Triple dislocation around the knee joint: a case report

Background Dislocation of the knee is a serious and potentially limb-threatening injury. There are three types of dislocation around the knee joint: patellofemoral, tibiofemoral, and tibiofibular. Tibiofemoral dislocation is the variant that is deemed the most serious, with a higher risk of compromise to the popliteal artery and common peroneal nerve. Although simultaneous dislocations of two types have been described, there has been no such description of all three types occurring simultaneously. Case presentation We present a case of a 40-year-old hairdresser who suffered a fall off her moped in Spain, and simultaneously dislocated all three articulations around the knee. Diagnosis was achieved with clinical examination, plain films, and computed tomography and magnetic resonance imaging scans. Management consisted of initial surgical debridement and reduction with stabilization of the affected joints. Conclusion Dislocation of the knee is an uncommon but life changing and potentially limb-threatening injury. It should always be suspected in trauma patients who present with multiligamentous knee injuries. The main concern is of neurovascular compromise to the lower leg, namely, the popliteal artery and common peroneal nerve. The treatment of multiligamentous knee injuries for most patients is surgical treatment with physiotherapy and adequate stabilization of the knee joint. Close monitoring of progress of the knee in terms of persistent laxity, range of movement, and functional status is required for at least 1-year post injury. Current evidence suggests that, despite good functional outcomes for knee dislocations in the short term, the prevalence of post-traumatic osteoarthritis is high in the long term.

Catheter knotting in a neonate

A 36-week preterm neonate with anal atresia and rectoperineal fistula was catheterized with a size 6F Foley’s catheter when she underwent anoplasty on the second day after birth. When the patient recovered from anesthesia, it was decided to remove the catheter. While the catheter was being removed, resistance was felt halfway through the procedure. Abdominal plain films revealed a catheter coiled in the pelvis. With copious lubricant injected into the bladder through the catheter and patient sedated, it was removed by manipulation alone using gentle traction (Figure 1). The infant had no bleeding at the urethral meatus and no obvious abnormality in urination during the 3-month of follow-up.

Resonant Precession of Magnetization and Precession - Induced DC voltages in FeGaB Thin Films

Measurements of frequency dependent ferromagnetic resonance (FMR) and spin pumping driven dc voltage (Vdc) are reported for amorphous films of Fe78Ga13B9 (FeGaB) alloy to address the phenomenon of self-induced inverse spin Hall effect (ISHE) in plain films of metallic ferromagnets. The Vdc signal, which is antisymmetric on field reversal, comprises of symmetric and asymmetric Lorentzians centered around the resonance field. Dominant role of thin film size effects is seen in setting the magnitude of static magnetization, Vdc and dynamics of magnetization precession in thinner films (≤ 8 nm). The film thickness dependence of magnetization parameters indicates the presence of a magnetically disordered region at the film – substrate interface, which may promote preferential flow of spins generated by the precessing magnetization towards the substrate. However, the Vdc signal also draws contributions from rectification effects of a ≈ 0.4 % anisotropic magnetoresistance and a large (≈ 54 nΩ.m) anomalous Hall resistivity (AHR) of these films which ride over the effect of spin – orbit coupling driven spin-to-charge conversion near the film – substrate interface. We have addressed these data in the framework of the existing theories of electrodynamics of a ferromagnetic film subjected to radio-frequency field in a coplanar waveguide geometry. Our estimation of the self-induced ISHE for the sample with 54 nΩ.m AHR shows that it may contribute significantly (≈ 90%) to the measured symmetric voltage. This study is expected to be very useful for fully understanding the spin pumping induced dc voltages in metallic ferromagnets with disordered interfaces and large anomalous Hall effect.

Aortic knob diameter in chest radiographs of healthy adults in Uganda.

Background The burden of cardiovascular diseases, such as aortic and degenerative diseases grows in the aging population. Chest radiograph still plays an important role in the diagnosis of cardiovascular diseases. Aortic knob diameter in chest radiographs can be used to evaluate early changes of the aortic structure and together with clinical and laboratory findings. This study was aimed at determining the mean values of aortic knob diameter among healthy adults in Uganda. Methods We conducted a descriptive cross-sectional study in three selected hospitals in Kampala Uganda. All participants had normal chest radiographs without radiological evidence of cardiovascular disease. Chest radiograph findings extracted included aortic knob diameter, aortic arch diameter, transverse heart diameter and transverse thoracic diameter. All films were independently examined by two experienced radiologists. Results We analyzed chest radiograph findings of 294 participants, of which 204 (69.4%) were male. Aortic knob diameter increased with age (p – 0.000). The mean aortic knob diameter of males was higher than for females (3.14±0.34cm versus 2.77±0.37cm, p – 0.000). The mean aortic knob diameter on the digital screen were higher than plain films (3.03±0.393cm versus 2.96±0.392cm, p – 0.000). Aortic knob diameter positively correlated with age (p – 0.000) and aortic arch diameter (p – 0.000). Aortic knob diameter also correlated positively with transverse thoracic diameter (p – 0.05), transverse heart diameter (p – 0.05) and cardiothoracic ratios (p – 0.05). Conclusion The aortic knob diameter was higher in males and there was a positive correlation with age, aortic arch diameter, transverse heart diameter and transverse thoracic diameter. Aortic knob diameter measurements should be done on digital screen than printed x ray films.

Efficacy of tantalum rod insertion for preventing femoral head collapse in osteonecrosis in a paediatric population: a pilot study

ABSTRACT Femoral head osteonecrosis in the paediatric population is difficult to treat, with the primary goals of management being prevention of subchondral collapse and the avoidance of early total hip replacement. This study aims to describe the use of a porous tantalum rod implant to provide mechanical support in preventing femoral head collapse in a paediatric population. A retrospective chart-based analysis of patients with osteonecrosis of the hip was performed at our institution to identify those who had undergone tantalum rod insertion. A total of 10 patients (fives males and five females, median age 12.5 years, 9–18) had tantalum rods implanted between December 2013 and February 2018. One patient was excluded due to follow-up at a different institution. The radiographic degree of osteonecrosis was characterized according to the Ficat classification and the Kerboul angle. Radiographic assessment of pre- and post-operative plain films was performed. The outcome measures were Tonnis grade and percentage collapse of the femoral head. Nine patients with a mean follow-up time of 18.4 months were included in the analysis. There was no significant increase in the femoral head collapse percentage post tantalum rod insertion compared to pre-operatively (P = 0.63). There was a significant increase in the Tonnis grade post-operatively (P < 0.05), with sub-group analysis showing minimal increase in Ficat Stage 1 patients. This study is the first to examine the role of tantalum rod insertion in preventing femoral head collapse in a paediatric population, with results suggesting potential benefit in a subset of patients.

Incidence of Screw Loosening in Cortical Bone Trajectory Fixation Technique between Single- and Dual-Threaded Screws

Purpose: This study aims to elucidate the radiological outcome after Cortical bone trajectory (CBT) screw fixation and whether dual-threaded (DT) screws should be used in the fusion surgery. Methods: 159 patients with degenerative lumbar disorder who had undergone midline lumbar inter-body fusion surgery by CBT screw-fixation technique (2014 to 2018). Patient subgroups were based on single-threaded (ST) or DT screw, fixation length, as well as whether fixation involved to sacrum level (S1). Serial dynamic plain films were reviewed and an appearance of a halo phenomenon between screw–bone interfaces was identified as a case of screw loosening. Results: 29 patients (39.7%) in ST group and 10 patients (11.6%) in DT group demonstrated a halo phenomenon (p < 0.0001 ****). After subgrouping with fixation length, the incidence rates of a halo phenomenon in each group were 11.1%:3% (ST-1L vs. DT-1L), 37%:13.8% (ST-2L vs. DT-2L), and 84.2%:23.5% (ST-3L vs. DT-3L). Among the 85 patients with a fixation involved in S1, 26 patients (52%) with single-threaded screw (STS group) and 8 patients (22.8%) with dual-threaded screw (DTS group) demonstrated a halo appearance (p = 0.0078 **). After subgrouping the fixation level, the incidence of a halo appearance in each group was 25%:0% (STS-1L vs. DTS-1L), 40.9%:26.3% (STS-2L vs. DTS-2L), and 87.5%: 30% (STS-3L vs. DTS-3L). Conclusion: Both fixation length and whether fixation involved to S1 contribute to the incidence of screw loosening, the data supports clinical evidence that DT screws had greater fixation strength with an increased fixative stability and lower incidence of screw loosening in CBT screw fixation compared with ST screws. Level of evidence: 2.

159 The Need Of Six Monthly Follow Up X-Rays Post Total Knee Replacement(TKR)

Background There is a longstanding culture of repeat x-rays after total knee replacement (TKR) as part of follow up, often combined with a clinic review. This is to check that the prosthesis is in a satisfactory position. There are inherently a number of issues with this historic approach including exposure of patients to further radiation who may be asymptomatic, time delays in busy clinics or x-ray departments and costs. Objectives The aim of this audit was to assess whether follow up plain films after TKR are methodically undertaken and of benefit to confirm satisfactory appearance if immediate post -operative x-rays were unremarkable. The findings of a six month follow up x-ray was specifically evaluated. The secondary aim was to establish the timing of further follow up x-rays within the department. Method 200 patients were included within the analysis, they all received a TKR at a major trauma centre, over a one-year period between December 2017 and December 2018. Results It was found that 100% of those patients having a post-operative film had a satisfactory appearance. 78% of patients had at least one further follow op x-ray of which 99.4% were satisfactory. Up to five follow up x-rays were taken with 53.5% of patients having a follow up x-ray at 6 months. Conclusions From the above results there is minimal, if any, evidence within the data set to support routine, additional follow up imaging if initial post-operative films are satisfactory, and the patient is asymptomatic.

Subaxial Lordosis Loss and Influence Factors After Posterior Atlantoaxial Fusion

Summary of Background Data: Cervical sagittal balance, an important evaluation index of cervical physiological function and surgical efficacy. Subaxial kyphosis after atlantoaxial fusion is negatively associated with worse clinical outcome and higher incidence of lower cervical disc degeneration. Objectives: This study aimed to confirm the factors that influence subaxial lordosis loss after posterior atlantoaxial fusion. Methods: We performed a retrospective review of all patients following posterior C1-C2 fusion for atlantoaxial dislocation between January 2015 and December 2017. All charts, records, and imaging studies were reviewed for each case, and preoperative, immediate postoperative, and final follow-up plain films were evaluated. Comparing final follow-up and preoprative C2-C7 angle, patients were divided into two groups for further comparison: subaxial lordosis loss group and subaxial lordosis increase group.Results: A total of 18 patients were included in the review, with an average radiographic follow-up of 8.4 ± 3.7 months (range, 6 to 17 months). Subaxial lordosis loss was observed in 5 cases (27.8%) at the final follow-up, whereas 13 cases had an increase of subaxial lordosis. The cervical sagittal parameters of preoperative and final follow-up between two groups were compared, the preoperative C2-C7 angle of the subaxial lordosis loss group was bigger than the subaxial lordosis increase group (27.6°±10.5° vs 10.5°±10.5°, P<0.05), but there was no statistical difference in other parameters. Univariate chi-square analysis showed that reduction of subaxial lordosis after posterior atlantoaxial fusion was associated with preoperative C2-C7 angle ≥20° (χ2=4.923, P=0.026). However, Logistic regression analysis showed that the preoperative C2-C7 angle ≥20° was not an independent risk factor (OR=0.147, P=0.225). Conclusion: Our study demonstrates that subaxial lordosis loss may occur after posterior atlantoaxial fusion, and preoperative C2-C7 angle ≥20° was a risk factor of postoperative loss of subaxial lordosis.

A rare case of intestinal obstruction in pregnancy

Intestinal obstruction (IO) in pregnancy is rare at 1 in 2500 to 1 in 16709 deliveries with an incidence of 0.001% to 0.003%. Although uncommon, IO in pregnancy carries significant maternal (6%) and fetal (26%) mortality. A 30-year-old, primigravida, at 33weeks 4 days of gestation presented to the emergency obstetrics department of Swaroop Rani Nehru Hospital, Prayagraj, Uttar Pradesh, India with a 2-day history of diffuse abdominal pain, distension and obstipation. The decision of emergency caesarean section was taken and a 2.5kg healthy female baby was delivered. Surgical opinion was sought intraoperatively. Segmental resection and anastomosis, adhesiolysis and appendicectomy was done. Patient discharged on 10 post-operative day along with her baby in satisfactory condition. Diagnosis of SBO can be difficult to make as symptoms are often attributed mistakenly to pregnancy and there can be a reluctance to request plain films owing to the risks of ionising radiation. Both of these factors can lead to a delay in diagnosis and initiating treatment. Clinical suspicion is vital and joint management between surgeons and obstetricians is crucial. In agreement with previous literature reviews regarding the need for prompt laparotomy in most cases of SBO, we recommend that patients with confirmed adhesional obstruction may be managed conservatively in the first instance but with a low threshold for progressing to laparotomy.

Neoplastic Elbow Diseases and Mimickers

Tumors around the elbow are infrequent, and delayed diagnosis is a common theme because of the low incidence and lack of familiarity. However, just like any other site, the radiologic work-up of musculoskeletal tumors around the elbow remains the same, with plain films the first investigation in a patient with a suspected bone tumor and ultrasound the first modality to evaluate a soft tissue lump. The management of both bone and soft tissue tumors around the elbow is unique because of a large number of important structures in an anatomically confined space and little normal tissue to spare without severely compromising the joint's function. Many benign nonneoplastic entities can mimic bone and soft tissue tumors on imaging. It is important to keep the characteristic imaging appearance in mind while formulating a differential diagnosis to avoid an unnecessary additional work-up. This article reviews the most common benign and malignant bone and soft tissue tumors around the elbow, mimickers, imaging features, and current therapeutic concepts.