Chronic Patellar Tendon Rupture Reconstructed with Hamstring Graft – A Case Report

Neglected patella tendon rupture which are presented 6 weeks after injury are rare but it can be disabling. Aim of study is to determine the outcomes of chronic patellar tendon rupture reconstructed using hamstring graft. This case report concerns a 26 year-old man who came with complaints of weakness of legs, difficulty in climbing stairs up and down, difficulty in getting up from squatting position. X-ray of Right knee showed high riding patella. MRI showed full thickness rupture of ACL. The patient was operated with a combination of Chen et al and ganga hospital SR Sundararajan7. Our outcome was also excellent with no extensor lag, Kujala score was 94.1, Lysholm score was 92.3. From our study it is found that even in chronic neglected cases of patellar tendon rupture, good functional results can be obtained by repair using hamstring graft.

Conservative versus Surgical Treatment in Management of Closed Mallet Finger:A Systematic Review and MetaAnalysis

Background Several methods of treatment have been mentioned in management of closed mallet finger injury, as conservative methods using stack splint,dorsal aluminum splint or custom thermoplastic splint, or surgical procedures as direct pinning method, extention block technique or hook plate fixation, there is no consensus for the best method of treatment. Objectives to review and meta-analyze the outcomes of conservative versus surgical treatment in management of closed mallet finger injury and statistically compare between their results of pain, extensor lag, range of motion of distal inter-phalangeal joint. Materials and Methods The review will be restricted to randomized controlled trials (RCTs), clinical trials, and comparative studies, either prospective or retrospective, which studied the outcome of conservative versus surgical treatment in management of closed mallet finger, articles published in English. PRISMA flow chart 950 articles were found using search keywords. By filtration and screening of the title and exclusion of unrelated articles, 150 articles were found. By applications of all inclusion and exclusion criteria, only 55 articles which met all inclusion criteria, 50 studies were systematically reviewed, and 5 randomized controlled trials were fit to undergo a meta-analysis, after conducting meta-analysis we found that P value for pain svore based on visual analogue score (VAS) was 1, extensor lag P value < 0.001, and range of motion P value <0.001. Conclusion No significant differences was found between the conservative and the surgical groups regarding the pain score, distal inter-phalangeal joint extensor lag, and distal inter-phalangeal joint range of motion in treatment of closed mallet finger.

Patellar Tendon Allograft Reconstruction

Background: Chronic patellar tendon injuries can cause significant functional deficits due to anterior knee pain, extension weakness, and extensor lag. With chronic injuries, the tissue is inadequate and of poor quality. Chronic injuries require autograft or allograft for augmentation or reconstruction. We present reconstruction of a chronic patellar tendon injury with Achilles tendon allograft. Indications: Chronic patellar tendon injuries causing functional deficits, including knee extension weakness, extensor lag, and anterior knee pain. Technique Description: A longitudinal incision is made over the patellar tendon, and the patellar tendon is excised. Two guide pins are drilled in a retrograde fashion through the patella and are overdrilled with a reamer. A trough is made at the tibial tubercle using an oscillating saw. The Achilles allograft calcaneal bone block is contoured to the appropriate size, and then press fit into the trough. Two 4.0-mm fully threaded cannulated screws with washers are used to secure the bone block. The fresh frozen Achilles allograft is doubled over, and a double Krackow running locking suture is placed. A V-Y advancement of the quadriceps tendon is performed to ensure adequate advancement of the patella. The limbs of the Krackow suture are pulled through the patella drill holes and tied with knee in full extension. Results: At 1 year, patients can expect near full range of motion with minimal extensor lag. Reconstruction results in improved pain and function as compared with preoperatively, as well as return to activities. Conclusion: Achilles tendon allograft is a good option for reconstructing chronic patellar tendon injuries. Advantages of the Achilles allograft include the bone-to-bone healing at the tibia, lack of donor site morbidity, and the large amount of tissue available for reconstruction.

A 4-year study of the use of the short metacarpal cast in the management of metacarpal shaft fractures

We report on our experience of using a short, moulded metacarpal cast over a 4-year period in the non-surgical management of metacarpal shaft fractures. Between 6 April 2015 and 6 April 2019, 117 patients were treated using this method. The majority were male, and the mean age was 24.6 years. The most common mechanism of injury was a punch injury (73 patients, 62%). Fifteen patients (13%) were treated for multiple metacarpal fractures. Immediately after cast removal, 68% had a full range of finger movement and 68% were pain free. Few required formal hand therapy. Fifteen patients experienced minor complications, primarily soft tissue irritation from the cast and non-limiting extensor lag. The moulded short metacarpal cast is an effective non-surgical treatment for angulated extra-articular metacarpal fractures of the diaphysis and diametaphyseal junction. Level of evidence: IV

Outcomes After Surgically Managed Oblique Extra-Articular Proximal Phalanx Fractures: A Comparison of Closed-Reduction Percutaneous Pinning and Open-Reduction Internal Fixation With Lag Screws

Background Long oblique extra-articular proximal phalanx fractures are common orthopedic injuries. When unstable and without substantial comminution, treatment options include closed-reduction percutaneous pinning (CRPP) and open-reduction internal fixation using lag screws (ORIF-screws). The aims of this study are primarily to compare the functional outcomes and complication rates between these techniques and secondarily to assess potential factors affecting outcomes after surgery. Methods All patients with long oblique extra-articular proximal phalanx fractures treated surgically within a single orthopedic institution from 2010 to 2017 were identified. Outcome measures and complications were assessed at the final follow-up. Results Sixty patients were included in the study with a mean time to the final follow-up of 41 weeks (range: 12-164 weeks). Thirty-four patients (57%) were treated with CRPP and 26 patients (43%) with ORIF-screws. The mean Disabilities of the Arm, Shoulder, and Hand score across both fixation types was 8 (range: 0-43) and did not differ significantly between the 2 groups. Mean proximal interphalangeal extension at the final follow-up was 9° short of full extension after CRPP and 13° short of full extension after ORIF-screws. The rates of flexion contracture and extensor lag were 15% and 41% in the CRPP group compared with 12% and 68% in the ORIF-screws group. Reoperation rates and complication rates did not differ significantly between fixation strategies. Conclusions Acceptable outcomes can be achieved after surgical fixation of long oblique extra-articular proximal phalanx fractures using both CRPP and ORIF-screws. Extensor lag may be more common after ORIF-screws.

The non-operative management of bony mallet injuries

Over a 4-year period, 218 mallet fractures in 211 adult patients were treated using a custom-made thermoplastic splint. Clinical results were collected prospectively, including the visual analogue score for pain, the range of motion and extensor lag, and the Patient Evaluation Measure (PEM). The joints were congruent in 168 and subluxed in 50. There were no differences in range of movement, extensor lag or PEM associated with articular subluxation or the size of the articular fragment. Pre-existing joint degeneration did not influence outcome. Non-surgical treatment demonstrates predictably good outcomes regardless of fragment size or subluxation in most patients and should be considered when discussing treatment for patients with bony mallet fractures. Level of evidence: III

Transosseous Repair of Patellar Sleeve Fractures: A Case Series and Surgical Technique Guide

The purpose of this study is to describe the surgical technique and outcomes of transosseous repair of patellar sleeve fractures in a pediatric cohort. A retrospective review was performed on patients younger than 16 years undergoing transosseous repair of distal patellar sleeve fractures. A chart review was performed on demographics, surgical repair technique, and postoperative care. Primary outcomes included intact extensor mechanism function and range of motion (ROM) at final follow-up. In this study, 20 patients, 17 males and 3 females, with a mean age of 11.7 years were included. ROM was initiated at a median of 27.5 days following surgery. All patients had a healed patellar sleeve fracture and intact extensor function at final follow-up. Final mean knee ROM among the 18 patients with minimum 3-month follow-up was 132 degrees. Thirteen patients (72%) achieved full ROM (≥ 130 degrees) and 5 patients (28%) achieved less than 130 degrees knee flexion. Duration of initial immobilization was found to be the only variable strongly associated with final postoperative ROM. Mean duration of immobilization for patients achieving ≥ 130 degrees was 24 days versus 44 days in those patients achieving < 130 degrees, p = 0.009. All patients who began knee ROM within 21 days of surgery obtained full knee ROM. No patients experienced construct failure or extensor lag. Operative management of displaced patellar sleeve fractures with anatomic transosseous suture repair of the sleeve fracture, brief immobilization no more than 21 days, and initiation range of early ROM results in excellent outcomes.

Toe-to-Finger Vascularized Joint Transfers for Proximal Interphalangeal Joint Reconstruction: A Systematic Review

Vascularized joint transfer (VJT) from the proximal interphalangeal joint (PIPJ) of the toe is an attractive reconstructive option in cases of nonsalvageable finger PIPJ but is limited by equivocal functional outcomes. This systematic review aims to provide an update on vascularized toe-to-finger PIPJ transfers, examining functional outcomes, complications, and the latest refinements in operative technique. A systematic review of the available literature was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies examining vascularized toe-to-finger PIPJ transfer for post-traumatic indications were included for analysis. Outcomes assessed included postoperative active range of motion, extension lag, and complications. Thirteen studies examining 210 VJTs were analyzed. Five VJTs experienced microsurgical failure giving an overall survival rate of 97.6%. Average postoperative PIPJ active range of motion (ROM) was 40.3° ± 12.9°, with an average extensor lag of 29° ± 10.5° and mean flexion of 68.9° ± 10.9°. For studies reporting complication outcomes, 59/162 complications were seen. No significant differences were seen between studies published prior to 2013 and after 2013 when comparing digital ROM ( P = .123), flexion ( P = .602), and extensor lag ( P = .280). Studies using a reconstructive algorithm based on prior assessment of the donor toe central slip and recipient finger anatomy had significantly improved ROM outcomes ( P = .013). Although VJT provides a reliable option for autologous reconstruction in posttraumatic joints, it is limited by impaired postoperative ROM. Careful assessment of the donor toe and recipient finger anatomy followed by systematic and meticulous reconstruction may lead to improved functional outcomes.

Effectiveness of Quickcast Versus Custom-Fabricated Thermoplastic Orthosis Immobilization for the Treatment of Mallet Fingers: A Randomized Clinical Trial

Background: Mallet finger is a common injury involving a detachment of the terminal extensor tendon from the distal phalanx. This injury is usually treated with immobilization in a cast or splint. The purpose of this study is to compare outcomes of mallet fingers treated with either a cast (Quickcast) or a traditional thermoplastic custom-fabricated orthosis. Methods: Our study was a prospective, assessor-blinded, single-center randomized clinical trial of 58 consecutive patients with the diagnosis of bony or soft tissue mallet finger treated with immobilization. Patients were randomized to either an orfilight thermoplastic custom-fabricated orthosis or a Quickcast orthosis. Patients were evaluated at 3, 6, and 10 weeks for bony and 4, 8, and 12 weeks for soft tissue mallets. Skin complications, pain with orthosis, compliance, need for surgical intervention, and extensor lag were compared between the 2 groups. Results: Both bony and soft tissue mallet finger patients experienced significantly less skin complications (33% vs 64%) and pain (11.2 vs 21.6) when using Quickcast versus an orfilight thermoplastic custom-fabricated orthosis. The soft tissue mallet group revealed a greater difference in pain, favoring Quickcast (6.2 vs 22). No significant difference in final extensor droop or need for secondary surgery was found between the 2 groups. Conclusions: Quickcast immobilization for the treatment of mallet finger demonstrated fewer skin complications and less pain compared with orfilight custom-fabricated splints.

Evaluation of functional outcome after osteosynthesis of intra articular distal humerus fracture with pre contoured locking compression plates

<p><strong>Background:</strong> Intra articular distal humerus fractures are challenging and cumbersome to treat. Therefore osteosynthesis of such fractures is required. The aim of our study was to evaluate the functional outcome of intra articular distal humerus fractures AO type 13C by osteosynthesis using olecranon osteotomy with pre contoured locking compression plates in orthogonal plate configuration.</p><p><strong>Methods:</strong> Thirty patients were included in our study comprising of 18 males and 12 females. Mean age was 39.63 years with mean follow up of 34 weeks. 7 were AO type 13C1, 9 were AO type 13C2 and 14 were AO type 13C3. Osteosynthesis was done for all fractures by olecranon osteotomy approach. Functional outcome was assessed using mayo elbow performance score.</p><p><strong>Results:</strong> Mean flexion attained at the end of follow up was 127.56 degrees with mean extensor lag of 7.16 degrees. Mean arc of motion was 120.4 degrees. Mean mayo elbow performance score at the end of follow up was 80.36. Mayo elbow performance score in patients aged less than 40 years of age was not statistically significant as compared to patients more than 40 years of age. Functional outcome was also dependent on fracture subtype.</p><p><strong>Conclusions:</strong> Osteosynthesis of distal humerus fractures AO type 13C using pre contoured locking compression plates in orthogonal plate configuration by olecranon osteotomy provides excellent visualization of fracture and better functional outcome.</p>