Bony Fragments Research Articles

AN ENIGMATIC ELUSIVE LESION OF THE MANDIBLE THAT REFUSED TO HEAL: A PATHOLOGIST’S NIGHTMARE!!!

<h3>Case report</h3> A 62-year-old woman complained of a nonhealing extraction socket in the lower left back teeth region. She underwent extraction of tooth no. 37 at a private clinic, after which an ulceroinfiltrative lesion developed on the operated side. Multiple biopsies from the lesion were inconclusive. The patient was referred to ONCO OPD at the medical hospital. Fine-needle aspiration cytology and histopathology of an excised lymph node confirmed reactive lymphadenitis. Computed tomography revealed an osteolytic lesion radiologically simulating carcinoma or a chondrosarcoma. Because of persistent debilitating symptoms, the patient underwent white-light examination with left segmental mandibulectomy. Frozen sections were negative for malignancy. Biopsy at the general pathology lab depicted parakeratotic lining with dense inflammation. No evidence of osteomyelitis, necrosis, dysplasia, or malignancy was noted. All margins were free from malignancy. Lymph nodes dissected showed reactive morphology. ZN, PAS, and Gram stain were all negative. Later, a 5 × 2 cm ulceroinfiltrative lesion redeveloped in the region of teeth 32 to 42 slowly progressing toward tooth 45. Positron emission tomography/computed tomography of the lesion showed focal FDG uptake in the anterior mandibular region. Because of increased suspicion of malignancy, white-light examination up to tooth 47 was carried out. Histopathology showed degenerated bony fragments and flakes of lamellated keratin. No evidence of dysplasia or malignancy was noted. The lesion continued to spread even after successful surgical intervention with an adequate surgical margin. The patient was eventually lost because of severe cardiac arrest during her last surgical intervention for mandibular arch reconstruction. This could be a case of a lifetime in which multiple consultations with oral and general pathologists failed to reach a conclusive diagnosis.

Fracture of the inferior pole of the patella: tension band wiring versus transosseous reattachment

BackgroundThe optimal surgical technique for the fixation of inferior pole patellar fracture remains controversial. The aims of this study were (1) to compare clinical and radiological outcomes following fixation of inferior pole patellar fracture by using tension band wire (TBW) and transosseous reattachment (TOR) without excision of the bony fragment and (2) to determine the risk factors for postoperative radiological loss of reduction.MethodsFor this retrospective cohort study, consecutive patients with inferior pole patellar fracture between January 2010 and December 2017 were recruited. The patients were grouped according to their fixation method (TBW or TOR), and demographic data, clinical outcomes, and postoperative Insall–Salvati (IS) ratio were analyzed. Then, the patients were grouped according to radiological loss of reduction, the possible risk factors for loss of reduction were identified, and odds ratios were calculated.ResultThis study included 55 patients with inferior pole patellar fracture; 30 patients were treated using TBW and 25 were treated using TOR. Clinical failure occurred in two patients in the TBW group (7%) and three in the TOR group (12%). The rate of radiological loss of reduction was significant higher in the TOR group, whereas removal of implants was significantly more common in the TBW group. Patella baja was noted immediately after surgery in the TOR group, but the IS ratios of the two groups were similar after 3 months. Fracture displacement of more than 30 mm was the only independent risk factor for postoperative radiological loss of reduction.ConclusionFor treating inferior pole patellar fracture, both TWB and TOR were effective and had a low clinical failure rate. In 60% of patients undergoing TBW fixation, however, additional surgery was required to remove the implants. Patella baja occurred immediately following TOR, but the patellar height was similar to that in the TBW group after 3 months. Surgeons should be aware of the high risk of postoperative radiological loss of reduction, especially when the fracture displacement is more than 30 mm.

Conservative management of posterior cruciate ligament avulsion with a large bony fragment: a prospective cohort study

Background: Internal fixation is the standard choice for treatment of posterior cruciate ligament (PCL) avulsion with a large bony fragment. However, it is not without complication. This study investigated PCL avulsions with large bony fragments to determine if conservative management resulted in acceptable outcomes. Methods: In a prospective cohort study, the outcome of conservative management of PCL avulsion with large bony fragment was evaluated in 40 patients. The inclusion criteria were a fracture size of more than 20 mm and a displacement of less than 2 mm. The outcomes were evaluated after 12 mo and included the evaluation knee range of motion and scoring of the modified Lysholm questionnaire and the International Knee Documentation Committee. Knee instability was checked by the drawer test and confirmed by stress radiography. Results: The mean patient age was 36.9±16.1 yr. The mean final knee range of motion (ROM) was 125.6±8.2 degrees. The mean Lysholm score was 92.3±6.1 points. Accordingly, the excellent, good, and fair results were observed in 29 (72.5%), eight (20%), and three (7.5%) patients, respectively. The mean International Knee Documentation Committee score of the patients was 94.2±5.3 points. Postoperative instability was seen in two patients. Nonunion was observed in two other patients. The size of the bony fragment was 30 and 32 mm in patients with nonunion. Conclusions: Conservative management of the PCL avulsion with a large bony fragment could result in acceptable outcome. However, application of this technique needs further characterization, particularly with respect to the size of bony fragment. Level of Evidence: Level II.

A review of bone grafting techniques for glenoid reconstruction.

Traumatic anterior shoulder dislocations can cause bony defects of the anterior glenoid rim and are often associated with recurrent shoulder instability. For large glenoid defects of 20-30% without a mobile bony fragment, glenoid reconstruction with bone grafts is often recommended. This review describes two broad categories of glenoid reconstruction procedures found in literature: coracoid transfers involving the Bristow and Latarjet procedures, and free bone grafting techniques. An electronic search of MEDLINE and PubMed was conducted to find original articles that described glenoid reconstruction techniques or modifications to existing techniques. Coracoid transfers involve the Bristow and Latarjet procedures. Modifications to these procedures such as arthroscopic execution, method of graft attachment and orientation have been described. Free bone grafts have been obtained from the iliac crest, distal tibia, acromion, distal clavicle and femoral condyle. Both coracoid transfers and free bone grafting procedures are options for reconstructing large bony defects of the anterior glenoid rim and have had similar clinical outcomes. Free bone grafts may offer greater flexibility in graft shaping and choice of graft size depending on the bone stock chosen. Novel developments tend towards minimising invasiveness using arthroscopic approaches and examining alternative non-rigid graft fixation techniques.

"Trap Door" Orbital Floor Fractures in Adults: Are They Different from Pediatric Fractures?

Background:“Trap door” orbital floor fractures are usually seen in children. In the linear fracture type, a break occurs in the bones of the orbital floor that permits orbital tissue to prolapse into the fracture site during fracture formation. The bony fragments of the fracture then return to their original position, entrapping the prolapsed orbital tissue. In the hinged fracture type, the fractured part of the floor is minimally displaced into the maxillary sinus and acts as the hinge of a “swinging door” entrapping the orbital tissue.Methods:We report on a series of 10 adult patients with hinged orbital floor fractures.Results:The mean patient age was 35 years. Seven patients had a pure orbital floor fracture and the remaining 3 patients had fractures of both the orbital floor and the inferior orbital rim. All 10 patients had diplopia in the upgaze. None of the patients had signs of the oculocardiac reflex. None of the CT scans showed a “tear-drop” sign. However, the sagittal CT scans showed evidence of entrapment of the inferior rectus. All patients had a small area of a slightly depressed orbital floor at the site of entrapment, without a bony defect. All patients underwent surgery through an infraorbital incision and a titanium mesh was used in all patients. There were no postoperative complications. All patients regained full range of motion of the globe.Conclusion:This is the first series in the literature that reports on the characteristics and outcome of trap door orbital floor fractures in adults.

A clinicoradiological classification and a treatment algorithm for traumatic triceps tendon avulsion in adults

PurposeTriceps tendon avulsion (TTA) is an uncommon injury, and there are no classifications or treatment guidelines available. This study aims to describe a clinicoradiological classification and treatment algorithm for traumatic TTA in adults. The functional outcome of surgical repair has been evaluated too. MethodsA retrospective analysis of adult patients with traumatic TTA treated in our institution between January 2012 and December 2017 was done. We only included complete TTA injuries. Children below 15 years, with open injuries, associated fractures, or partial TTA were excluded. The data were obtained from hospital records. The intraoperative findings were correlated with the clinicoradiological presentation for classifying TTA. The functional outcome was analyzed using the Mayo Elbow Performance index and Hospital for Special Surgery elbow score. ANOVA test was used to assess the statistical significance. ResultsThere were 15 patients included, 11 males and 4 females. The mean age was (31.5 ± 9.15) years, and the mean follow-up was (22.4 ± 8.4) months. Fall on outstretched hand was the mode of injury. In 6 patients, diagnosis was missed on the initial visit. TTA were classified as Type I: palpable soft-tissue defect without bony mass; Type II: palpable soft-tissue defect with a wafer-thin/comminuted bony fragment on X-ray; Type III: palpable soft-tissue defect with a bony mass and a large bony fragment on X-ray without extension to the articular surface; and Type IV: an olecranon fracture with less than 25% of the articular surface. An algorithm for treatment was recommended, i.e. transosseous suture repair/suture anchor for Type I, transosseous suture repair for Type II, and tension band wiring or steel wire sutures for Types III and IV. All the patients achieved good to excellent outcome: the mean Mayo Elbow Performance index was 100 and Hospital for Special Surgery score was 98.26 ± 2.60 on final follow-up. ConclusionOur clinicoradiological classification and treatment algorithm for TTAs is simple. Surgical treatment results in excellent functions of the elbow. Since it is a single-center study involving a very small number of cases, a multicenter study with a larger number of patients is required for external validation of our classification and treatment recommendations.

A Biomechanical, Cadaveric Evaluation of Single- Versus Double-Row Repair Techniques on Stability of Bony Bankart Lesions

Background: Previous studies comparing stability between single- and double-row arthroscopic bony Bankart repair techniques focused only on the measurements of tensile forces on the bony fragment without re-creating a more physiologic testing environment. Purpose: To compare dynamic stability and displacement between single- and double-row arthroscopic repair techniques for acute bony Bankart lesions in a concavity-compression cadaveric model simulating physiologic conditions. Study Design: Controlled laboratory study. Methods: Testing was performed on 13 matched pairs of cadaveric glenoids with simulated bony Bankart fractures with a defect width of 25% of the inferior glenoid diameter. Half of the fractures were repaired with a double-row technique, and the contralateral glenoids were repaired with a single-row technique. To determine dynamic biomechanical stability and ultimate step-off of the repairs, a 150-N load and 2000 cycles of internal-external rotation at 1 Hz were applied to specimens to simulate early rehabilitation. Toggle was quantified throughout cycling with a coordinate measuring machine. Three-dimensional spatial measurements were calculated. After cyclic loading, the fracture displacement was measured. Results: The bony Bankart fragment–glenoid initial step-off was found to be significantly greater (P < .001) for the single-row technique (mean, 896 µm; SD, 282 µm) compared with the double-row technique (mean, 436 µm; SD, 313 µm). The motion toggle was found to be significantly greater (P = .017) for the single-row technique (mean, 994 µm; SD, 711 µm) compared with the double-row technique (mean, 408 µm; SD, 384 µm). The ultimate interface displacement was found to be significantly greater (P = .029) for the single-row technique (mean, 1265 µm; SD, 606 µm) compared with the double-row technique (mean, 795 µm; SD, 398 µm). Conclusion: Using a concavity-compression glenohumeral cadaveric model, we found that the double-row arthroscopic fixation technique for bony Bankart repair resulted in superior stability and decreased displacement during simulated rehabilitation when compared with the single-row repair technique. Clinical Relevance: The findings from this study may help guide surgical decision-making by demonstrating superior biomechanical properties (improved initial step-off, motion toggle, and interface displacement) of the double-row bony Bankart repair technique when compared with single-row fixation. The double-row repair construct demonstrated increased stability of the bony Bankart fragment, which may improve bony Bankart healing.

Results of Arthroscopic Treatment of Acute Posterior Cruciate Ligament Avulsion Fractures With Suspensory Fixation

This study aimed to evaluate the clinical outcomes for arthroscopic treatment for acute posterior cruciate ligament (PCL) avulsion fractures with a suspensory technique. A total of 30 acute (<3 weeks) isolated PCL tibial avulsion fractures were fixed under arthroscopy using the Endobutton device. After arthroscopic exploration and reduction of the bony fragment, a single tibia tunnel was established; then, the titanium button was guided through the tunnel and flipped onto the bony fragment to stabilize the fracture. Finally, an interference screw was squeezed into the tunnel to fix the end of the loop. Clinical and functional outcomes were evaluated using the Lysholm score, the 2000 International Knee Documentation Committee (IKDC) subjective score, and the IKDC examination form. The mean follow-up time was 32 months (range, 24-47 months). The mean age of the patients was 41 years (range, 21-65 years). All patients achieved bony union and regained satisfactory knee function. No popliteal neurovascular complications or implant loosening was observed. The mean Lysholm score increased from 20.9 ± 7.0 before operation to 97.1±2.7 at the final follow-up. The mean 2000 IKDC subjective score improved from 17.2 ± 5.2 to 96.8 ± 2.6. The IKDC examination grade also improved significantly. This suspensory technique under arthroscopy is a simple, safe, and minimally invasive treatment for PCL tibial avulsion fracture. Suspensory fixation resulted in satisfactory outcomes, including good knee stability and fracture union; this technique can be a reliable alternative to various surgical methods. Level IV, therapeutic study.

Acute Seymour fractures in children/adolescents overlooked as a simple nail injury: Reduction without pinning

We retrospectively report the outcomes of several cases in which acute Seymour fractures were treated by open reduction of displaced distal bony fragments with concurrent nail repair, following complete incision and drainage without K-wire fixation. Among 21 patients surgically treated between March 2004 and December 2018, the final 12 were evaluated after at least 2 years of follow-up. All children/adolescents presented more than 24 h after the injury. All injuries were unreduced in the emergency department, with typical features of skin disruption around the eponychium/perionychium. Reduction was maintained without a K-wire after repairing the bone-periosteum-nail bed-nail plate of the distal fragment and the corresponding physis-periosteum-germinal matrix-proximal nail-fold of the proximal stump. Dorsal angulation, finger length, postoperative pain on visual analog scale (VAS), Disabilities of the Arm, Shoulder, and Hand (DASH) score, and active range of motion (ROM) were evaluated at the final follow-up. The mean patient age was 9.3 years (range, 3–13 years) and the mean time from injury to surgery was 35 h (range, 28–44 h). Only one child suffered a superficial infection; however, it resolved with 1 week of oral antibiotic treatment. At the final follow-up, mean dorsal angulation was 0.50° ± 1.24°; the length ratio compared with the corresponding contralateral phalanx was 98% (both, P > 0.05). The final pain on VAS, DASH score, and ROM ratio were 0.25 ± 0.45, 0.83 ± 1.34, and 99 ± 2%, respectively. Unreduced Seymour fractures presenting more than 24 h after the injury were treated by proper debridement and reduction of the fracture without the use of a K-wire. However, to determine whether the infection rate is definitively lower, this procedure should be compared with the conventional procedure using a K-wire.Level of Evidence: Therapeutic level IV

The diagnostic value of intravenous contrast computed tomography in addition to plain computed tomography in dogs with head trauma

BackgroundThe aim of this study is to evaluate additional findings which can be detected by post-contrast computed tomography (CCT) in relation to plain CT (PCT) findings in patients presented with head trauma. Medical records of canine patients with the history of head trauma from three institutions were reviewed. PCT- and CCT-anonymized images were evaluated by a veterinary radiologist separately. From the categorized findings the following conclusions were drawn as: abnormalities were identified on (A) PCT but missed on CCT, (B) CCT but missed on PCT, (C) both PCT and CCT.ResultsThirty-two patients were included. The results showed that findings identified on CCT or PCT (category A and B) but missed on the other series were limited to mild soft tissue and sinus changes. Overall, 61 different fracture areas, 6 injuries of the temporomandibular joint (TMJ), 4 orbital injuries, 14 nasal cavities with soft tissue density filling, 13 areas of emphysema, 4 symphysis separations, 12 intracranial hemorrhages, 6 cerebral edema, 5 cerebral midline shifts, 3 intracranial aeroceles, 3 brain herniations and 6 intraparenchymal foreign bodies (defined as an abnormal structure located within the brain: e.g. bony fragments, bullet, teeth,..) were identified on both PCT and CCT separately (category C). Severity grading was different in 50% (3/6) of the reported cerebral edema using PCT and CCT images.ConclusionThe results showed that PCT is valuable to identify the presence of intracranial traumatic injuries and CCT is not always essential to evaluate vital traumatic changes.

Follow Up Case of Left Knee TKR: Case Review

Poor wound healing following a major lower limb amputation can result in poor rehabilitation outcomes, which can be further worsened if the patient has recurrent falls and stump trauma during the wound healing stage. Direct trauma to the stump can result in bony fractures at the margins of the residual bones, and loose bony fragments may form inside the stump. These bony fragments can hinder the process of stump wound healing and interfere with prosthetic limb use and rehabilitation.

Periangular transmasseteric infraparotid approach in the treatment of condylar-base and low condylar‑neck fractures

Mandibular condylar fractures account for 25 to 52 % of all mandibular fractures. Though current literature favors open reduction and internal fixation (ORIF) of condylar‑base and low condylar‑neck fractures, extraoral approaches are usually considered to be complicated by the risk of facial nerve injury and other possible complications. This study was undertaken to demonstrate that the periangular transmasseteric infraparotid surgical approach (TMIP) to condylar‑base and low condylar‑neck fractures provides excellent access to the bony fragments with minimal risk of complications such as facial nerve and parotid gland injury. In the period from January 2010 to December 2018, 81patients (96 fractures) with condylar‑base and low condylar‑neck fractures underwent ORIF via periangular transmasseteric infraparotid surgical approach. The results of this retrospective study showed minimal postoperative complications. The periangular transmasseteric infraparotid surgical approach allowed precise anatomic repositioning and fixation of the bony fragments in almost all cases except for two juvenile cases with noticeable scars and one case with plate fracture. There were no transient or permanent facial nerve palsies, parotid gland or salivary fistulae complications during a 12‑month follow‑up period. The periangular infraparotid transmasseteric approach to ORIF of condylar‑base and low condylar‑neck fractures is an effective and safe approach allowing accurate anatomic reposition and fixation of the fragments with minimum surgical complications (Tab. 1, Fig. 12, Ref. 21).

Arthroscopic repair of acute bony Bankart lesions: An analysis of risk factors for instability recurrence

Purpose. To determine clinical and radiological outcomes of patients with acute bony Bankart lesions treated via the arthroscopic approach and evaluate the hypothesis that instability recurrence is associated with fragment reduction quality and/or glenoid defect. Material and Methods . Between 2008 to 2013, 27 patients (mean age 24.3 years) were examined before, and (on average) 29 months after, arthroscopic repair. Inclusion criteria were acute bony Bankart lesions, glenoid osseous defects of less than 20%, and postoperative follow-up period of at least 24 months. Functional recovery was assessed using the Rowe, Western Ontario Shoulder Instability Index (WOSI), and UCLA shoulder rating scales. Computed tomography scans were used to evaluate reduction and healing of bony fragments. Cases of instability recurrence were documented. Results. Postoperative mean Rowe score was 90.4 points (range, 35 to 100 points), the mean WOSI was 282.0 (range, 25-1100 points), and the mean UCLA was 28.5 points (range, 15 to 35 points). The recurrence rate of shoulder instability was 7.4% (2/27), which only occurred in cases of fragment malposition. The average loss of external rotation was 5o at 0o of abduction, and 7o at 90o of abduction. Twenty three patients (85.19%) returned to preinjury sport level. Radiological assessment revealed complete union of the bony fragment in all cases. Conclusion . Arthroscopic reduction and suture anchor fixation of acute bony Bankart lesions yield excellent outcomes providing a low recurrence instability and high bone union rates. In addition, non-anatomical reduction of the bony fragment is a reliable risk factor for instability recurrence in acute cases.

Clinical outcome of tibial spine ACL avulsion fracture in adults treated with suture bridge fixation

Introduction: Anterior cruciate ligament avulsion from the tibia with a bony fragment of the tibial spine is an uncommon injury of the knee joint. These are predominantly seen in children and young adults. Arthroscopic reduction and fixation of the tibial avulsion fracture is a technically demanding procedure as restoring the ACL length and tension during fixation is important to ensure stability of the knee while maintaining range of motion and minimal knee laxity. The purpose of the study was to evaluate the outcome of Arthroscopic Suture bridge fixation of tibial spine anterior cruciate ligament avulsion fractures. Materials and Methods: We followed up seven patients prospectively after Arthroscopic suture bridge fixation. The patients were assessed with clinical examination, Tegner Lysholm and IKDC (International Knee Documentation Committee) knee scores. The study group consisted of 5 males and 2 females with a mean age of 24.28 years (Range 18 years to 32 years). Mean follow-up time was 28.7 months (range 24 to 36 months). The study included 4 type II and 3 type III Meyer and McKeever fractures. Results: At follow-up the mean Tegner lysholm score was 91.28. The best results were seen in younger patients. Younger patients had significantly better score for IKDC functional and final scores. Conclusion: Displaced tibial spine avulsion fractures can be successfully treated in younger and older patients using arthroscopic suture bridge fixation with most patients returning back to preinjury levels of activity. Keywords: Arthroscopy, Tibial fractures, Avulsion, Anterior cruciate ligament injuries, Fracture fixation internal.

Long PFN nailing in comminuted high subtrochanteric fractures femur in lateral position on ordinary table

Introduction: Most of the hip fractures are managed in supine position on a fracture table with foot attached to foot plates and biplanar fluoroscopy supervision under c-arm. But this procedure has its own difficulties in managing especially comminuted subtrochanteric fractures, where in different fragments and segments are being pulled by strong muscles around hip, and getting good reduction and alignment is difficult due to displaced bony fragments being held in traction on fracture table and cannot be manipulated easily. This leads to prolonged operative time, opening of fracture site, increased bleeding, increased chances of infection and over all increased anaesthesia time adding up to risk factors. The purpose of this study was to report how these difficulties can be overcome by operating on a simple radioluscent top operating table in lateral position without a fracture table. Materials and Methods: 74 cases of subtrochanteric fractures with or without comminution were operated in lateral position on simple ordinary radioluscent top table with lesser attachments and adjustments to operating table during the study duration were included in the study. We used long Proximal Femur Nail (PFN) (length more than 25cms 34, 36, 38, 40cms long) to fix these fractures. Results: In the present study, age group of patients was 25yrs to 74yrs. Male patients (83.7%) were more than female patients (16.3%) An average of less than 150 ml in closed surgery. The average operative time for all cases was 80 minutes. Union time varied from 16 weeks in simple fractures to 26 weeks in comminuted fractures. Clinical function of hip and knee was excellent with full range of movements. Conclusions: Reduction and fixation of proximal femoral fractures in the lateral position with fluoroscopy or portable radiography in the anteroposterior view for small set ups and rural hospitals that lack a fracture table or advanced fluoroscopic devices may be executable and probably safe. Keywords: L

Arthroscopic Acute Bony Bankart Repair in Lateral Decubitus

The optimal management of anterior shoulder instability continues to be a challenge. The presence of an anterior glenoid rim fracture in the context of a glenohumeral dislocation, also called “bony Bankart lesion,” can alter therapeutic behavior. Reduction and fixation of the bone fragment has been shown to greatly reduce the risk of recurrence once bone consolidation is achieved. However, there is no gold standard surgical technique. Stability of fixation and the healing of the bony fragment are still a concern, and there are no clinical studies comparing the different techniques to date. The aim of this report is to describe an arthroscopic double-point fragment fixation technique in lateral decubitus for the treatment of an acute traumatic shoulder dislocation with a bony Bankart lesion.

Progression of Epiphyseal Cartilage and Bone Pathology in Surgically Treated Cases of Osteochondritis Dissecans of the Elbow

Background: Although a variety of pathologic conditions associated with osteochondritis dissecans (OCD) have been reported, the pathological progression has remained unclear. Hypothesis: Separation of the immature epiphyseal cartilage is an early event in OCD, and osteonecrosis in the articular fragment is a late event. Study Design: Case Series; Level of evidence, 4. Methods: The participants were 26 boys (mean age, 13.8 years; mean skeletal age score for the elbow, 24.6 points) with capitellar OCD who underwent osteochondral autograft transplantation. A total of 28 cylindrical osteochondral plugs, including the articular fragment, an intermediate layer, and proximal epiphyseal bone, were harvested from the central area of the capitellum and were examined histologically. The articular fragments of OCD were independently assessed by 5 observers and divided into 4 pathological variations: IA, nearly normal-cartilaginous; IB, deteriorated-cartilaginous; IIA, cartilage-ossifying; and IIB, cartilage-osteonecrotic. The reliability of assessment and the correlation of the pathological variations with the clinical data were examined. Results: The reliability of the assessment among 5 observers was almost perfect (Cohen kappa value = 0.91). OCD variations of IA, IB, IIA, and IIB were evident in 5, 10, 5, and 6 patients, respectively. OCD-I (cartilaginous) and OCD-II (osteochondral) corresponded significantly to radiographic stage I (radiolucency or slight calcification with open physis) and stage II (delayed ossification or bony fragment), respectively (Cohen kappa value = 0.79; percentage agreement = 81%). The pathological OCD variations were significantly correlated with the clinical data, including the period from symptom onset to surgery, patient age, and the skeletal age score (P < .01, in each). Conclusion: The present study has revealed that the pathological variations correspond to the progression of OCD, thus proving our hypothesis. OCD-IA was shown to be an early lesion caused by separation of the immature epiphyseal cartilage. OCD-IB appeared to result from ossification arrest over a prolonged period from the onset of OCD-IA, whereas OCD-IIA showed delayed ossification in the epiphyseal cartilage where vascularization from the surrounding bone had been established. Osteonecrosis in OCD-IIB was shown to be a late pathological event caused by disruption of the vascular supply to OCD-IIA.

Relationship between Fracture of the Ulnar Styloid Process and DRUJ Instability: A Biomechanical Study.

Background There has been clinical question in the treatment of ulnar styloid fracture with distal radius fracture, surgical fixation of the styloid fragment, or ignorance of the fragment. We examined relationship between size of the ulnar styloid fracture and distal radioulnar joint (DRUJ) stability biomechanically to answer the above clinical question. Methods Changes in the dorsopalmar stiffness of the DRUJ after experimentally simulating in four types of ulnar styloid fractures were examined in cadavers. After tip, middle, base-horizontal, and base-oblique type of styloid fractures were made sequentially, changes in dorsopalmar DRUJ stiffness were measured using the MTS machine in the intact wrist, for each fracture, at 60 degrees pronation, neutral, and 60 degrees supination, respectively. Additional cutting of the radioulnar ligament (RUL) at the fovea was also simulated with the base-horizontal fracture. Results The tip and middle type fractures did not demonstrate significant loss of stiffness compared with the intact. The base-horizontal fracture demonstrated only significant loss of stiffness in the dorsal direction (radius palmar; ulnar dorsal) with forearm in neutral rotation. The base-oblique fracture demonstrated significant loss of dorsopalmar stiffness of the DRUJ. Additional section of the RUL with the base-horizontal fracture induced significant loss of stiffness of the DRUJ compared with the intact. Conclusions Because the RUL originates from the fovea as well as from the base of the ulnar styloid, these results suggest that DRUJ instability closely correlates with how much of the bony fragment includes the originating portions of the RUL. The findings further suggest that larger base-oblique and base-horizontal fragments with resultant DRUJ instability must be reattached, but that even base-horizontal fragment as well as tip and middle ulnar styloid fragment can be ignored when there is no instability.

CONSERVATIVE VERSUS K-WIRE PINNING OF ACUTE MALLET FINGER IN ADULTS

Mallet finger lesions are common. The diagnosis of mallet finger is essentially clinical, the patient's recent history includes the mechanism of injury. A radiographic lateral and anteroposterior views of the DIPJ usually see bony avulsion of distal phalanx or it may be a ligamentous injury with normal bony anatomy, Wehbe and Schneider described a method to measure the size and displacement of the bony fragment. The aim of this study is to compare the results between of conservative and K-wire pinning management of acute mallet finger Doyle type I in adult patients. Patients were divided into two groups. Group (A) were treated with aluminum orthosis that immobilized the DIPJ in full extension for six weeks. And Group (B) were treated with percutaneous fixation of the distal interphalangeal joint using a smooth Kirschner wire. No external splint age was used and the wire was removed after six weeks. A total of 40 patients suffering from acute mallet finger type I Doyle's classification admitted in orthopedics and traumatology department of Sohag university hospital from February 2019 to November 2019. All patients had Follow up radiographs taken of the affected finger at one week, four weeks, and eight weeks. Functional outcomes were determined using Crawford’s evaluation criteria. The final extensor lag was significantly better in the pin group (12.3 vs 6.6°). The amount of improvement between the groups was statistically significant and in favor of percutaneous pinning (16.15 vs 20.55°), also the flexion loss was lesser in pin group (5.4 vs 4.1°). The optimal treatment for mallet finger injuries remains controversial in the literature. Many orthotic devices for conservative management and surgical techniques have been described in the past. This study shows that closed reduction by use of K-wires provide functionally better result in acute mallet finger cases. Surgical treatment by a single k-wire is better than conservative treatment as regard clinical and radiological results. Conservative technique may have less complications, but the difference in final clinical results is in favor of surgical treatment

Symptomatic ossicle lesion at the anterior tip of the medial malleolus in soccer players

BackgroundUnfused accessory ossification centers in the medial ankle are sometimes misdiagnosed and should be distinguished from other bone lesions such as fracture, stress fracture, os subtibiale, or pseudoarthrosis of the medial malleolus. The purpose of this study was to report our experience in treating soccer players with bony elements in the subtibial region. MethodsWe surgically treated seven soccer players who experienced medial ankle pain with bony fragments at the tip of the medial malleolus. Their ages were between 13 and 27 years. The mean duration from symptom onset to hospital visit was 4.7 years (range: 2 months to 14 years). The bony lesion located at the anterior tip of the medial malleolus in all patients and we diagnosed the lesion as an unfused accessory ossification center. ResultsThree types of surgical treatments were performed in patients according to age, ossicle size, status of the epiphyseal plate, and degenerative changes around the lesion. Bony fusion was achieved in patients who underwent open reduction and fusion with bone graft. Patients who underwent focal drilling or removal of the bony fragment experienced improvement in symptoms, and all patients were allowed to resume their sports or full preinjury activities. ConclusionWe believe that surgery is the first-line treatment for the patients with unfused accessory ossification centers with their prolonged symptom and favorable outcomes can be expected. Bony fusion should be attempted in the patients with the large ossicle especially in their growth period.