IRANIAN JOURNAL OF ORTHOPAEDIC SURGERY
Year:2004 | Volume:2 | Issue:3 (7)|Papers Count:16

Background: Primary total hip replacement performed through an incision that is ≤10 cm in length has been advocated as a minimally invasive technique. Proponents have claimed that mini-incision techniques reduce blood loss, transfusion requirements, postoperative pain, and the kngth of the hospital stay compared with standard techniques through a longer incision. However, we are aware of no well-designed comparison study that supports these claims. The purpose of the present study was to compare the short-term results of a mini-incision with a standard incision technique for total hip replacement. Materials and Methods: A consecutive series of patients who underwent 135 primary unilateral total hip replacements (fifty with use of a mini-incision [≤10cm] and eighty-five with use of a standard incision) by three surgeons at one hospital were studied. Each surgeon selected patients to have a mini-incision procedure and performed a standard approach in the remaining patients. A posterior approach was used for all procedures. In-hospital data were collected retrospectively, and the initial postoperative radiographs were analyzed. Because of the selection process, the patients who had a mini-incision had both a significantly lower average body-mass index (p=0.008) and a lower average score on the American Society of Anesthesiologists rating (p=0.006), indicating that they Were thinner and healthier than the patients who had a standard incision. Results: With the numbers of patients available, no significant differences were found between the groups with respect to the average surgical time, intraoperative blood loss, in-hospital transfusion rate, length of hospital stay, or the patients' disposition after discharge. The mini-incision group was found to have a significantly higher risk of a wound complication (p=0.02), a higher percentage of acetabular component malposition (p=0.04), and poor fit and fill of femoral components inserted without cement (p=0.0036). Conclusion: There was no evidence that the mini-incision technique resulted in less bleeding or less trauma to the soft tissues of the hip, factors that would have produced a quicker recovery and a shorter hospital stay, than did the standard technique. The present study, which was based on the authors' initial experience With the mini-incision technique, failed to confirm the positive clinical outcomes reported by previous uncontrolled cohort studies, and the findings suggest that further analysis of this new technique is needed before it can be recommended for general use.

Background: Impingement syndrome is one of the numerous causes of shoulder pain. The purpose of this study is to define the factors that can affect the prognosis of conservative treatment of subacromial impingement syndrome. Materials and Methods: From July 2001 to 2002, 102 patients with subacromial impingement, being confirmed by clinical tests of impingement, were enrolled in a prospective case-series study. They were treated conservatively with corticosteroid injection in subacromial bursa, NSAID administration and physiotherapy, and were followed for 12 months. Any patient with less than 11 months follow-up, with radiographic evidence of glenohumeral and acromioclavicalur arthritis, history of acute traumatic rupture of rotator cuff, proximal fracture of humorous, frozen-shoulder, and diabetes was excluded from the study. The scoring system of Constant and Murley was used for evaluation of treatment outcome. Results: 89 patients (44 male and 45 female) with mean age of 56.4 years completed the study. 67 patients (75.3%) were properly treated. There was a significant difference in Constant scores before and after treatment (p<0.05). A poor prognosis could be anticipated in those with weakness and/or atrophy of rotator cuff muscles, more than 120 days interval between initiation of symptoms and treatment, hooked acromion morphology, Acromio-Humeral Interval of less than 7 mm, moderate to severe restriction in active range of motion, and spur in antero-inferior edge of acromion. Age, gender, hand dominancy, side of involvement and history of previous trauma had no significant effect. Conclusion: Patients with "some defined poor prognostic factors" will fail conservative treatment. It might be better to consider other treatment modalities, even surgery, early on.

Background: Congenital scoliosis has often a progressive course, resulting into major cosmetic and functional problems. Early detection of malicious patterns and early treatment planning could prevent major deformities. The distribution of its different forms and treatment results has not been previously reported in Iran. This study presents the incidence and treatment outcome in Southern part of Iran. Materials and Methods: Sixty cases of congenital scoliosis over a 13-year period were studied. The pattern of deformities, all demographic data, the associated anomalies including renal, cardiac, and, in particular, neural canal defects, were studied. The progression of deformities and the results of treatment were evaluated clinically and radiographically. Results: Two peaks of presentation were seen - one in 2 years and another in 8-13 years of age. Parental consanguinity was seen in 40% of cases. From the five patterns that were observed, hemivertebra was the most common; and unilateral unregimented bar with contralateral hemivertebra the most progressive form. Curves at thoracic level were most prevalent. Curve progression index was 9 degrees when un-segmented bar was presenting with a contralateral hemivertebra, and 6 degrees without such a combination. This index was 1.5 degrees for hemivertebra and 0.5 for block vertebra. Presence of fused ribs on concave side of lower thoracic curves was associated with increased progression rate. Spinal dysraphism was diagnosed in 20% of cases. Conclusion: Early detection of progressive patterns of congenital scoliosis and early intervention is necessary. Fusions on concave side of curve are associated with faster progression and may contribute to pulmonary insufficiency.

Background: Knee maniacal and anterior cruciate ligament (ACL) injuries are common. Arthroscopic surgery for maniacal pathology is one of the most common arthroscopic operations done for knee derangement. Different clinical tests have been designed to pinpoint the status of ACL post trauma; such as Pivot Shift and Lachman. Meniscus tear is more commonly diagnosed clinically by Mc Murray test and joint line tenderness. Use of MRI, to confirm the diagnosis has become popular in recent years. Arthroscopic evaluation is a more direct and fruitful technique for diagnosis of such intra-articular pathologies. This study is aimed at assessing the value of clinical tests in diagnosis of ACL and meniscus injuries. Materials and Methods: 177 patients, underwent diagnostic knee arthroscopy in accordance with their positive clinical findings for meniscus or ACL injury. The clinical examinations were all done by a single surgeon and included Mc Murray testing, joint line tenderness, Lachman and Pivot Shift tests. The arthroscopic findings were compared with clinical pre-operative tests. The sensitivity, specificity, positive and negative predictive values of the clinical tests were calculated. Results: The sensitivities of tests for diagnoses of medial maniacal, lateral maniacal and ACL injuries were 98%, 60% and 95% respectively, while specificities were 97%, 100% and 98%. The positive predictive values were 97%, 100% and 96%; and the negative predictive value were 98%, 84% and 97%. Conclusion: Using Mc Murray test combined with joint line tenderness in the case of maniacal injuries, and Lachman test combined with lateral Pivot Shift test in the case of ACL injuries increases the sensitivity, specificity, reliability and accuracy of diagnosis in clinical examination of knee injuries.

Background: Osteochondritis dissecans (OD) is a syndrome that can be characterized as a non-infectious disturbance of enchondral ossification or as a post-traumatic event. OD occurs in the joint cartilage and physis of long bones, as well as in the talus. The medial femoral condyle is the most commonly affected site. OD of the weight-bearing, inferocentral portion of medial femoral condyle is an uncommon, but still challenging issue in knee surgery. Materials and Methods: This study reports one surgeon's experience in the treatment of OD of the weight-bearing surface of the medial femoral condyle in adult patients. A total of 29 knees in 28 patients with OD were reviewed as the basis of this study. Four patients were women and 24 men. The mean age was 29.5 Years. Patients were observed for an average of 2 years after surgery. Medial joint line tenderness, anterior knee pain, stiffiness and locking were the major complaints in 60% of cases, Arthroscopic excision of loose bodies with or without drilling of the crater and fixation of the lesions with 2 K.-wires, with or without bone grafting, was undertaken for the patients.Results: In our study, the clinical outcome was excellent in 11 patients, good in 13, fair in four, poor in one. Arthroscopic internal fixation using two smooth K-wires in 12 cases resulted in an excellent knee in 10 cases and good in 2. All patients reported marked improvement and satisfaction with the surgery. Conclusion: Prognosis for knee function is poor when the OD defect involves a large area of weight bearing surface. Arthroscopic treatment is beneficial in all types of OD lesions. For the lesions of similar size, the stage of OD determines the treatment outcome.

Background: Brachial plexus avulsion injuries cause major devastating neurological dysfunction. Microsurgical repair with nerve transfer from either intraplexus or extra plexus origin, sometimes in combination with free muscle transfer, may produce acceptable functional improvement. Materials and Methods: 62 cases of brachial plexus injury who were treated with nerve transfer and have a 3 year follow-up, are reported here. The aim was to obtain elbow flexion. 44 patients (group 1) received transfer of spinal accessory nerve either to musculocutaneous nerve or directly to suprascapular nerve. 12 patients (group 2) were treated by transfer of intercostals nerves to musculocutaneous nerve. Part of ulnar nerve was used as nerve transfer in 6 more patients (group 3). Results: Elbow flexion power of 3 or 4 was achieved in 29 cases of group 1 (91%). 9 patients in group 2 (75%) and 5 cases of group 3 (83%). Pneumothorax in 5 cases in group 2 and muscle weakness in 6 cases in group 3 (flexor carpi ulnaris weakness in 4 and interossei in 2) were the observed complications. Conclusion: Avulsion injuries of brachial plexus injury are best treated by nerve transfer. Accessory nerve transfer to musculocutaneous nerve is the preferred technique with less complication.

Background: Chondrosarcoma is a primary malignant cartilage forming tumor seen more commoly after fourth and fifth decades of life. It is mostly seen in flat bones of pelvis and around shoulder girdle or in femur. Surgical resection with a wide margin is the main modality of treatment as this tumor is not sensitive to chemotherapy or radiotherapy. This paper analyzes the results of treatment and the survival rate in a group of patients with pelvic chondrosarcomas. Materials and Methods: A total of 28 patients (19 males and 9 females) with chondrosarcoma of pelvis having been treated by different surgeons for the past 20 years were studied in a retrospective manner. The mean age was 38.9 and the average follow-up was 27.8 months. Clinical presentation, surgical methods and complications, and survival rates were studied. Hams Hip Scoring was used to evaluate the functional outcomes in those that limb-sparing surgery was chosen and were still alive at follow-up. Results: Pain and palpable mass were the primary symptoms while two cases had pulmonary metastasis at time of presentation. The tumors were secondary to osteochondromas in 5 and primary chondrosarcomas in the rest. Sixteen patients had low grade and 12 high grade tumors. Twenty-one patients were treated by limb sparing methods and 5 had undergone hemipelvectomy while 2 patients had no surgery. Fourteen patients (12 from limb salvage group and 2 from limb ablation group) are still alive among whom are disease free, 10 have metastatic lesions in lungs and 2 have local recurrence in pelvis. The disease free survival is 32% and overall survival is 27% for patients with pelvic chondrosarcoma. The Harris Hip Scoring was 71 in surviving group. Conclusion: Early diagnosis and wide surgical-margin resection in high grade chondrosarcoma improves prognosis, yielding higher survival and disease-free-interval rates.

Chondrosarcoma is a malignant bone tumor, and treatment is surgical resection. Reasonable survival with radical surgery is to be expected. Such a surgery in scapula would result in major functional impairment. We would like to report on an interesting case with a good upper limb function following the difficult surgery of total scapulectomy.

Cystic Angiomatosis of bone is a rare disease presenting as multiple cystic honey comb-like lesions, involving axial and appendicular skeleton. Lesion size varies from millimeters to several centimeters. The cysts have discrete sclerotic borders and their centers are radiolucent. The inner wall of the cysts is covered with endothelial cells and cysts are filled with gelatinous or bloody liquid. Soft tissues or viscera may be involved too. When bone alone is involved, the prognosis is benign, but whenever simultaneous viscera involvement is present, the disease would be progressive, with poor prognosis. This is a report of two cases of cystic angiomatosis.

The ability of an athlete to return to sporting activities after an anterior cruciate ligament injury is a major point of concern. The question about how long and at what capacity he or she will remain an athlete is difficult to answer. The general answer is that many different factors play role in this matter including: Whether the injury is an isolated tear or is associated with meniscus tear, cartilage defect or antero-lateral instability; what type of sporting activity is considered; what degree of instability is felt by the athlete; what the patient's age is; and what degree of motor loss (especially extension) is present. While the above factors determine the patient's return to sports, they may also contribute to later degenerative process in the knee. In this review, an attempt is made to answer some of the above questions.

Structural bony allograft is bones taken from the same species in the treatment of a variety of tumoral and non tumoral lesions. The major short-term complications of allograft are fracture, infection and nonunion. Allograft fracture and nonunion can be managed with different surgical and non surgical methods.  Allograft infection, especially in immune-compromised cancer patient is very hard to treat and can often lead to limb ablation surgery.