Sindrom kubitalnog kanala

Sindrom kubitalnog kanala susrećemo relativno često te on predstavlja značajan javnozdravstveni problem. Specifičnost tijeka ulnarnog živca niz ruku, a napose anatomski međuodnosi s koštanim i mekotkivnim strukturama u području lakta čine ga vrlo podložnim vanjskim utjecajima, ponajviše silama kompresije. Progresija parestezija na ulnarnoj strani četvrtog prsta i na čitavom petom prstu zahvaćene šake uz pojavu motoričke slabosti i atrofije mišića šake uvelike ograničava bolesnike, najčešće one koji se bave aktivnostima koje zahtijevaju da im je lakat duže vremena u fleksiji, da neometano obavljaju svakodnevne aktivnosti. Stoga je iznimno važno pravovremeno dijagnosticiranje sindroma koje se zasniva na iscrpnoj anamnezi i detaljnom kliničkom pregledu uz pomoć niza specifičnih testova koji su detaljno opisani u radu. Elektromioneurografijom možemo utvrditi stupanj kompresije ulnarnog živca te pratiti uspješnost daljnjeg liječenja. Blaži oblici sindroma kubitalnog kanala uspješno se liječe konzervativnim načinom, dok teže oblike sindroma te one koji su neosjetljivi na provedeno konzervativno liječenje treba liječiti kirurški. Metode kirurškog liječenja sindroma možemo podijeliti na one koje ostavljaju živac u ležištu u kubitalnom kanalu poput in situ dekompresije i medijalne epikondilektomije te na one tijekom kojih se živac premješta u novo ležište ispred i iznad medijalnog epikondila, što nazivamo antepozicijom ulnarnog živca. Sve opisane metode pokazale su se gotovo jednako uspješnima, no usprkos tomu istraživanja pokazuju da se u današnje vrijeme kao metoda izbora kirurškog liječenja sindroma kubitalnog kanala najčešće koristi in situ dekompresija

Rekonstrukcija distalne ulne nakon resekcije gigantocelularnog tumora

Giant cell tumour (GCT) is a rare, benign tumour, but it has a locally aggressive nature and a high rate of recurrence. A wide en-bloc resection of the distal part of the ulna, with or without stabilisation of the ulnar stump, is the recommended treatment option. Functional results after that kind of surgery are mostly satisfying but, in some cases, it can result in wrist instability, causing pain and weakness of grip strength. That is why when it comes to young people, with high functional demands, we prefer reconstruction of distal ulna and distal radioulnar joint after an en-bloc resection of the distal ulna. The distal ulna is reconstructed with an autologous free fibular graft and the distal radioulnar joint is stabilised with an autologous palmaris longus tendon graft. We present our operative technique and good functional results of three young patients treated with this procedure. Our results confirm the hypothesis that the reconstruction of the distal ulna and the distal radioulnar joint leads to a satisfactory functional result in young and active patients with higher functional demands.Gigantocelularni tumour distalnog dijela ulne je izrazito rijedak, lokalno agresivan tumor sa velikom vjerojatnošću recidiva. Danas preporučena i najčešće korištena metoda liječenja ovih bolesnika je široka resekcija ulne sa ili bez stabilizacije proksimalnog dijela ulne tetivom. Funkcionalni rezultati ovakvog načina liječenja su uglavnom zadovoljavajući, ali se neki slučajevi kompliciraju razvojem nestabilnosti ručnog zgloba i značajnim smanjenjem snage šake. Zato u mladih osoba sa visokim funkcionalnim zahtjevima preferiramo nakon resekcije tumora učiniti rekonstrukciju distalne ulne i distalnog radioulnarnog zgloba. Distalnu ulnu rekonstruiramo pomoću slobodnog koštanog presatka dijafize bolesnikove fibule, a distalni radioulnarni zglob stabiliziramo koristeći presadak bolesnikove tetive mišića palmaris longusa. Ovim radom prikazujemo našu operativnu tehniku i dobre funkcionalne rezultate troje mladih bolesnika operiranih na ovaj način. Naši rezultati potvrđuju pretpostavku kako rekonstrukcija distalne ulne i distalnog radioulnarnog zgloba dovode do zadovoljavajućeg funkcionalnog rezultata u mladih i aktivnih bolesnika sa većim funkcionalnim zahtjevima

HAND SURGERY IN PATIENTS WITH RHEUMATOID ARTHRITIS

Reumatoidni artritis kronična je, progresivna, sistemska upalna bolest koja u većine oboljelih dovodi do progresivnog razvoja deformiteta i gubitka funkcije šaka i ručnih zglobova praćenih bolima te uzrokujući teškoće u svakodnevnom životu. Kirurško liječenje ovih bolesnika ima ulogu u postizanju što bolje funkcije šake i ručnog zgloba, olakšavanju boli, ali i postizanju boljeg estetskog rezultata. U ranim fazama bolesti izvode se preventivni zahvati, kojima usporavamo prirodni tijek bolesti uklanjajući upaljeno i reaktivno tkivo. Oni popravljaju funkciju zgloba i snižavaju rizik od rupture tetiva i razvoja težih deformacija. U kasnijim fazama bolesti, kada su znatne promjene već nastupile, rekonstruktivnim kirurškim zahvatima pokušavaju se poboljšati funkcija i smanjiti bol ili zbrinuti rupture tetiva. Pri odluci o obliku liječenja u prvom su redu važni suradnja reumatologa i ortopeda te individualizirani pristup svakom bolesniku kako bi se odabrali najbolji oblik kirurškog zahvata, kao i najbolji trenutak za njegovo izvođenje.Rheumatoid arthritis is a chronic, progressive, systematic inflammatory disease which canoften cause progressive development of deformity and loss of function of the hand and the wrist, accompanied by pain and difficulties in everyday life. The goal of surgical treatment of these patients is regaining better function of the hand and the wrist, relief of pain, and achieving a better esthetic result. Preventive procedures slow down the natural course of the disease by the removal of inflamed and reactive tissue. They enhance joint function and reduce the risk of tendon ruptures and development of more severe deformities. In the later course of the disease, with severe changes already present, reconstructive surgical treatments are performed with the goal to regain better function and reduce pain, or to treat ruptured tendons. Cooperation of rheumatologists and orthopedic surgeons is necessary in the treatment decision, with an individualized approach to each patient, to determine the best timeline and surgical procedure

Gorlin-Goltz Syndrome and Stroke: a Case report

We report on the case of a 32-years old male patient who was previously diagnosed with Gorlin-Goltz syndrome. The patient presented with sudden-onset right-sided hemiparesis, supranuclear facioparesis, and motor aphasia. He was treated with thrombolytic therapy, which successfully alleviated the symptoms. Subsequent radiologic work-up revealed anomalies in the vertebral arteries, a bifid rib, an ischemic lesion in the supply area of the left middle cerebral artery, and falx calcifications. Laboratory tests showed a 4G/4G polymorphism of the plasminogen activator inhibitor 1  (PAI-1) gene whose correlation with stroke is discussed in the article. </p

Auditory evoked potentials and vestibular evoked myogenic potentials in evaluation of brainstem lesions in multiple sclerosis

OBJECTIVE: The aim of this study was to determine the roles of magnetic resonance imaging (MRI), auditory evoked potentials (AEP) and vestibular evoked myogenic potentials (VEMP) in the evaluation of brainstem involvement in multiple sclerosis (MS). ----- PATIENTS AND METHODS: Altogether 32 patients with the diagnosis of MS participated in the study. The following data was collected from all patients: age, gender, Expanded Disability Status Scale (EDSS) score, brainstem functional system score (BSFS) (part of the EDSS evaluating brainstem symptomatology), and involvement of the brainstem on the brain MRI. AEP and ocular VEMP (oVEMP) and cervical VEMP (cVEMP) were studied in all patients. ----- RESULTS: BSFS, MRI, AEP, oVEMP and cVEMP involvement of the brainstem was evident in 9 (28.1%), 14 (43.8%), 7 (21.9%), 12 (37.5%) and 10 (31.0%) patients, respectively. None of the tests used showed statistically significant advantage in the detection of brainstem lesions. When combining oVEMP and cVEMP 18 (56.3%) patients showed brainstem involvement. This combination showed brainstem involvement in greater percentage than BSFS or AEP, with statistical significance (p=0.035 and p=0.007, respectively). ----- CONCLUSION: VEMP is a reliable method in detection of brainstem involvement in MS. It is comparable with MRI, but superior to clinical examination or AEP

Thromboprophylaxis in pregnant patient-specific risks

Background: Pregnancy and the puerperium are well-established risk factors for venous thromboembolism. Prothrombotic changes start after conception and normal coagulation returns eight weeks after the labour. The risk of DVT is approximately twice as high after caesarean delivery than vaginal birth. Specific risks: Inherited or acquired thrombophilias increase thromboembolic risk and influence the approach to thromboprophylaxis. Additional factors that increase thrombotic risk include immobilisation, such as bed rest for pregnancy complications, surgery including caesarean section, ovarian hyperstimulation during gonadotropin use for in vitro fertilisation, trauma and malignancy. The preferred agents for thromboprophylaxis in pregnancy are heparin compounds; these agents do not cross the placenta and therefore appears safe for the fetus. Because of the theoretical risk of epidural spinal haemorrhage in women receiving heparin that undergo epidural or spinal anaesthesia many anaesthesiologist will not perform neuraxial regional anaesthesia in women who have recently received heparin. Anaesthesia guidelines advise waiting to insert the needle at least 10 to 12 hours after the last prophylactic dose of LMWH, and at least 24 hours after the last therapeutic dose. Conclusion: Despite the increased risk of thrombosis in pregnancy, anticoagulants are not routinely indicated, because the risks usually outweigh the benefits. The exception is women on life-long anticoagulation or women with history of thrombosis or thrombophylia.Heparin therapy must be interrupted temporarily during the immediate peripartum interval to minimise the risk of haemorrhage and to allow for the option of regional anaesthesia

RARE LOCALIZATION OF OSTEOID OSTEOMA – DISTAL PHALANX OF THE RING FINGER

Ovim kliničkim zapažanjem želimo upozoriti na osteoid osteom kao mogući uzrok tegoba u području distalne falange prstiju šake. Ta iznimno rijetka lokalizacija osteoid osteoma predstavlja problem za prepoznavanje i zbog atipične prezentacije. Dvadesetogodišnji bolesnik se pet godina žalio na bol u području jagodice IV. prsta desne šake koja je bila praćena oteklinom i crvenilom jagodice prsta te deformacijom nokta. Na rendgenskim snimkama vidjela se osteoliza u području baze distalne falange. Magnetskom rezonancijom je postavljena sumnja na osteoid osteom, što je potvrđeno kompjuteriziranom tomografi jom. Nakon kirurškog liječenja tijekom kojeg je osteoid osteom ekskohleiran, dolazi do potpunog nestanka tegoba. Potpuni oporavak bolesnika pokazuje i rezultat DASH upitnika, koji je već tri mjeseca nakon zahvata pao sa 54,5 na 0 što je prema tom upitniku uredan nalaz. Na osteoid osteom se uvijek mora posumnjati ako je oteklina distalne falange prsta s deformacijom nokta praćena bolovima koji se smanjuju korištenjem NSAIL. Metoda izbora u dijagnostici je kompjuterizirana tomografi ja koja mora biti načinjena tako da slojevi ne budu deblji od 1 do 2 mm. Zbog blizine neurovaskularnih struktura i tetiva najboljim oblikom liječenja osteoid osteoma u području distalne falange prstiju šake smatra se kirurška ekscizija ili ekskohleacija.With this clinical observation we would like to bring to mind osteoid osteoma as a possible cause of problems of distal phalanx of the fi ngers. Osteoid osteoma occurs rarely at this location and has atypical presentation. The main symptoms are swelling and redness of the fi ngertip with nail deformity, while typical night pain may not be present. Unusual clinical and x-ray presentation of tumor in this localization can make diagnosis of osteoid osteoma very difficult. A 20-year-old patient reported pain in the fi ngertip of his right ring finger persisting for fi ve years. Swelling and redness of the fi ngertip combined with nail deformity was also present. X-rays showed osteolysis in the base of distal phalanx. Magnetic resonance imaging showed suspicion of osteoid osteoma, which was confi rmed by computed tomography (CT). We performed surgical removal of osteoid osteoma in February 2014. The tumor was approached by longitudinal incision on the lateral side of the distal phalanx of the ring fi nger and the basal part of distal phalanx was cut with a small chisel to enable access to cystic change of the bone. Tumor removal with excochleation was performed and the material thus obtained was sent for histopathologic analysis. After surgery, the ring fi nger was immobilized in a plaster splint for a three-week period. After removal of immobilization, the patient was referred to physical therapy consisting of individual exercises in order to obtain the full range of motion in all joints of the hands and strengthen hand and forearm muscles. After surgical removal of osteoid osteoma, all symptoms disappeared completely. Histopathologic findings confi rmed the diagnosis of osteoid osteoma. After physical therapy, he returned to daily activities without any problems. On regular follow ups at 3, 6 and 12 months after surgery, clinical fi ndings were normal and the patient had no pain or discomforts. Full recovery was shown by the result of the DASH questionnaire three months after the procedure. Preoperative DASH score 54.4 decreased to 0. Distal phalanx of the fi nger is a very rare localization of osteoid osteoma, and typical night pain may not be present. In addition, appearance on x-rays is not typical. Instead of central enlightenment surrounded with sclerosis, x-rays usually show a lytic lesion. For this reason, it may be diffi cult to make the diagnosis of osteoid osteoma. The main symptom is permanent pain, swelling and redness of the fi nger, with nail deformity. The imaging method of choice is CT, which must be performed with thin layers of 1 to 2 mm. Furthermore, cooperation of surgeon and radiologist is extremely important to reach the accurate diagnosis. Many treatment options are described in the literature, such as CT-guided percutaneous thermocoagulation, destruction of lesions with alcohol, or CT-guided radiofrequency ablation. However, due to the proximity of neurovascular structures, tendons and joints, the best method for treatment osteoid osteoma in distal phalanx of the fi ngers is surgical excision or excochleation. Our conclusion is that one should always bear in mind that osteoid osteoma can be the cause of swelling of distal phalanx of the fi nger with nail deformity, and pain that alleviated with the use of non-steroidal anti-infl ammatory drugs. Surgical excision or excochleation is the best method for the treatment osteoid osteoma of distal phalanx of the finger