Mohamed Mohamed*, Rohit Singhal, Jamie Howie and Eugene Toh
Stress fractures are an uncommon injury in children and often present diagnostic dilemmas. They may have features both clinically and radiologically in common with infection and malignancy. Early suspicion is critical in order to eliminate the need for invasive investigations, incorrect treatment and distress to both child and parent. We report the case of a 12 year old boy who presented with unilateral leg pain and subsequently diagnosed with bilateral proximal tibial stress fractures and a unilateral proximal fibula stress fracture. Stress fracture is an uncommon diagnosis in children thus it is important to maintain a high index of suspicion and if necessary to investigate for and exclude the possibility of more sinister pathologies such as infection or neoplasm.
Nowadays, one of the main orthopedic diagnostic problems is the referral of the Patient to other physicians that do not examine the injured individuals themselves.
Iulian Nusem* and Marjoree Sehu
Early diagnosis together with appropriate treatment is essential for the management of septic arthritis of the hip. Abnormal joint anatomy and intra-articular injections increase the risk of joint infection in adults. In children-young age, male gender, respiratory distress syndrome, umbilical artery catheterization, phagocytic deficiencies, haemoglobinopathies, joint interventions and instrumentation of the urinary or intestinal systems are risk factors. Staphylococcus aureus is the most commonly identified pathogen while a growing concern is the methicillin-resistant Staphylococcus aureus. Most adults present with one or two week history restricted motion and painful joint. At least two sets of blood cultures should be obtained before initiating antibiotic treatment. Blood samples for white blood cell count, erythrocyte sedimentation rate and C-reactive protein concentration should also be obtained. Synovial fluid white cell count of > 50,000 cells/mm3 is considered diagnostic for septic arthritis. Specimens for gram-stain and culture should be obtained before antibiotic therapy is started. Repeat aspiration is an available option in the paediatric age group, but open arthrotomy remains the gold-standard for surgical treatment. As opposed to arthrotomy, hip arthroscopy offers a minimally invasive approach, increased access to the hip joint and improved visualization, while eliminating risks such as a vascular necrosis of the femoral head, joint instability, need for large surgical exposure, scarring, postoperative pain and prolonged hospital stay. The initial antibiotic choice is based on the patient's clinical history and risk factors, local prevalence of drug-resistant pathogens and Gram-stain results. As Staphylococcus aureus is the most common pathogen empiric antibiotic treatment with b-lactamase-stable penicillins is recommended. UK guidelines recommend intravenous antimicrobial therapy for two weeks followed by four weeks oral therapy.
Nikhil Nair and Nikhil Gupta*
Fluorosis occurs due to excessive fluorine entry into the body. Dental, skeletal and non-skeletal fluorosis is different types of fluorosis. Endemic skeletal fluorosis is prevalent in many countries including India. Conventional radiographs and more recently MRI are helpful in diagnosis of fluorosis which classically reveals a wide and intriguing spectrum of findings. We review the various radiological findings in a case of fluorosis.
Pelin Arican*, Bernatekin Okudan, and Nur Kodaloglu
Planar bone scintigraphy is a radionuclide imaging used for the evaluation of many pathologies such as osteoarthritis, trauma, degeneration, infections and tumors in the joints of the upper and lower extremity. However, planar images cannot reach satisfactory results especially in the wrist, foot and ankle with complex structures and small bones. Recently use of Single Photon Emission Computerize Tomography/Computerize Tomography (SPECT/CT) is increasingly widespread. SPECT/CT combines scintigraphic findings with morphological findings. It provides accurate anatomical localization of increased radiotracer uptake and evaluates morphological changes of this area. SPECT/CT increases diagnostic accuracy and specificity of planar bone scintigraphy. It improves patient management and treatment planning. Although bone SPECT/CT application is widely used in oncology patients, the number of studies about the role of assessment in the extremities and joints are limited.
The aim of this review is to evaluate the contribution of bone SPECT/CT to the pathology of shoulder, elbow, hand-wrist, hip, knee, foot and ankle joint and to give examples from our cases.
Imran Ahmed*, Louise Fraser, Andrew Sprowson, and Peter Wall
Background: Tourniquets are routinely used in total knee arthroplasty (TKA) with an estimated use by up to 93% of surgeons. Advantages include the ability to provide a bloodless field of view to facilitate cement application and increase the success of the procedure. Overall reduction in blood loss is another perceived advantage; however recent research has demonstrated no measurable reduction and conversely a substantial increase in complications such as deep vein thrombosis and systemic emboli. Given the significant complications of tourniquet use we aim to identify patients' views on tourniquets and of emphasis their awareness of the possible risks involved prior to the procedure.
Method: A questionnaire - based study was carried out on 35 patients attending an elective orthopaedic centre for TKA surgery. Ethical approval was granted by NRES committee - East of England (REC Ref: 14/EE/1265). Patients were provided with an information sheet detailing the reasons for the tourniquet use and the associated risks and benefits. They were then provided with a questionnaire to ascertain their views and previous understanding of the subject. Simple statistical measures were implemented to analyse the data.
Results: Only 32% of patients were aware of the use of tourniquets during the operation. 19% were aware of the benefits prior to reading the information sheet provided with 29% understanding the risks involved prior to their procedure. Finally we found 97% of patients would like more information on the use of tourniquets preoperatively.
Conclusion: Tourniquets are widely used in TKA surgery; however, they carry significant risks which are not clearly relayed preoperatively to all patients. Given that 91,000 TKA operations are performed per year we believe it is of paramount importance that all patients are appropriately counselled on the risks and benefits of its use and fully informed consent, including risks of tourniquet use, should be obtained prior to the procedure.
Coady-Fariborzian L*, McGreane A, Pagan C, and Jain S
Clostridium collagenase (trade name "Xiaflex", Auxilium Pharmaceuticals, Inc. Malvern, PA, USA) is an enzymatic, non-operative treatment for Dupuytren's disease that was approved by the FDA in February 2010. The purpose of the study is to determine our rate of success and complications with this treatment in the veteran population. An IRB approved (2015-00576) retrospective chart review of patients treated with Xiaflex for Dupuytren's disease between December 2010 and June 2015 was performed. Clinic records were reviewed for collagenase injection and cord rupture. Charts were reviewed for pre procedure joint measurements, cord rupture, post procedure measurements, and complications. There were no major complications. The most common complication other than bruising and edema was skin tears. A Fisher exact test found that skin tears were more likely to be found in patients with preexisting metacarpal phalangeal joint measurements = or > 60 degrees. Xiaflex is a reasonable and safe non operative treatment for the veteran population with digital contractures resulting from Dupuytren cords in the palm.
Neel Anand*, Ryan B. Cohen, Jason Cohen, Khoi Than, Paul Park, Richard G. Fessler, Pierce Nunley, Stacie Nguyen, Praveen Mummaneni, Joseph Zavatsky, Dean Chou, Juan Uribe, Michael Y. Wang, Adam S. Kanter, David O. Okonkwo, Vedat Deviren, Behrooz Akbarnia, Robert K. Eastlack, Christopher Shaffrey, and Gregory M. Mundis Jr
Background: Current treatment strategies for the correction of adult spinal deformity (ASD) include the options of circumferential minimally invasive surgery (CMIS), open surgery, and hybrid correction. This study compares outcomes and complications of CMIS and hybrid surgery for the management of ASD.
Methods: This is a retrospective analysis of a multicenter database using prospectively collected dataon patients with ASD. Patients were evaluated for early and late complications following treatment with CMIS or hybrid techniques.
Results: Of the 190 patients in the study, 104 were in the CMIS group and 86 were in the hybrid group. Compared to the hybrid group, CMIS patients reported less blood loss, shorter operative time, fewer posterior levels fused, and lower follow-up ODI (p < .05). Radiographic parameters were similar between the two groups; however, the mean of 4.7 levels fused in the CMIS group was significantly less (p < 0.001) than the mean of 8.2 levels fused in the hybrid group.
There was a significantly lower rate of early major (p < 0.01) and minor (p < 0.001) complications in the CMIS group (Major: 13.5%; Minor: 9.6%) compared to the hybrid group (Major: 29.1%; Minor: 36.0%). However, there was no statistically significant difference in the rate of late complications between the two groups. Patients who had an early major or early minor complication had a higher 2-year ODI compared with those that did not.
Conclusion: Both CMIS and hybrid techniques are effective in the treatment of ASD. The greatest advantage of CMIS techniques may be in reducing the early morbidity associated with these surgeries. In the late period, both the CMIS and hybrid techniques fair similarly well as evidenced by an equivalent late complication rate. Hybrid deformity surgery was associated with a higher reoperation rate than circumferential minimally invasive surgery.
Hassan Serhan and Melissa Kuhn*
Scoliosis is a complex three - dimensional spinal deformity that results from both known and unknown causes in patients of all ages. Scoliosis can be classified by etiology: idiopathic, congenital, or neuromuscular. Idiopathic scoliosis is the diagnosis when all other causes are excluded, and comprises about 80% of all cases. Idiopathic scoliosis progression is dependent on the patient's skeletal maturity, the curve pattern, and the curve magnitude, while the other forms of childhood scoliosis can have an unpredictable course, with most being progressive .
Piet JM van Loon*
Revision of older knowledge on spinal deformities shows causing factors in all day life and the source of rotational forces in men in respiration. The role of lordosis as a causative factor can change towards a correcting force, supported by different studies. The thoracolumbar spine is the originating area of many deforming processes.
Cornelius Wimmer, ElsayedShaheen, Thomas Pfandlsteiner, and Ahmed Ezzat Siam
Purpose: Reporting preliminary results of MCGR.
Study design: A prospective uncontrolled, single-center, single-surgeon, clinical and radiological study
Patient sample: Between November 2012 and March 2015, 14 children with EOS were treated using MCGR
Outcome measures: Preoperative, postoperative and final follow-up (FFU) whole spine radiographs were reviewed to determine the degree of spinal deformity and correction, measured using Cobb angle. T1-S1 length was calculated. Clinical notes to determine number of rod lengthening procedures using remote control device and to record any complications during surgery or FU period.
Methods: Mean age was 12.1 years, 2 boys and 12 girls, nine children had primary correction by MCGR; five of them had neuromuscular, three infantile and one congenital scoliosis. All had a dual MCGR implanted. The remaining five patients had previously undergone other growing rod operation before converting to MCGR implant.
Results: Mean pre-operative Cobb angle of the primary group was 73.4°, postoperative 34.8° (51.3% correction), FFU 28.8°. Mean initial percentage of the lengthening was 18.4%. Thoracic kyphosis changed significantly from preoperative mean of 48.7° to 31.2° postoperatively (p=0.008). Of the revision group, mean pre-operative Cobb angle was 49.6°, postoperative 41.1° (16.5% correction) and 40.3° at FFU. Mean initial percentage lengthening was 6.9%. One patient had wound infection, two had pull-out of proximal screws, one sustained a breakage of a single-rod construct 6 months after surgery and was replaced by a double magnetic-rod construct.
Conclusions: In our consecutive series of patients treated with MCGR we found that scoliosis was well controlled. Cobb angle was significantly reduced following surgery in patients who had MCGR performed as a primary procedure. Generally, the correction was maintained at FFU. Comparing our results for MCGR and other growing rod techniques, they are comparable, without need to repeated surgery.
Imane Ben Slama*, F Allali, S El kabbaj, T Lakhdar, L Medrare, A Ngeuleu, R Abouqal, H Rkain, and N Hajjaj Hassouni
Background: Disease Activity Score-28 joints (DAS-28) is nowadays the gold standard for measuring the disease activity in patients with RA. The original DAS-28 was based on erythrocyte sedimentation (ESR), but an alternative formula incorporating C-reative protein (CRP) [DAS-28(CRP)] has been developed.
Objectives: To compare the disease activity score DAS28-ESR versus DAS28–CRP, and to determine the factors that might influence their difference. To estimate the disease activity score DAS28-CRP threshold values that correspond to DAS28- ESR values in Moroccan patients with rheumatoid arthritis.
Patients and methods: Patients with RA were included in a cross-sectional study. We have collected the demographic characteristics and the characteristics of the RA: duration of evolution, global disease activity on a 100 mm visual analogue scale assessed both by the patient (GDAP), morning stiffness in minutes, functional impact of the disease assessed by the HAQ (Health Assessment Questionnaire), and current corticosteroid dose. The disease activity was assessed by the DAS28-ESR and DAS28-CRP. A concordance correlation between DAS28-ESR and DAS28 -CRP was performed. We defined a new variable DIFDAS=DAS28-ESR – DAS28-CRP (differences between the two indexes). Factors influencing this difference were tested by univariate then multivariate logistic regression. Using DAS28-ESR as gold standard, the passing Bablok and Bland- Altman methods were used to assess the agreement between DAS28-ESR and DAS28-CRP.
Results: 103 patients were included with a female predominance (87.4 %). Mean age was 49.7 ± 11.4 years. Median disease duration was 8 years [3-14]. There was a strong positive concordance between the two indexes of 0.93 with CI 95% [0.91-0.95], although the DAS28-ESR value obtained was higher than that of DAS28-CRP at approximately 90% of the visits (n= 93). Significantly, the difference between both indexes was higher than 0.6 in 42.7% of the visits studied (n=44). In multivariate analysis, factors significantly associated with this difference were high dose of steroids and significant functional impairment (p< 0.05). There was a difference between DAS28-ESR and DAS28-CRP values (p< 0.05). Using bland and Altman method, we found that DAS28-CRP under-estimate threshold values of DAS28-ESR by 0.49 with CI 95% [-1.96, +1.96].
Conclusion: Our study showed a positive concordance between the DAS28-ESR and DAS28 -CRP. But DAS28-ESR would be higher than DAS28-CRP in patients with high dose of corticosteroids and significant functional impairment.