Baghdadi T, Sadeghifar A, Mortazavi S.m.j, Espandar R,
Volume 65, Issue 4 (3 2007)
Abstract
Background: People vary greatly in their response to painful stimuli, from those with a low pain threshold to those with indifference to pain. However, insensitivity to pain is a rare disorder, characterized by the lack of usual subjective and objective responses to noxious stimuli. Patients who have congenital indifference to pain sustain painless injuries beginning in infancy, but have sensory responses that are otherwise normal on examination. Perception of passive movement, joint position, and vibration is normal in these patients, as are tactile thresholds and light touch perception.
Case report: A twelve-year-old boy was admitted to the hospital for a painless deformity, degeneration in both knees and a neglected femoral neck fracture that was inappropriately painless. Further examination revealed normal sensory responses, perception of passive movement, joint position, vibration tactile thresholds and light touch perception. Spinal cord and brain MRI were normal as was the electromyography and nerve conduction velocity (EMG/NCV) examination. There was no positive family history for this disorder.
Conclusion: The deficits present in the different pain insensitivity syndromes provide insight into the complex anatomical and physiological nature of pain perception. Reports on pain asymbolia, in which pain is perceived but does not cause suffering, and related cortical conditions illustrate that there can be losses that independently involve either the sensory-discriminative component or the affective-motivational component of pain perception, thus highlighting their different anatomical localization. The paucity of experience with this entity and the resultant diagnostic problems, the severity of the associated disabling arthropathy and underscore the importance of this case report of indifference to pain.
Kaseb Mh, Sobhan Mr, Espandar R, Motamedi M,
Volume 65, Issue 10 (2 2008)
Abstract
Background: Posterolateral rotatory instability is one of the most complex problems in ligamentous injuries of the knee. It represents a challenging diagnostic and therapeutic problem for the orthopaedic surgeon. We present the results of biceps tenodesis in chronic posterolateral rotatory instabilily of the knee.
Methods: In this case series we included all of the patients with positive reverse pivot shift test and prone external rotation test at least 3 weeks after their trauma. We excluded the patients with varus malalignment of the knee and concomitant anterior cruciate ligament (ACL) rupture. Biceps tenodesis (Clancy method) was performed. We did not reconstruct posterior cruciate ligament (PCL) if its insufficiency was diagnosed in addition to posterolateral rotatory instability. Knee scoring scale of Lysholm was used during and after follow ups. The results were statistically compared using Wilcoxon signed rank test (WSRT), paired samples t-test and friedman test. Data analysis was done using SPSS (version 11.5) and Stata (version 8) computer softwares.
Results: Our series consists of 13 patients (12 male and one female). 31% of the patients had isolated posterolateral injury and 69% of the patients had combined posterolateral and PCL injuries. The patients were between 17 to 45 years old (mean 30.25 years). Follow up was between 4 to 44 months (mean: 31 months). At the end of follow up 85% of patients had negative reverse pivot shift test. Prone external rotation test at 30° of knee flexion was negative in 92% of patients. In 92% of patients giving way was negative and in 77% of patients pain was decreased. Before operation the average Knee scoring scale of Lysholm was 73 and at the end of the follow up it increased to 85 (p value<0.001).
Conclusions: Biceps tenodesis using Clancy method is a safe, effective and reliable method in management of chronic posterolateral rotatory instability of the knee. During surgery careful exploration of the common peroneal nerve is recommended. Although we found this method effective in combined posterolateral and PCL injuries the results are much better in the cases with isolated posterolateral injuries.
