Recurrent elbow dislocation—an uncommon presentation

The choice of reconstructive procedure to restore limb function is challenging after internal hemipelvectomy. Hip transposition arthroplasty, also known as resection arthroplasty, removes a malignant or aggressive tumor of the pelvis and acetabulum after which the remaining femoral head is moved proximally to the lateral surface side of the sacrum or the underside of the resected ilium after internal hemipelvectomy. It may provide reasonable functional results and have some advantages such as lowering the risk of an infected implant compared with other reconstructions because no foreign implants are used. Hip transposition is generally managed with prolonged bed rest or immobilization postoperatively to stabilize the soft tissue surrounding the remaining femur. Because enabling patients to be mobile while the soft tissues heal might be advantageous, we reviewed our experience with an external fixation for this procedure. (1) Does temporary external fixation facilitate postoperative physiotherapy in patients who undergo hip transposition arthroplasty? (2) What functional Musculoskeletal Tumor Society (MSTS) scores were achieved at short term in a small series of patients treated with hip transposition and temporary external fixation? (3) What were the complications of using external fixation in a small series of patients who received it for malignant tumors? Between 2008 and 2012, we treated seven patients (three men and four women; median age, 37 years; age range, 18-53 years) with acetabular resection for malignant bone tumors; all were managed with a hip transposition, initially stabilized using external fixation. No other types of procedures were used for this indication in this period. Minimum followup in this retrospective study was 45 months, except for one patient who died at 18 months (range of followup duration, 18-90 months; median followup, 57 months), and no patients were lost to followup. The pins for external fixation were inserted into the affected side of the femur and the healthy contralateral ilium. External fixation was removed 6 weeks postoperatively and weightbearing was started at that time. Preoperative chemotherapy was administrated in four patients, but postoperative chemotherapy was delayed since it was given after external fixation removal in three patients. The postoperative rehabilitation course and functional results were assessed by chart review, functional results were determined using MSTS scores, tallied by physiotherapists who were not part of the surgical team, and complications were ascertained through chart review. Major complications were defined as complications that were treated with additional operations, such as deep infection, or ones that could cause severe postoperative dysfunction, such as nerve injury. With temporary external fixation, standing next to a bed was achieved in median 7 days (range, 6-9 days) postoperatively, transferring to a wheel chair in median 8 days (range, 6-28 days), and gait training using parallel bars in median 15 days (range, 7-48 days). At most recent followup, three patients could walk without a crutch or cane, three could walk with a cane, and one could walk with a crutch. The median MSTS score at most recent followup (median, 57 months) was 63%. Two patients had complications that resulted in reoperations; one had a wound dehiscence, and one had an abdominal herniation that gradually developed, and which was reconstructed using polypropylene mesh 2 years after pelvic resection. Two patients had nerve palsies that recovered by the end of the first year. All patients had pin tract infections that resolved with nonsurgical approaches. Hip transposition with temporary external fixation can stabilize the bone soft tissue after pelvic resection. Although we did not have a comparison group of patients, we believe that external fixation facilitates early postoperative physiotherapy and rehabilitation and provides good functional results without major surgical complications. Because it delays the resumption of chemotherapy, more patients with longer followup are needed to determine whether this will be associated with poorer oncologic results. Level IV, therapeutic study.

To compare infection rates after external fixation removal, comparing pin sites that were primary closed with those left open to heal by secondary intention. Retrospective review. Multicenter study. All adult patients (18 years and older) who underwent removal of external fixator that was used for extremity fractures from 2007 to 2023 with at least 30 days follow-up. Patients were stratified into 2 cohorts: (1) external fixator pin sites primarily closed after external fixator removal and (2) pin sites left open to heal with secondary intention after external fixator removal. Patient characteristics, fracture characteristics, and details of the external fixator removal surgery were recorded. Comparison of the rate of surgical site infection (SSI) of pin site after external fixation removal were performed between the 2 groups (pin sites that were closed primarily and those left open after external fixator removal). A total of 412 patients were included, with a mean follow-up of 259 days. There were 254 patients in the closed pin site after pin removal group (mean age 53 years, range 18-95, 39% female) and 158 in the pin sites left open after pin removal group (mean age 54 years, range 18-93, 49.4% female). The median duration of external fixator in the closed group was 11 days and 19 days in the open group ( P < 0.05). Multivariate analysis demonstrated increased odds of SSI of pin site after pin removal if the pin site was left open (odds ratio = 3.2; 95% confidence interval, 1.44-7.19, P < 0.01) and with tibial plateau fractures (odds ratio = 4.45; 95% confidence interval, 1.92-10.32, P < 0.001). After external fixation removal, closure of pin sites was associated with lower risk of pin site SSI after pin removal compared with leaving them open when external fixation duration was less than 2 weeks. External fixation is a common procedure, and this study can help change practice and decrease the risk of SSI of pin site after pin removal. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Introduction: Primary patellar dislocation is usually the initial manifestation of patellofemoral instability. Among the long-term repercussions of this disorder are recurrent dislocation and indefinable knee dysfunction. At present, there is no agreement on the optimal treatment of patellar dislocation. Objective: to detail the current information related to patellar dislocation, epidemiology, mechanism of action, clinical evaluation, imaging evaluation, classification, differential diagnosis, treatment and complications of the disease. Methodology: a total of 30 articles were analyzed in this review, including review and original articles, as well as clinical cases, of which 22 bibliographies were used because the other articles were not relevant to this study. The sources of information were PubMed, Google Scholar and Cochrane; the terms used to search for information in Spanish, Portuguese and English were: patella, knee anatomy, patellar dislocation, knee instability. Results: Approximately 5% of the time it is related to osteochondral fractures. To define whether a patella is high or low, a lateral radiograph should be taken with the knee in 30° of flexion to determine Blumensaats line. The increase in the Q angle facilitates patellar dislocation. Most patellar dislocations are related to congenital anomalies of the patella or trochlea, high patella, hypoplasia of the vastus medialis and hypertrophy of the lateral retinaculum. Conclusions: Patellar dislocation is usual in individuals with connective tissue disorders and hypermobility, the patella can be dislocated laterally, superiorly or intra-articularly, presenting different mechanisms of action for each case. It is important to have a good knowledge of the anatomy and to measure the Q angle because the increase of this angle facilitates patellar dislocation. It is essential to establish the etiology of the dislocation, especially in those with recurrent dislocations as this may alter the management plan. In addition to the clinical evaluation it is important to request anteroposterior, lateral knee and axial projections. When conservative treatment is chosen, reduction and immobilization with a cast or orthosis should be performed with the knee in extension, the long knee brace can be used, with or without arthrocentesis to relieve the symptomatology; surgical treatment is mostly used in recurrent dislocations. At the moment, no surgical technique is able to correct all the problems of patellar alignment. It should be kept in mind that the surgical procedure should take into account the individuals age, diagnosis, activity level and the situation of the patellofemoral joint. Patellofemoral instability should be treated with the goal of correcting all of the alignment issues. The usual complications are loss of knee mobility, recurrent dislocation and patellofemoral pain. KEY WORDS: dislocation, patella, knee, instability.

Several clinical studies have reported that the use of hydroxyapatite- (HA) coated pins enhance external fixation. Although these studies have demonstrated higher extraction torques and lower rates of pin loosening with HA coating, there is little evidence to suggest that these biomechanical advantages translate to a lower rate of pin replacement prior to healing. The research question posed was "Is there sufficient evidence to prove that hydroxyapatite coating lowers the rate of pin replacement for external fixation?" An electronic search of Medline (Ovid, 1946 - December Week 4 2011), Embase (Ovid, 1980-2011 Week 52), and the Cochrane Central Register of Controlled Trials (Issue 4 of 4, October 2011) was conducted to identify all randomized and quasi-randomized controlled trials which compared HA-coated pins with non-coated pins for external fixation, with particular emphasis on the premature replacement of pins as a consequence of loosening. The combined search strategies retrieved 72 citations. Four randomized controlled trials (101 patients, 327 HA-coated vs. 354 uncoated pins) were included in this review. None of the studies demonstrated a clear benefit between pin types with respect to premature replacement of pins prior to healing. This review did not find sufficient evidence to validate the preferential use of HA-coated pins over standard pins as a means of avoiding premature replacement of pins used for external fixation. The use of uncoated pins is justifiable, especially within the context of limited financial resources.

External Fixation and Adjuvant Pins Versus Volar Locking Plates in Unstable Distal Radius Fractures: A Randomized Controlled Study with a 10-Year Follow-Up.

SummaryMultiple pin and methylmethacry-late external fixation devices were applied in 74 animals to successfully treat several different types of orthopaedic injuries. The major advantages associated with use of the technique included increased versatility in the location and angle of fixation pin place-ment and greater ease in placement of the connecting bar when compared with conventional clamp and connecting bar systems, particularly with transarticular placement of a device. The major disadvantages associated with the technique included, increased difficulty compared to conventional K-E systems regarding postoperative adjustment of the device and difficulty in removing individual pins that were loose or infected. Generally, removal of the device was not a problem, provided sufficient space was left between the connecting bar and the skin surface.Complications associated with the technique were similar to studies which have evaluated other types of external fixation and include fixation pin loosening, pin tract drainage or infection, fixation failure, osteomyelitis, angular limb deformity, mal-union, delayed union and nonunion.The multiple pin and methylmethacrylate external fixator provides a useful and effective method of repair for a wide variety of orthopaedic injuries. The use of methylmethacrylate as a connecting bar is a helpful adjunct to standard external fixation systems.The use of multiple pin and methylmethacrylate external fixation (MPMF) increases the versatility of the external fixation technique in small animal orthopaedic injuries. Disadvantages include difficulty in removing or replacing individual fixation pins.

Reproducibility of the Dorr classification and its quantitative indices on plain radiographs

To report on pin-related complications in patients who underwent temporary staging external fixation using a self-drilling pin insertion technique. Retrospective cohort study. Single tertiary referral level 1 trauma center. Adult patients were included who underwent temporary spanning external fixation of the lower extremity (AO/OTA 32, 33, 41, 42, 43, 44, 81, 82, 83, 84, and 85 fractures) using self-drilling and self-tapping pins placed using the self-drilling technique (Stryker Hoffman External Fixation System, Kalamazoo, MI) between August 1, 2015, and December 31, 2022, with a minimum follow-up of 90 days. The self-drilling technique included use of a soft tissue sleeve for pin protection in the femur and tibia, release of the tourniquet if inflated, and full speed insertion with the final turns completed by hand. Irrigation of the pin-bone interface was not typically used. Outcome measures included pin site infection, pin loosening, loss of reduction in the external fixator, and deep infection of the primary surgical site. Two hundred sixty-five patients were included with a mean follow-up of 556 days. The mean age was 50 years (range 18-86 years). One hundred fifty-five patients (59%) were male. One thousand one hundred fifty-four total pins were placed: 289 (25%) in the femur (1 metaphyseal), 527 (46%) in the tibia (12 metaphyseal), 161 (14%) transfixion pins in the calcaneus, and 171 (15%) in the midfoot/forefoot. Seven patients (2.6%) developed a pin site infection. The infection rate for the total number of pins placed was 7 of 1154 (0.6%). One patient sustained a loss of reduction in the external fixator, and 3 pins were noted to be loose at the time of definitive fixation (2 in the tibial diaphysis and 1 in the first metatarsal shaft). In total, 35 of 265 patients (13.2%) developed deep fracture-related infection or septic nonunion in the postoperative period, none of which were associated with prior pin site infection. The self-drilling technique for temporary external fixator pin insertion in this study demonstrated low rates of pin site infection, pin loosening, and loss of reduction. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Certain distal humerus fractures and elbow fracture dislocations warrant early fixation with an external fixator. The distal humerus is close to the radial nerve and a hazardous area for the placement of an external fixator. No known safe zone for the placement of an external fixator has been identified on the lateral border of the humerus. We record the incidence of radial nerve damage following external pin fixation and note the relation of the radial nerve to each pin. A total of 39 cadavers were dissected for this study. Two 4 mm pins were placed with a multi-pin clamp into the lateral border of the right and left humerus at 100 mm and 70 mm proximal to the lateral epicondyle. We dissected the upper limbs and recorded the incidence of radial nerve damage and the position of the nerve in relation to the two pins. Data for right and left sides were combined. The radial nerve was damaged by the proximal and distal pin in 56.4% and 20.5% respectively. The radial nerve was located anterior to the proximal pin (41%) and distal pin (79.5%). The radial nerve was located posterior to the proximal pin (2.6%) and distal pin (0.0%). We were unable to identify a safe zone from this study. We propose that pins should be placed less than 100 mm proximally from the lateral epicondyle and as posterior as possible to minimise the risk of radial nerve damage.

Taylor spatial frame (TSF) is a modern multiplanar external fixator that combines ease of application and computer accuracy; it provides the capability of 1 to 6 axes of deformity correction sequentially or simultaneously by adjusting 6 connecting struts between 2 circular rings. Previous reports have documented the effectiveness of the TSF in acute fracture care, nonunion treatment, and in bone lengthening and deformity correction in the lower extremity. To the authors' knowledge, no previous case series in the English literature have documented the use of the TSF in treating upper extremity conditions. Our experience with the use of this external fixator in the treatment of upper extremity length abnormality, angulation, and bone transport is summarized. Over a period of 7 years, TSF was used in 12 patients with varying upper extremity pathologies that were collected from our prospective external fixator database. The classic TSF planning strategy was adopted and the TSF web-based program was used. All cases were followed for a minimum of 2 years. The database and radiographs were reviewed to obtain demographic data, malalignment parameters, final correction, time in the TSF, and complications. Patients' ages ranged from 8 to 18 years. Eight humeral and 4 radial cases were identified. These included 4 cubitus varus and 1 cubitus valgus deformity, 1 neglected supracondylar fracture, 2 humeral nonunion, 2 radial malunion cases, and 1 radial shaft septic nonunion. Time in the TSF varied according to patient age and bone involved. Five patients had superficial pin site infections that resolved with oral antibiotics. Postoperatively mean final angulation on the anteroposterior radiograph was 1 degree (range, 0 to 5 degrees) and the mean final angulation on the lateral radiograph was 0.5 degrees (range, 0 to 2 degrees). Union of bone was achieved in all cases. The TSF is an external fixator that can be successfully used as a treatment alternative for the definitive treatment of upper extremity conditions involving a deformity and or shortening or bone transport in the pediatric and adolescent patient population. Level IV.

Direct measurement of intervertebral motion was compared to motion determined by measuring the position of the exposed ends of the external fixation pins. To verify the accuracy of this technique, so that this protocol can be used to study intervertebral motion in the clinical setting. The transpedicular external fixation test has been shown to be a test that can predict the outcome of spinal fusion. In patients who are candidates for this test, intervertebral motion can be calculated from motion at the external ends of these pins. Six fresh cadaveric spinal segments from L2 to L5 were instrumented with titanium Schanz screws. Reflective markers were placed on the tips of the pins, and intervertebral motion was measured using a noncontacting camera system. Computed tomography data were used to determine the position of the vertebra relative to the reflective markers. Intervertebral distances were calculated and compared with direct measurements obtained using a three-dimensional digitizing arm. There was an excellent correlation (r2 = 0.931) between the directly measured intervertebral motions and those that were indirectly calculated from measurements of motion at the end of the Schanz screws. Intervertebral motion can be measured by monitoring motion of the ends of transpedicular external fixation pins. Motion of anatomic landmarks on the vertebrae can be calculated from the pin end's motion if computed tomography data are used to determine the geometric relation between the vertebrae and the external fixation pins. This validation study supports the use of this method in clinical investigations of intervertebral motion in patients with low back pain and external fixation.

Morel-Lavallée lesions (MLLs) are closed degloving injuries that result in inter-fascial hemolymphatic collections. These lesions develop as a result of shearing forces in the deep fascial planes and often arise in the context of significant high-velocity traumas. However, they are often underdiagnosed, especially in the case of atypical presentations such as sports or low-impact injuries. Here we present a case of MLL following a fall from a bike at low speed that resulted in a large area of soft-tissue ecchymosis and swelling that would not resolve following conservative treatment. Point-of-care ultrasound (POCUS) was used to diagnose and guide interventional treatment via ultrasound-guided drainage of the fluid collection. This case is informative as it serves as a reminder for providers to always consider MLL in the differential diagnosis of soft tissue injuries. It additionally demonstrates how POCUS can help identify and assist in management of MLLs in the primary care setting.

The aim of this study was to compare the accuracy of clinical diagnosis made by trained physiotherapists and orthopaedic surgeons when seeing elective patients in the outpatient clinic. The method involved a retrospective analysis of 100 case notes of patients who had been seen in the orthopaedic outpatient department and consecutively scheduled for knee arthroscopies. Fifty patients were seen by a physiotherapist and 50 by the orthopaedic surgical team. The physiotherapist was able to make a 66% clinically accurate diagnosis compared with 82% by the doctors (p = 0.07). Sensitivity was 90.7% for surgeons and 68.1% for physiotherapists, whereas specificity was shown to be 71.4% for surgeons and 66.6% for physiotherapists. The accuracy of clinical diagnosis by trained surgeons is better than that of physiotherapists, although not statistically significant. It is, therefore, justifiable to place patients on theatre lists based only on clinical examination by either physiotherapists or surgeons.

Pin-track infection remains one of the most troublesome complications of external fixation, in some cases compromising otherwise successful fracture treatment. One hundred and eighteen patients (120 wrists) who had been managed with the placement of an external fixation device for the treatment of a displaced, unstable, distal radial fracture were randomized into one of three treatment groups: (1) weekly dry dressing changes without pin-site care; (2) daily pin-site care with a solution of one-half normal saline solution and one-half hydrogen peroxide; and (3) treatment with the placement of chlorhexidine-impregnated discs (Biopatch) around the pins, with weekly changes of the discs by the treating surgeon. The patients were followed at weekly intervals until the external fixator was removed. Radiographs were made biweekly. The patients were evaluated with regard to (1) erythema, (2) cellulitis, (3) drainage, (4) clinical or radiographic evidence of pin-loosening, (5) the need for antibiotics, and (6) the need for pin removal before fracture-healing due to infection. Differences in complication rates among the three groups, with adjustment for patient age, gender, and the performance of an associated open procedure, were evaluated. The average age of the patients was fifty-four years. Forty-seven wrists had an open procedure (either bone-grafting or open reduction and internal fixation) in addition to treatment with the external fixator. The fixators remained in place for an average of 5.9 weeks. Twenty-three patients (19%) had a complication related to the pin track, with twelve of these patients requiring oral antibiotics for the treatment of a pin-track infection. There were no significant differences among the three groups with regard to the prevalence of pin-site complications. The age of the patient was found to be significantly associated with an increased risk of postoperative pin-track complications (p = 0.04). We found a high rate of local wound complications around external fixation pin sites; however, most complications were minor and could be observed or treated with oral antibiotics. The prevalence of these complications was not decreased in association with the use of hydrogen peroxide wound care or chlorhexidine-impregnated dressings. On the basis of these results, we do not recommend additional wound care beyond the use of dry, sterile dressings for pin-track care after external fixation for the treatment of distal radial fractures.

BackgroundSeveral methods of measurement of anteversion of acetabular components after total hip arthroplasty (THA) have been described in the literature using plain radiographs or computed tomography (CT) scans. None of these have proved to be the gold standard. We aimed to study the correlation between the CT and radiographic methods of calculation of acetabulum anteversion.MethodsCT scans of the pelvis, anteroposterior (AP) and cross-table lateral (CL) radiographs were obtained in 60 patients who underwent THA two weeks after surgery. Anteversion was measured using Widmer method and Liaw method on AP radiographs, and the ischiolateral method on CL radiographs. Anteversion measured on the CT scan was taken as the reference anteversion and the above measurements were analysed for correlation with the measurements on CT scan. Intraclass correlation coefficients (ICCs) were calculated for both intra- and interobserver reliability.ResultsMean acetabular version on CL radiographs was 53.1 ± 10.7. Mean version on AP radiographs by Widmer method was 21.4 ± 3.6 and by Liaw method was 20.3 ± 4.8. Mean version on CT scans was 26.02 ± 6.8. There was a good correlation between the acetabular version on CT scans with the version on AP radiographs by Widmer method (r = 0.78, p < 0.001) and Liaw method (r = 0.87, p < 0.001). Good correlation was seen between the acetabular version on CL radiographs and CT scans (r = 0.91, p < 0.001). Also, a good correlation was observed between the acetabular version measurements on CL radiographs and AP radiographs by Widmer method (r = 0.81, p < 0.001) or Liaw method (r = 0.70, p < 0.001). Excellent inter- and intraobserver reliability were seen for all the measurements.ConclusionsCalculation of acetabular component version on AP views as well as CL views of plain radiographs showed a strong correlation with the version measurements on CT scans. Good correlations were observed between different techniques of measurement on radiographs. Therefore, all these measurements can be valid methods for assessment of anteversion.