibia nail. In a random manner, the left or right leg underwent nailing with a suprapatellar or parapatellar approach in a semi-extended position. Fluoroscopy was utilized in each case to localize the entry point, and a tibia nail was inserted in all cases. A knee arthrotomy was then performed and the status of the following structures was assessed: patella and trochlea cartilage, tibia plateau cartilage, inter-meniscal ligament, lateral and medial meniscus, and the ACL.ResultsThe correct fluoroscopy entry point was achieved in all of the specimens (20). Three legs (3/10) with parapatellar approach had intra-articular disruption. In legs with a suprapatellar approach, patellar cartilage and trochlea cartilage damage was found in two of the specimens, respectively. There was one specimen with cartilage damage in the parapatellar approach. There were no meniscal injuries. Partial laceration of the intermeniscal ligament was found in three of the knees for each approach. One ACL injury was found in the suprapatellar group. Mean distance from the entry point to major structures is not significantly different with either approach. (p = 0.45).ConclusionsA good fluoroscopic entry point can be achieved using either the parapatellar or suprapatellar approach. The parapatellar approach for tibia nailing has similar rate of soft tissue damage compared to the suprapatellar approach. The suprapatellar approach damaged the cartilage in one-third of the cases and if cartilage injury occurs with the parapatellar approach, this is located in a low risk area.     

Intra-operative fluoroscopy time and radiation dose during suprapatellar tibial nailing versus infrapatellar tibial nailing

BackgroundFractures of the tibial shaft are routinely managed with intramedullary nailing. An increasingly accepted technique is the suprapatellar extended leg method. The aim of this study was to investigate whether the suprapatellar tibial nailing technique offers shorter intraoperative fluoroscopy times and lower radiation doses when compared to the traditional infrapatellar technique.Study design and methodsData from 200 consecutive intramedullary tibial nailing operations in our level 1 Major Trauma Centre were retrospectively collected from a prospective database (January 2014–December 2017). Only acute diaphyseal nailing procedures were included. The operations were performed by seven senior trauma consultants experienced in both suprapatellar and infrapatellar tibial nailing. The operations were divided into two groups: infrapatellar and suprapatellar. Intraoperative radiation time and dose data were collected.ResultsA total of 90 cases were included and analysed. The majority of the patients were male (82%). 37 operations were infrapatellar and 53 were suprapatellar. Independent samples t-test revealed lower radiation time and dose for the suprapatellar group. The infrapatellar group had a mean radiation time of 129.7 ± 56.6 s versus 94.4 ± 47.9 s for the suprapatellar group. The infrapatellar group had a mean radiation dose (Dose Area Product) 53.6 ± 34.2 cGY cm² versus 38.2 ± 26.7 cGY cm² for the suprapatellar group. The difference in mean radiation time and mean radiation dose were both significant (p = 0.002 and p = 0.02 respectively).ConclusionsSuprapatellar tibial nailing is an increasingly accepted technique in the management of tibial fractures. It is shown here that amongst surgeons experienced in both suprapatellar and infrapatellar nailing techniques, the suprapatellar approach trends towards lower use of intra-operative fluoroscopy as measured by time and dose and thus potentially lower radiation exposure to the operating surgeon, assistants and patient.     

Distal locking in short hip nails: Cause or prevention of peri-implant fractures?

ObjectivesThe most common cause of femoral fractures after osteosynthesis of trochanteric fractures with short nails is weakening of the femoral cortex via distal locking and stress concentrations at the tip of the nail. The aim of the study was to verify whether the incidence of peri-implant fractures is dependent upon the distal locking technique.MethodsWe prospectively analysed a group of 849 pertrochanteric fractures (AO/ASIF 31-A1 + 2) managed with short nails from 2009 to 2013. Unlocked nailing was performed in 70.1% and distal dynamic locking was performed in 29.9%. The mean age was 82.0 years. Peri-implant fractures were divided into 3 groups according to the height of the fracture in relation to the tip of the nail.ResultsIn total 17 fractures (2.0%) were detected. One peri-implant fracture occurred after locked nailing, whereas 16 cases occurred after unlocked nailing (p = 0.037). Patients without distal locking had an 85.7% greater risk of peri-implant fracture. Fractures of the proximal femur (Type I) occurred significantly earlier than fractures at the tip of the nail (Type II) (p = 0.028).ConclusionUnlocked nails do not guarantee sufficient stability. Distal locking serves to prevent postoperative femoral fractures. We recommend the routine use of distal locking when utilizing short nails.     

Is device-assisted reduction prior to semi-extended intramedullary nailing of distal tibial fractures necessary?

IntroductionTraditional methods of nailing distal tibial fractures have an unacceptable risk of mal-alignment due to difficulty in obtaining and maintaining reduction intra-operatively. Methods to obtain and maintain reduction when nailing these fractures, and therefore reducing the risk of Mal-alignment include modified external fixators, distractors and commercial reduction tools. Semi-extended intramedullary nailing of distal tibial fractures via a supra-patellar approach is now being used more commonly. The aim of this study was to assess whether a commercial reduction device (Staffordshire Orthopaedic Reduction Machine − STORM, Intelligent Orthopaedics, Stafffordshire, UK) is necessary to reduce the risk of mal-alignment in patients undergoing semi-extended nailing for distal tibial fractures.MethodologyA case-control study was conducted in 20 patients who had STORM-assisted reduction of distal tibial fractures prior to intramedullary nailing and 20 controls without STORM. The control group was matched for age, sex, fracture type (AO/OTA), ASA and gender. All patients had an intramedullary nail (IMN) using the semi-extended system. Primary outcome measures were coronal and sagittal mal-alignment. Secondary outcome measure was unplanned return to theatre for complications and problems with fracture healing.ResultsThere was no difference in post-operative mal-alignment in both groups. There was no significant difference in time to union in both groups Both groups had equal number of patients requiring unplanned return to theatre. The STORM group was associated with a significantly increased operative time [p = 0.007, 130.3 min (SD 49.4) STORM vs 95.6 mins (SD 22.9) Control].ConclusionIntraoperative use of STORM significantly increases operative time with no difference in outcome. The superior orthogonal views and manual control obtained during semi-extended nailing via a supra-patellar approach obviate the need for additional methods: of intraoperative reduction for this fracture group.     

Efficacy of knee joint aspiration in patients with acute ACL injury in the emergency department

PurposeTo evaluate the influence of joint aspiration on the sensitivity of physical examination for diagnosing acute anterior cruciate ligament (ACL) lesion in the second outpatient-department (OPD) follow-up referred from emergency department (ED).MethodsThis retrospective study included sixty patients underwent ACL reconstruction with initial visit at ED. They were divided into two groups based on the presence or absence of joint aspiration at ED. All participants were referred to second OPD follow-up within 7–14 days after the injury. Clinical manifestation (including visual analogue scale (VAS) for pain, range of motion (ROM), and severity of knee effusion) and physical examination (Lachman test and pivot shift test) were checked in ED and the second OPD follow-up.ResultsThe group of patients with joint aspiration (G1) showed substantial decreases in mean values of VAS for pain (p = 0.005), ROM (p = 0.001), and effusion level (p < 0.001), even higher VAS and effusion level and lower ROM at the initial visit of ED than the other group (G2). The sensitivity of positive Lachman and pivot shift test was significantly (p < 0.05) increased following knee joint aspiration. Positive Lachman test was recorded at 76.5% in the second follow-up in G1, which was significantly (p = 0.047) higher than that (47.6%) in G2. The percentage of positive pivot shift test was recorded at 76.5% in the second follow-up in G1, which as significantly (p < 0.001) higher than that (31.0%) in G2.ConclusionsKnee joint aspiration in acute ACL injury with suspected hemarthrosis could be considered as a diagnostic procedure. Joint aspiration in early medical attendance might be able to lower pain scores or raise the sensitivity of physical examination for diagnosing acute ACL injury at follow up visit in orthopedic outpatient department.Level of evidenceRetrospective cohort study III.     

External versus internal fixation for arthrodesis of chronic ankle joint infections — A comparative retrospective study

BackgroundArthrodesis of the ankle is a salvage procedure in case of chronic ankle joint infection. External fixation still is the gold standard.We compared the outcome of external fixator versus intramedullary nailing for arthrodesis of the infected ankle joint.MethodsAll patients with ankle joint infection who received arthrodesis with either external fixator or intramedullary nail between 08/2009 and 09/2017 were retrospectively analyzed. Endpoints were the successful control of infection, osseous fusion, and mobilization with full weightbearing.ResultsSeventy-one patients were included. Nineteen patients (27%) suffered reinfection. Patients with intramedullary nailing showed significantly fewer reinfections (p = 0.019), achieved full weightbearing significantly more often (p = 0.042) and faster and developed significantly fewer complications (p < 0.001). Forty-three patients showed bone fusion without significant differences between the groups.ConclusionsAnkle arthrodesis with intramedullary nailing appears to be a successful alternative to the established procedure of external fixation in cases of chronic ankle joint infection.     

Treadmill versus overground gait training in patients with lower limb burn injury: A matched control study

IntroductionGait impairment is commonly seen in patients with a lower limb burn injury (LLBI). Therefore, the aim of this study was to investigate the effects of two different gait training modes on gait symmetry, functional mobility and kinesiophobia in patients with LLBI.MethodsThis matched control study was conducted between January 2017 and August 2018. Patients with LLBI (n = 28) were allocated to 2 different groups by matching according to burn localization, age, and gender. Group 1 (overground group: n = 14) received overground gait training in addition to standard burn rehabilitation, and Group 2 (treadmill group: n = 14) received treadmill gait training in addition to standard burn rehabilitation. The rehabilitation program and gait training were started when the patient was admitted to the hospital and ended on discharge. These physical therapy interventions were performed 5 days per week. The gait training intensity, including walking speed and duration, was determined according to patient tolerance. Gait parameters, functional mobility, kinesiophobia and pain values were evaluated with GAITRite, the timed up-and-go test (TUG), Tampa Kinesiophobia Scale and Visual Analogue Scale, respectively. These evaluations were made twice; on admission and immediately prior to discharge. Gait symmetry was calculated using the Symmetry Index.ResultsThe baseline characteristics of the groups and initial outcome values were similar. In the comparison of the differences between the overground and treadmill groups, the change in kinesiophobia and TUG values were significantly higher in the treadmill group (p = 0.01, p = 0.02, respectively). The intragroup comparisons showed significant differences in SI in respect of step length (p = 0.004), swing (p = 0.006), stance (p = 0.008) and velocity (p = 0.001), cadence (p = 0.001), TUG (p = 0.001), kinesiophobia (p = 0.001) and pain (p = 0.001) in the overground group. Statistically significant differences were determined in step length (p = 0.01), swing (p = 0.01), stance (p = 0.02) and velocity (p = 0.001), cadence (p = 0.001), TUG (p = 0.001), kinesiophobia (p = 0.001) and pain (p = 0.001) in the treadmill group, when pre and post-training values were compared.ConclusionsThe results of this study have shown that treadmill gait training was more effective in the improvement of functional mobility and reduction in kinesiophobia levels of patients with LLBI compared to overground gait training. Both overground and treadmill gait training also provide greater improvements in the velocity and cadence, and gait symmetry for step length, swing and stance in patients with LLBI.Clinical trial registration numberNCT03217526.     

Return to duty following combat-related multi-ligamentous knee injury

IntroductionThis retrospective cohort study characterized injury patterns, treatment practices, and identified the return to duty (RTD) rate following combat-related multi-ligament knee injuries (MLKI).Patients and methodsWe evaluated injury characteristics and treatment methods of 46 military service members who had sustained a MLKI during combat activity. The primary clinical outcome measure was ability to return to active military duty. Secondary outcomes included subjective pain score, knee motion, knee instability, and use of ambulatory assistive device.ResultsThe RTD rate was 41% (19/46). High-energy mechanism, neurovascular injury, compartment syndrome, traumatic knee arthrotomy, and intra-articular femur fracture (Orthopedic Trauma Association Classification (OTA) 33-B/C) were all more prevalent in subjects who were unable to return to duty (p < 0.05). Acute external fixator application and poor knee range of motion (ROM) were also associated with military separation (p = 0.041 and p = 0.016, respectively). The most common ligament injury pattern (n = 9; 20%) was combined disruption of the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), posterolateral corner (PLC), and medial collateral ligament (MCL). However, number of ligaments injured was not associated with RTD status.ConclusionMLKIs sustained in a combat setting have a high incidence of associated lower extremity injuries. Certain associated injuries, such as intra-articular femur fracture, knee arthrotomy, neurovascular injury, and compartment syndrome may be more important than the severity of the knee ligamentous injury in determining RTD outcome.     

Treatment of shoulder calcifications of the cuff: A controlled study

ObjectivesAbout 1 in 10 patients with shoulder calcifications complains of chronic pain. Removal techniques have been developed. We carried out the first randomized study to validate bursoscopy (BS) and (needling fragmentation irrigation) (NFI) versus a control group (CT).Methods102 shoulders (96 patients) with calcifications >5 mm whose medical treatment had failed (>4 months) were first injected using a corticosteroid; 49 shoulders improved by more than 70%. The other 53 shoulders were randomized in 3 groups: NFI (n = 16), BS (n = 20), and CT (n = 17). All patients were reviewed at T 1–4–12–24 months.ResultsAfter 4 months, we observed respectively in groups NFI – BS – CT: 62%, 65% and 29% patients showing global improvements >70% (NFI vs CT: p = 0.03; BS vs CT: p = 0.02); ?37%, ?29% and ?11% pain VAS variation (ns), +16%, +12% and ?15% Constant score variation (NFI vs CT: p = 0.03; BS vs CT: p = 0.02), and ?58%, ?77% and +4% area calcification variation (NFI vs CT: p = 0.005; BS vs CT: p = 0.0002; BS vs NFI: p = 0.01). After 24 months, results were maintained in NFI and BS groups, and in the CT group only 6/17 patients were still improved. There were no significant differences between NFI and BS groups. Three partial tears of the cuff were found using MRI in failures, (1 in each group).ConclusionNFI and BS are now validated removal techniques of shoulder calcifications when there is chronic pain and other medical treatments have failed. Results were maintained after 24 months, and were similar between NFI and BS. However NFI could be preferred because of its simplicity and low cost.     

The effect of foot reflexology massage on burn-specific pain anxiety and sleep quality and quantity of patients hospitalized in the burn intensive care unit (ICU)

BackgroundBurn-specific pain anxiety and sleep disorders are common factors in burned patients that affect wound healing process, as well as the severity of burn pain. This study aimed to investigate the effect of foot reflexology massage on burn-specific pain anxiety and sleep condition of patients hospitalized in the burn ICU.MethodIn this randomized controlled clinical trial, 52 patients were assigned by permuted block randomization 1:1 to the intervention (n = 26) and control (n = 26) groups. The intervention group received 20 min of foot reflexology massage during 3 days on their third, fourth and fifth days of hospitalization and 15 min before changing wound dressings. Patients in the control group merely received routine care. The Burn-Specific Pain Anxiety Scale (BSPAS) was completed for three consecutive days before and after changing wound dressings, and St. Mary's Hospital Sleep Questionnaire (SMHSQ) was filled out for four consecutive days before changing wound dressings for patients in both groups. The data were analyzed by IBM SPSS 16 software, Chicago, independent t, Chi-square, Friedman, Mann–Whitney and Wilcoxon tests.FindingsWe found no significant difference between pain-anxiety in the two groups before the intervention. The trend of different days in each groups were compared with Friedman test and showed that pain anxiety (p < 0.001), sleep latency (p < 0.001), duration of the last day's sleep (p < 0.001) and satisfaction of the last night sleep (p < 0.001) had a significant difference. In addition, Mann–Whitney test results showed that there were significant differences between the two groups at different times in terms of the above variables (p < 0.05). The effect size was = 0.82 for pain anxiety between group after the intervention.ConclusionBased on the results, foot reflexology massage can effectively reduce pain anxiety levels and improve sleep quality and quantity of patients with burn injuries; therefore, this non- pharmacological therapeutic method is recommended to be used in the burn ICUs. (Clinical trial’s registration code: IRCT20110906007494N27)     

Randomised Controlled Trial Comparing Sapheno-Femoral Ligation and Stripping of the Great Saphenous Vein with Endovenous Laser Ablation (980 nm) Using Local Tumescent Anaesthesia: One Year Results

ObjectivesComparison of sapheno-femoral ligation and stripping (SFL/S) versus endovenous laser ablation (EVLA, 980-nm) in the treatment of great saphenous vein (GSV) insufficiency, using local tumescent anaesthesia.DesignRandomised, single centre trial.Materials and methodsPatients with GSV incompetence and varicose veins were randomised to either SFL/S or EVLA. At days 1, 2, 3, 7, 10, and 14 post-treatment, patients completed questionnaires on pain and quality of life. Recurrent varicose veins were evaluated by Duplex ultrasound (DUS) performed at 1 and 6 weeks, and 6 and 12 months.Results130 legs in 121 patients were treated by SFL/S (n = 68) or EVLA (n = 62). Significantly more post-treatment pain was noted after EVLA at days 7, 10 and 14 (p < 0.01; p < 0.01; p = 0.01), more hindrance in mobility at days 7 (p < 0.01) and 10 (p = 0.01), and in self care (p = 0.03) and daily activities (p = 0.01) at day 7 compared to SFL/S. DUS at 1-year follow-up showed 9% recurrences (5/56) after EVLA and 10% (5/49) after SFL/S.ConclusionBoth SFL/S and EVLA, using local tumescent anaesthesia, were well tolerated, with no difference in short-term recurrence rate. In the second week after EVLA, patients experienced significantly more pain resulting in restricted mobility, self care and daily activity compared to SFL/S.     

Assessment of foot posture: Correlation between different clinical techniques

BackgroundClinical evaluation of foot posture is necessary for assessing and treating patients with lower extremity dysfunction. Although several studies have explored the reliability and validity of different clinical techniques for the measurement of foot posture, there is limited research in studies investigating whether two or more such techniques correlate with each other.ObjectivesTo explore the correlations between the valgus and arch index measurements with the measurements of the navicular drop and drift in bipedal and single-leg stance.MethodsClinical measurements of the valgus index, the arch index, the navicular drop and drift were performed on the left foot of 26 healthy subjects in bipedal and in single-leg stance with 30° knee flexion.ResultsThe valgus index yielded moderate to strong correlations with the measurement of navicular drop (bipedal: r = 0.657, p < 0.001; single-leg stance: r = 0.613, p = 0.001) and small correlations with navicular drift (bipedal: r = 0.481, p = 0.13; single-leg stance: r = 0.335, p = 0.094). The arch index demonstrated small correlations with the navicular drop and drift in both bipedal and single-leg stance (r = 0.317-0.428, p = 0.115–0.029).ConclusionsAlthough strong associations were obtained between the valgus index and the navicular drop, all other correlations demonstrated low degrees of association. Further research should explore the association of these clinical measurements in patients with foot/lower limb impairments.     

Trochanteric entry femoral nails yield better femoral version and lower revision rates—A large cohort multivariate regression analysis

IntroductionIntramedullary nailing (IMN) has become the standard of care for the treatment of most femoral shaft fractures. Different IMN options include trochanteric and piriformis entry as well as retrograde nails, which may result in varying degrees of femoral rotation. The objective of this study was to analyze postoperative femoral version between three types of nails and to delineate any significant differences in femoral version (DFV) and revision rates.Materials & methodsOver a 10-year period, 417 patients underwent IMN of a diaphyseal femur fracture (AO/OTA 32A-C). Of these patients, 316 met inclusion criteria and obtained postoperative computed tomography (CT) scanograms to calculate femoral version and were thus included in the study. In this study, our main outcome measure was the difference in femoral version (DFV) between the uninjured limb and the injured limb. The effect of the following variables on DFV and revision rates were determined via univariate, multivariate, and ordinal regression analyses: gender, age, BMI, ethnicity, mechanism of injury, operative side, open fracture, and table type/position. Statistical significance was set at p < 0.05.ResultsA total of 316 patients were included. Piriformis entry nails made up the majority (n = 141), followed by retrograde (n = 108), then trochanteric entry nails (n = 67). Univariate regression analysis revealed that a lower BMI was significantly associated with a lower DFV (p = 0.006). Controlling for possible covariables, multivariate analysis yielded a significantly lower DFV for trochanteric entry nails than piriformis or retrograde nails (7.9 ± 6.10 vs. 9.5 ± 7.4 vs. 9.4 ± 7.8°, p < 0.05). Using revision as an endpoint, trochanteric entry nails also had a significantly lower revision rate, even when controlling for all other variables (p < 0.05).ConclusionComparative, objective comparisons between DFV between different nails based on entry point revealed that trochanteric nails had a significantly lower DFV and a lower revision rate, even after regression analysis. However, this is not to state that the other nail types exhibited abnormal DFV. Translation to the clinical impact of a few degrees of DFV is also unknown. Future studies to more in-depth study the intricacies of femoral version may lead to improved technology in addition to potentially improved clinical outcomes.     

The effect on improvement of recovery and pain scores of paravertebral block immediately before breast surgery

ObjectivesParavertebral block (PVB) has the potential to reduce postoperative pain after breast surgery. The aim of the study was to investigate whether PVB performed immediately before surgery could affect the postoperative morbidities in terms of pain and emesis, and improve the quality of recovery (QoR) in patients after surgery for breast cancer.MethodsPostoperative data were collected prospectively from two groups of patients undergoing unilateral breast surgery during the study period of 1 month. Forty consecutive patients received either solely general anesthesia (GA group, n = 25) or GA plus ultrasound-guided PVB (GA + PVB group, n = 15) for the surgery. Pain scores and areal distribution of pain were compared between the two groups 1 hour and 6 hours postoperatively and on the midmorning of postoperative Day 1 (POD1). The QoR scores were compared between the two groups 6 hours postoperatively and on the midmorning of POD1. Incidence of postoperative nausea and vomiting and doses of analgesics and narcotics given were also compared.ResultsPain scores at rest were significantly lower in the GA + PVB group at all designated time points [1 hour (p < 0.0001), 6 hours (p < 0.0001), and on midmorning of POD1 (p = 0.041)]. Pain scores with movements was also significantly lower at all time points in the GA + PVB group (1 hour, p < 0.0001; 6 hours, p < 0.0001; midmorning of POD1, p = 0.0012). Areal distribution of pain at rest and with movement was wider in the GA group 1 hour and 6 hours postoperately but was identical to that of GA+ PVB group on the mid-morning of POD1 [1 hour postoperatively at rest (p < 0.0001), with movement (p < 0.0001); 6 hours postoperatively at rest (p = 0.0018), with movement (p = 0.0048)]. The QoR scores were significantly higher in the GA + PVB group at 6 hours (p < 0.0001) and on midmorning of POD1 (p = 0.0079). The incidences of postoperative nausea and vomiting were significantly lower in the GA + PVB group (p = 0.0004). Doses of postoperative analgesics and narcotics were significantly less in the GA + PVB group (p < 0.0001 and p = 0.001, respectively). Time to first request for analgesics was significantly longer in the GA + PVB group (p = 0.0002).ConclusionsPVB given before surgery in combination with GA could provide better postoperative analgesia and better QoR than did GA alone in patients undergoing surgery for unilateral breast cancer.     

Assessment of calcific tendonitis of rotator cuff by ultrasonography: Comparison between symptomatic and asymptomatic shoulders

ObjectiveCalcific tendonitis of rotator cuff is observed on plain radiographs in 10% of adults, but remains asymptomatic in half these cases. We looked for differences on ultrasound (US) and power Doppler findings between symptomatic and asymptomatic cases of shoulder calcific tendonitis.MethodsUS was performed in 62 patients (81 shoulders) with symptomatic (n = 57) or asymptomatic (n = 24) calcific tendonitis. Calcific plaque morphology, power Doppler signaling, and widening of the subacromial-subdeltoid bursa (SSB) were recorded. US-guided steroid injection into the SSB (n = 21) or needle puncture of calcific deposits (n = 29) was performed at the end of US evaluation in 50 of the 57 patients, and a questionnaire was sent to each patient after 11 ± 6 months.ResultsLarger (p = 0.0015) and fragmented (p = 0.01) calcifications were associated with pain. A power Doppler signal and a widening of the SSB was identified in 21 and 17 of the 57 symptomatic calcification respectively, but in none of the cases of asymptomatic calcification (p < 0,005). At least one of these signs was present in 31 of the 57 (54%) symptomatic shoulders (p < 0.001). Long-term outcome was favourable for 60% of our patients after steroid injection. The presence of a SSB widening before bursal steroid injection was associated with an improvement of the symptoms (p = 0.06).ConclusionPositive power Doppler signal within the calcific deposit and SSB widening are US features strongly associated with pain. Moreover, larger calcifications are also more symptomatic. According to these results, US can help physicians to confirm that calcification is responsible for shoulder pain.     

Dexmedetomidine as supplement to low-dose levobupivacaine spinal anesthesia for knee arthroscopy

AimTo evaluate efficiency of dexmedetomidine compared to fentanyl as supplements to low-dose levobupivacaine spinal anesthesia in patients undergoing knee arthroscopy.Materials and methodsSixty adult patients (ASA I or II) scheduled for knee arthroscopy were randomized to receive plain levobupivacaine (4 mg) plus dexmedetomidine (3 μg) in group D or fentanyl (10 μg) in group F.ResultsDexmedetomidine shortened time to surgery (P = 0.002), time to highest sensory level (P = 0.001), and time to highest Bromage score (P < 0.001). The highest sensory level was comparable in both groups (P = 0.969), but the duration of sensory block was significantly longer in group D (P = 0.009). The highest Bromage score was 2 in both groups. This score was attained in significant higher number of patients in group D (P = 0.038) that showed better muscular relaxation (P = 0.035). At the end of surgery, a residual motor block (Bromage score 1) was observed in significant higher number of patients (P = 0.033) and time to ambulation was significantly longer in group D (P = 0.001). There was no difference in the number of patients bypassed post-anesthesia care unit (PACU) (P = 0.761) or time to hospital discharge (P = 0.357) between groups. The pain free period was more prolonged (P < 0.001), and the visual analog scale (VAS) for pain was lower at the 2nd, 4th, 6th, and 8th postoperative hours (P < 0.001, <0.001, 0.013, 0.030 respectively) in group D.ConclusionDexmedetomidine is a good alternative to fentanyl for supplementation of low-dose levobupivacaine spinal anesthesia for knee arthroscopy.     

Hallux rigidus: A cross-sectional study to evaluate clinical parameters

BackgroundHallux rigidus (HR) is a common condition with history and physical examination used to help evaluate pathology, grade clinical changes and to inform treatment.MethodA cross-sectional study was undertaken to evaluate the demographics of and clinical parameters encountered in HR. In 110 subjects (180 feet) aged 18–70 years (mean 52 years) a standardized history and physical examination was undertaken. Clinical parameters associated with HR were evaluated. The Foot Health Status Questionnaire (FHSQ) was used to measure health-related quality-of-life dimensions.ResultsSeventy (64%) subjects had bilateral HR and 73 (66%) were female. Mean HR onset was 44 (14–68 years) years and median HR duration 6 years (1–33 years). A history of 1st MTPJ trauma presented in 22% of subjects; 74% of whom had unilateral HR. Eighty-four (47%) feet had pes planus based on a positive Foot Posture Index. A correlation between pes planus and 1st MTPJ pain was found (r = 0.84, p = 0.05). In 74% of feet, hallux abductus interphalangeus angle (HAI°) was greater than normal (≤10°). A correlation between HAI and reduced 1st MTPJ ROM was found (r = 0.92, p = 0.05). Second toe length was the same as the hallux in 111 feet (62%). A correlation between valgus hallucal rotation and 1st MTP joint pain in HR was found (r = .78, p = .05). A positive relationship was found between 2nd toe length and 1st MTPJ pain (p = 0.001 < 0.05). A correlation between hallucal interphalangeal joint (IPJ) hyperextension and 1st MTPJ pain was found (r = 0.78, p = 0.01). A positive relationship was found between lesser MTPJ pain and supination at propulsion (p < 0.001). There was no evidence of Achilles tendon contracture. The FHSQ results concur with clinical findings.ConclusionsHR was associated with female gender, bilateral involvement, older age groups, increased HAI°, 2nd toe length similar to hallux, hallucal IPJ hyperextension, lesser MTP joint pain, flat foot and certain gait alterations. HR was not associated with Achilles tendon tightness or footwear. The content validity of clinical parameters of HR needs to be established by formal research prior to their inclusion in a classification of HR.     

Effectiveness of controlled telescoping system for lateral hip pain caused by sliding of blade following intramedullary nailing of trochanteric fracture

IntroductionThe purpose of this study was to demonstrate the effectiveness of controlled telescoping system for lateral hip pain caused by sliding of the blade following intramedullary nailing of trochanteric fractures.Materials and methodsA retrospective cohort study was performed to compare the controlled telescoping system (Compression Hip Nail; CHN) with the conventional sliding system (Proximal Femoral Nail Antirotation; PFNA) for trochanteric fractures. 74 cases in the PFNA group and 77 cases in the CHN group were included from two university hospitals in this study. All patients had a minimum of 12-month follow up period. Lateral hip pain was evaluated and operation time and blood loss during the surgery were measured. The fracture classification was evaluated. The quality of postoperative reduction and other complications after surgery were also evaluated and tip-apex distance (TAD), telescoping and lateral protrusion of the blade and lag screw were measured.ResultsThe mean age was 78.5 years in the PFNA group and 74.7 years in the CHN group (p = 0.25). The mean telescoping was 19.2 mm in the PFNA group and 10.7 mm in the CHN group (p < 0.001). The mean length of lateral protrusion was 10.5 mm in the PFNA group and 2.5 mm in the CHN group (p < 0.001). Twenty-eight patients in the PFNA group complained of lateral hip pain, whereas 12 patients in the CHN group did (p = 0.002). These four variables showed statistically significant differences between the PFNA and CHN groups (p < 0.05). The length of lateral protrusion was the only variable significantly related to lateral hip pain through multivariate logistic regression analysis (p = 0.045).ConclusionsThe degree of lateral protrusion was mainly related to lateral hip pain. Therefore, controlled telescoping would help to decrease lateral hip pain by decreasing the lateral protrusion beyond the lateral femoral cortex.     

Efeitos da musicoterapia sobre dor e estresse oxidativo na aspiração folicular: estudo clínico randomizado

Background and objectiveThe aim was to investigate the effects of Turkish classical music on pain and oxidative stress in patients undergoing oocyte pick‐up.MethodsThe study was a randomized, controlled trial. The groups included were Group NM (Non‐Music), control group; Group PM, which comprised patients who listened to music before the operation; and Group CM, which comprised patients who listened to music both before and during the operation. Blood was drawn prior to the operation to measure the oxidative stress values. Pain, hemodynamic parameters, oxidative stress values were assessed postoperatively.ResultsThe number of patients requiring additional propofol was higher in Group PM than in Groups NM and CM (p = 0.003). The postoperative Visual Analog Scale (VAS) score were lower in Groups PM and CM than in Group NM (p = 0.001, p = 0.007) in the 1^st and 60^th minutes. The postoperative VAS score was lower in Group CM than in Group NM (p = 0.045) in the 5^th minute. The postoperative additional analgesic requirements were lower in Groups PM and CM than in Group NM (p = 0.045). The postoperative blood glutathione peroxidase values were significantly higher in Groups PM and CM than in Group NM (p = 0.001). The postoperative catalase values were significantly higher in Groups PM and CM than in Group NM (p = 0.008 and p ≤ 0.001). The preoperative malondialdehyde values were significantly lower in Groups PM and CM than in Group NM. The preoperative nitric oxide values were higher in Groups PM and CM than in Group NM (p ≤ 0.001), whereas the postoperative nitric oxide values were lower in Groups PM and CM than in Group NM (p ≤ 0.001).ConclusionTurkish classical music has beneficial effects on pain and oxidative stress in oocyte pick‐up patients.     

Do columns or sagittal displacement matter in the assessment and management of Lisfranc fracture dislocation? An alternate approach to classification of the Lisfranc injury

AimThe classification of a Lisfranc injury has conventionally been based around Myerson's system. The aims of this study were to review whether a novel classification system based on sagittal displacement of the tarsometatarsal joint and breadth of injury as determined by a columnar theory was associated with functional outcomes and thus had a greater utility.PatientsWe retrospectively reviewed 54 Lisfranc injuries with a minimum follow up of two years at our Level One Trauma Centre. Each fracture was sub-classified based on our novel classification system which assessed for evidence of sagittal displacement and involvement of columns of the midfoot. Our primary outcome measures were the FFI and AOFAS midfoot scores.ResultsInjuries involving all three of the columns of the midfoot were associated with significantly worse functional outcome scores (FFI p = 0.004, AOFAS p = 0.036). Conversely, sagittal displacement, whether dorsal or plantar, had no significance (FFI p = 0.147, AOFAS p = 0.312). The best predictor of outcome was the quality of anatomical reduction (FFI p = 0.008, AOFAS p = 0.02).ConclusionColumn involvement and not sagittal displacement is the most significant factor in considering the severity Lisfranc injury and long term functional outcomes. This classification system has greater clinical utility than those currently proposed.