Clinical Characteristics, Current Treatment Options, Potential Mechanisms, Biomarkers, and Therapeutic Targets in Avascular Necrosis of Femoral Head

Avascular necrosis of femoral head (AVNFH) is a debilitating disease of the young, affecting the quality of life significantly and eventually leading to total hip replacement surgery. The disease is diagnosed clinico-radiologically and MRI is the investigation of choice to diagnose the early stages of the disease. There is neither an early biomarker for detection nor is there a permanent cure for the disease and most of the patients are managed with various combinations of surgical and medical management protocols. In this review, we comprehensively address the etiopathogenesis, clinical characteristics, therapeutic procedures, bone characteristics, histopathology, multi-omic studies, finite element modeling, and systems analysis that has been performed in AVNFH. The etiology includes various factors that compromise the blood supply to the femoral head which also includes contributions by environmental and genetic factors. Multi-omic analysis has shown an association of deregulated pathways with the disease. The cell types involved include mesenchymal stem cells, osteoblasts, osteoclasts, endothelial and immune cells. Biochemical, hematological, histopathology, IHC, and other bone remodeling and degradation marker studies have been performed. A systems analysis using multi-omic data sets from published literature was carried out, the relevance of which is discussed to delineate potential mechanisms in etiopathogenesis, diagnosis, and effective management of this debilitating disease.

Treatment Trends and Epidemiologic Changes in Acetabular Fracture Management over the Course of 10 Years: An Analysis Based on 2853 Patients as Treated by the German Pelvic Multicenter Study Group

Background/Objectives: Acetabular fractures, traditionally linked to high-impact trauma in younger adults, are increasingly observed in the elderly due to falls and poor bone quality. This demographic shift necessitates updated treatment approaches. This study analyzes demographic trends and treatment evolution over a decade using the German pelvic fracture registry. Methods: Data on acetabular fractures were analyzed from the German pelvic fracture registry of the German Trauma Society. Parameters included classification, demographics, treatment methods, and surgical details. Trends were assessed by grouping patients based on treatment intervals and age, comparing treatment methods, surgical approaches, and reduction quality across these groups, considering fracture types and treatment volume. Results: The study included 2853 unilateral acetabular fractures with a mean patient age of 61.5 years, showing an increasing age trend. A shift from simple to complex fractures involving the anterior acetabular column was observed. Operative treatment was performed in 62.5% of cases, more common in non-geriatric patients and those with posterior column involvement. The use of anterior intrapelvic approaches increased over time, replacing the Ilioinguinal extrapelvic approach. Anatomical reduction was achieved in 47.4% of cases, with 31.7% having imperfect reductions and 20.9% poor reductions. High-volume centers had significantly better reduction outcomes, particularly for simple fractures. Geriatric patients exhibited worse reduction quality compared to younger patients. In-hospital mortality was stable at 3.3%. Conclusions: The study highlights a demographic shift towards an older patient population, leading to more complex fracture patterns. Despite advancements in surgical techniques and new implant technologies, these demographic changes have resulted in lower reduction quality for complex fractures. Emphasis is placed on careful patient selection for reconstructive surgery or endoprosthetic replacement to ensure high-quality outcomes.

Management of Grade Three Open Distal Humerus Intra-articular Fracture Using the BB Joshi External Fixator: A Case Study and Review of Outcomes

Distal humeral intra-articular fractures often result in functional impairment if treated conservatively. These fractures are particularly challenging due to osteoporosis and severe comminution. A 32-year-old female with a grade three open distal humerus intra-articular fracture presented with a 5 cm x 5 cm open wound on her right elbow. The patient underwent open reduction and internal fixation (ORIF) using the BB Joshi external fixator and a local flap for skin coverage, achieving stable fixation and early mobilization. The patient regained a near-normal range of movements and adequate skin coverage of the wound at follow-up. Compared to traditional ORIF, it showed lower infection rates and comparable union rates, leading to better functional outcomes when compared with the studies reported earlier. The BB Joshi external fixator effectively treats grade three open distal humerus intra-articular fractures, minimizing complications and promoting functional recovery.

Core Decompression with Bone Marrow Aspirate Concentrate Implantation in Osteonecrosis of the Femoral Head with a Minimum of 2-year Follow-up - A Pilot Study

Introduction

Osteonecrosis of the femoral head (ONFH), resulting from impaired blood supply to the head of the femur, presents a significant challenge to clinicians due to its debilitating nature. Conservative treatment often offers insufficient pain relief and debilitating functional outcomes which necessitate alternative therapies. Bone marrow aspirate concentrate (BMAC), a potent orthobiologics and rich in mesenchymal stromal cells and growth factors, holds good promise as the minimally invasive procedure for ONFH. With the preceding research suggesting clinical and functional efficacy, we assessed the therapeutic effectiveness of BMAC in ONFH management in joint preservation.

Materials and Methods

A prospective cohort study was conducted with 20 patients suffering from ONFH who failed to respond to 6 months of conservative treatment. A uniform surgical procedure was performed by a single surgeon, involving bone marrow extraction from the anterior iliac crest and subsequent processing into an 8-10 mL of BMAC concentrate. The BMAC was then injected into the implanted into the decompressed femoral head. The post-operative protocol comprised weight-bearing mobilization, physiotherapy, and a 4-week NSAID-free regimen. Outcome measures included pain scores, hip function, knee symptoms, sports activities, patient satisfaction, and recommendation of the procedure.

Results

Of the 20 patients suffering from ONFH, primarily the left side, most of whom were at stage 2b, significant pain reduction and functional improvement were observed over 24 months. The mean pain score decreased from 9.00 to 3.55, while the hip function score increased from 46.12 to 88.60. However, some patients encountered complications such as symptom recurrence (5%), disease progression (10%), and persistent pain (5%).

Conclusion

Core decompression with BMAC implantation emerges as a promising, effective, and safe treatment for ONFH with better costeffectiveness and minimal side effects, making it a feasible treatment alternative.

An Unusual Presentation of Intramuscular Cysticercosis in a Vegetarian Patient: A Case Report

Cysticercosis is a parasitic infection. It can involve any tissue in the body, the brain being the most common site. Intramuscular cysticercosis is rare, and few cases have been reported. Here, we are reporting a case of incidental finding of intramuscular cysticercosis in a 22-year-old male having a purely vegetarian diet presented with pain, swelling, and tingling sensation in the forearm without any other systemic involvement after taking Albendazole for unrelated reasons. Diagnosis of intramuscular cysticercosis remains a challenge and should be considered in the differential diagnosis of intramuscular swelling, especially in endemic areas.

Management of pediatric distal humerus metaphyseal-diaphyseal junction fracture: A systematic review and meta-analysis

Purpose

Fractures occurring at the metaphyseal-diaphyseal junction of the distal humerus in children are not commonly documented in the literature. Until this moment, there is no gold standard technique regarding its management and most surgeons treat it as a regular supracondylar humerus fracture by conventional pinning. This systematic review explores the relevant literature to assess the efficacy of different techniques.

Methods

This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Our literature search encompassed several online databases, including PUBMED/MEDLINE, Scopus, Web of Science Core Collection, and Google Scholar. Data from articles that met our general inclusion criteria were extracted and categorized into treatment method groupings. Functional and cosmetic outcomes, demographic characteristics, and complications were the main parameters used to analyze the data.

Results

Ten retrospective studies met our inclusion criteria with a total of 178 participants of unilateral pediatric distal humerus metaphyseal-diaphyseal junction fractures. Most literature chose closed reduction and percutaneous pinning in seven articles, followed by elastic stable intramedullary nail technique used in three articles, then conservative treatment was chosen in two articles, while only one article used lateral miniplate and assisted K-wire and another article used combined closed reduction and percutaneous pinning and intramedullary K-wire. As regards the operation time; elastic stable intramedullary nails had the shortest time with a mean of 39.7 min (range: 37.5-41.9 min), while closed reduction and percutaneous pinning had the longest time with a mean of 75.47 min (range: 55.9-92.1 min). The shortest healing time was observed in miniplate with a mean of 7.2 weeks, while the most prolonged was in conservative management with a mean of 12 weeks and closed reduction and percutaneous pinning was a mean of 10 weeks. Regarding Flynn's criteria, all participants received excellent and good except in closed reduction and percutaneous pinning; 13 cases were fair and 2 cases were poor. Regarding complications, the most commonly observed complication after metaphyseal-diaphyseal junction fracture was cubitus varus, the highest incidence was in conservative management (33% of cases), followed by closed reduction and percutaneous pinning (10.9% of cases), the least incidence was observed in elastic stable intramedullary nails (3.77% of cases), and none of the cases treated with mini plate developed this complication. Other complications were observed only with closed reduction and percutaneous pinning; 8.5% of cases developed fixation loss, 6.2% of cases had a significantly reduced range of motion, and one case refractured.

Conclusion

Pediatric distal humerus metaphyseal-diaphyseal junction fractures should be distinguished from the more prevalent supracondylar humerus fractures, as conventional pinning techniques are associated with a higher incidence of complications and increased both operative and healing times.Level of evidence: III.

Total knee arthroplasty and periprosthetic distal femoral fracture: looking beyond the osteoporosis to previous osteoporotic fracture

Osteoporosis increases the risk of periprosthetic distal femoral fractures after TKA, especially in patients with a history of osteoporotic fractures. Therefore, careful assessment and proper treatment of osteoporosis need and the importance of taking osteoporotic medication needs to be recognized by the patients following primary TKA.

PURPOSE

Osteoporosis is a risk factor for fractures, including those of the hip, vertebrae, and distal radius; however, the association between osteoporosis and periprosthetic fractures after total knee arthroplasty (TKA) has not been much investigated. Therefore, we aimed to investigate the association of the presence of systemic osteoporosis with periprosthetic fractures after TKA.

METHODS

This study included 34 patients with periprosthetic fractures following primary TKA and 106 controls matched for age and sex. Bone mineral density was evaluated at the femoral neck, total hip, and lumbar spine using dual X-ray absorptiometry. Medical records were reviewed for age; sex; body mass index; smoking; rheumatoid arthritis, endocrine diseases, and cardiovascular diseases; history of glucocorticoid use; medication for osteoporosis; and history of previous osteoporotic fracture. In addition, anterior femoral notching after TKA was evaluated. Univariable and multivariable logistic regression analysis were used to determine factors associated with periprosthetic fracture.

RESULTS

The prevalence of osteoporosis in the fracture group was higher than that in the control group (61.8% vs. 40.6%, p=0.045). The rate of medication for osteoporosis was significantly low in the fracture group (47.6 % vs 76.7%, p=0.026). History of previous osteoporotic fracture (odds ratio [OR], 9.1; p=0.015) and osteoporosis (OR, 3.6; p=0.013) were significant risk factors for periprosthetic fractures after TKA. Medication for osteoporosis could decrease the risk of periprosthetic fracture (OR 0.3; p=0.020).

CONCLUSION

Osteoporosis is a major risk factor for periprosthetic distal femoral fractures after TKA. Therefore, careful assessment and proper treatment of osteoporosis need and the importance of taking osteoporotic medication needs to be recognized to the patients following primary TKA, especially in patients with a history of osteoporotic fracture.

LEVEL OF EVIDENCE

Prognostic study, level III.

Augmentation of Autologous Platelet-Rich Plasma in Hip Salvage in Stages I and II of Avascular Necrosis: Randomized Blinded Trial Comparing 3 Surgical Techniques in 82 Patients

Introduction

Avascular necrosis of the femoral head is common in routine orthopedic clinics. The challenge arises in managing early stages (I and II) without obvious radiological evidence. Authors explore this naïve research area by comparing surgical procedures in early AVN patients.

Materials and Methods

A prospective multicentric study was performed from November 2020 to February 2023 on 82 patients treated with surgical decompression and adjuvants, concerning the defined inclusion and exclusion criteria. Radiopacity and intraosseous edema resolution and THA conversion rates were assessed. Hip pain VAS, groin/thigh pain, difficulty in sitting cross-legged incidence, pain-free walking distance, Harris hip scores, 30-s chair test, and complications were noted.

Results

Among 82 patients, the mean age was 28.46 years. Male:female ratio of 3.9:1. 8.5% had bilateral affection and 48.78% had a positive family history. 93.90% presented with groin pain and difficulty in sitting cross-legged, restricted hip movements in 85.3%, and thigh pain in 54.87%. Harris hip scored worst in Group 3 followed by Group 2 and Group 1. 63.41% and 36.58% of patients had Grades 1 and 2 AVN, respectively. At 1 week post-operatively, 96.3% and 93.9% of patients were relieved from groin and thigh pain, respectively (p < 0.001); the trend being Group 3 > Group 2 > Group 1. Hip pain VAS followed a similar trend. At 4 weeks, Harris hip scores improved in Group 3 > Group 2 > Group 1. At 6 months, the trend was Group 2 > Group 3 > Group 1. Group 3 had better 30-s chair test results, pain-free walking distance, and longer cross-legged sitting time. Complication rate of 3.6%. 6.09% of patients underwent THA later. Sclerotic patch and marrow edema resolution early in Group 3, i.e., 46 and 31 days respectively, followed by Group 2 and Group 1.

Conclusion

In Stages I and II AVN, biplanar core decompression (double) and intraosseous PRP injection is a promising salvage option; patients have better early hip scores (4 weeks), and early groin and thigh pain recovery. Patients treated early have better clinical and radiological recovery.

Graphical abstract

Patient Expectations of Pain Versus Experienced Expectations of Pain Following Shoulder Injection

PURPOSE

Corticosteroids, platelet-rich plasma, and hyaluronic acid injections to either the subacromial space (SAS) or the glenohumeral joint (GHJ) of the shoulder are commonly used for diagnostic and therapeutic purposes in outpatient settings. The first aim of this study was to determine whether the anticipated pain level differed significantly from the actual pain level experienced by patients who underwent shoulder injections. The second aim was to determine whether there was a significant difference in these pain levels between SAS and GHJ injections. The secondary goal was to investigate the correlation between patients' demographic data, anxiety characteristics, and pain scores.

DESIGN

Prospective clinical study.

METHODS

This study involved patients who completed a three-part questionnaire prior as well as following an injections to the GHJ\SAS.

FINDINGS

Sixty-three patients (28 males; 35 females), mean age of 54.28 years (standard deviation 13.95, range 25 to 84) met the inclusion criteria. There was a significant difference between the anticipated and the experienced pain (visual analog score 6.03 vs 3.17, P < .001). Experienced pain of the GHJ injections (n = 34) was rated as being greater than that of the SAS injections (n = 29) with borderline significance (visual analog scale 3.79 vs 2.36; P = .05). Forty-five patients (71.42%) reported a decrease in at least one pain category between anticipated and experienced pain compared to an increase reported by two patients (3.17%).

CONCLUSIONS

Injections to the GHJ and SAS were shown to be significantly less painful than anticipated by the patients. GHJ injections were perceived as more painful than SAS injections. Communicating this evidence-based reassuring information with patients prior to an injection may alleviate fear of the procedure, reduce the perception of pain, and ultimately improve compliance with the procedure.

Serum 25(OH) vitamin D deficiency among young adults in the East Khasi Hills district of Meghalaya and its influence on bone mineral density: Investigating the involvement of the RANKL/RANK/OPG system

Introduction

Vitamin D's precise role in bone mineral density regulation remains elusive. Nevertheless, its deficiency is linked to increased bone turnover through the upregulation of RANK ligands by osteoblasts. This study aimed to (i) evaluate vitamin D status in young adults and (ii) assess the association between vitamin D deficiency and bone turnover markers receptor activator of nuclear factor-κB ligand (RANKL), RANK, and the osteoprotegerin (OPG) in determining bone mineral density.

Materials and Methods

This cross-sectional study involved 474 participants from the East Khasi Hills district, Meghalaya. Vitamin D levels were measured using the UniCel DxI 800 system, while OPG, RANK, and RANKL were assessed through enzyme-linked immunosorbent assay (ELISA). Additionally, a whole-body dual X-ray absorptiometry (DEXA) scan determined bone mineral density. Vitamin D deficiency was categorised as <20 ng/ml, insufficiency as 20-29 ng/ml, and sufficiency as ≥30 ng/ml.

Results

Findings indicated 54.6% vitamin D deficiency and 35.4% insufficiency in young adults. Osteoporosis affected 26%, and 67% exhibited osteopenia. A weak positive correlation was found between vitamin 25(OH) D and bone mineral density T score (r = 0.16, r2 = 0.02, P = 0.44). Additionally, moderately weak correlations were observed between serum vitamin D and OPG (r = -0.42, r2 = 0.18, P < 0.001) and between vitamin D and RANKL (r = -0.13, r2 = 0.01, P = 0.18).

Conclusion

The study suggests that vitamin D deficiency diminishes bone mineral density by promoting RANKL-RANK osteoclastogenesis and upregulating OPG expression. As young adults form a significant workforce, creating awareness is crucial for maintaining optimal health.

Two Case Reports of Isolated Intramuscular Cysticercosis: An Uncommon Pediatric Pseudotumor

Taenia solium, the pig tapeworm, produces larvae that cause cysticercosis, a common parasitic disease of the human nervous system including the brain. The disease is native to countries like Central and South America, Eastern Europe, Africa, India, and Indonesia. Cysticercosis is endemic in North India, particularly in Bihar, Uttar Pradesh, and Punjab. Asymptomatic cysts may have a history of trauma, while lower extremity involvement is less common. Isolated muscle involvement typically has no lethal consequences. Two cases, both pediatric, were diagnosed with intramuscular cysticercosis without involvement of the brain parenchyma. The patients received oral prednisolone therapy for seven days, followed by albendazole for 28 days. The swellings decreased in size and no new swellings or symptoms appeared during the two- and four-week follow-ups. At a three-month follow-up, the swellings completely resolved. Neurocysticercosis is a commonly encountered infection of the human central nervous system and one of the major causes of acquired epilepsy globally. Most cases are asymptomatic and go undiagnosed, with the first case likely due to trauma. Diagnosis is often delayed or overlooked due to vague clinical symptoms. Clinical differential diagnoses for intramuscular cysticercosis include lipomas, epidermoid cysts, neuromas, neurofibromas, pseudoganglia, sarcomas, myxomas, pyomyositis, cold abscess, and tuberculous lymphadenitis. High-resolution ultrasound is the most accurate method for diagnosing intramuscular cysticercosis, as it is quick, simple, and less expensive. Muscular cysticercosis sonographic patterns can be categorized into four types: first degree, uneven, irregular, and calcified. Magnetic resonance imaging (MRI) is the most accurate way to diagnose intramuscular cysticercosis, as it can show live scolex, cysts, and degenerating cysts. In every case, there is edema to varied degrees, with fluid-filled lesions without peripheral enhancement visible in early stages and peripheral rim augmentation and perilesional edema observed in later stages.

Serum IL-6 as a Surrogate Biomarker of Post-operative Complications in Invasive Orthopaedic Surgeries: A Prospective Observational Study

Background

Interleukin-6 (IL-6) is a cytokine released in response to tissue injury. Elevated serum IL-6 levels in trauma patients have been linked with increased risk of complications such as inapparent hypoxia (SpO2 < 94%), acute respiratory distress syndrome, fat embolism syndrome (FES), systemic inflammatory response syndrome, multiple organ dysfunction syndrome and sepsis. This study aims to determine the role of serum IL-6 as surrogate biomarker of post-operative complications after invasive orthopaedic surgeries.

Methods

Thirty-seven adults between 18 and 65 years of age undergoing invasive orthopaedic surgeries were included in this hospital-based study. Serum IL-6 levels were estimated serially in the pre-operative period, after 24 h and 7 days post-operatively. Cases were monitored for post-operative complications.

Results

Serum IL-6 levels showed maximum rise in the first 24 h post-operatively especially among older patients (> 60 years). Older patients undergoing bipolar hemiarthroplasty for neck of femur fracture showed highest median post-operative IL-6 level of 258 pg/ml. Serum IL-6 level > 130 pg/ml measured 24 h after surgery was predictive of post-operative complications (sensitivity of 75%). Among the cases with post-operative complications, inapparent hypoxia was the most common complication/event observed. Cases with sub-clinical FES had highest level of serum IL-6 in first 24 h following surgery with median IL-6 level of 300 pg/ml (range 155-444 pg/ml).

Conclusion

Monitoring serum IL-6 level may help in both anticipation and early detection of post-operative complications in patients undergoing invasive orthopaedic surgeries; potentially enhancing patient safety.

Implantation of Culture-Expanded Bone Marrow Derived Mesenchymal Stromal Cells for Treatment of Osteonecrosis of the Femoral Head

BACKGROUND

Although core decompression (CD) with stem cell for the treatment of osteonecrosis of the femoral head (ONFH) showed promising results in many reports, the efficacy remains uncertain. We aimed to evaluate the efficacy of CD with culture-expanded autologous bone marrow-derived mesenchymal stem cell (BM-MSC) implantation in early stage ONFH.

METHODS

A total of 18 patients (22 hips) with ONFH who underwent CD with culture-expanded BM-MSC implantation from September 2013 to July 2020 were retrospectively reviewed. The median age was 35.0 years [interquartile range (IQR), 28.5-42.0], and the median follow-up period was 4.0 years (IQR, 2.0-5.3). The median number of MSCs was 1.06 × 108. To evaluate radiographic and clinical outcomes, Association Research Circulation Osseous (ARCO) classifications, Japanese Investigation Committee classification, combined necrotic angle (CNA) visual analogue scale (VAS) and Harris Hip Score (HHS) were checked at each follow-up.

RESULTS

The preoperative stage of ONFH was ARCO 2 in 14 hips and ARCO 3a in 8 hips. The ARCO staging was maintained in 7 hips in ARCO 2 and 4 hips in ARCO 3a. The radiographic failure rate of ARCO 2 and 3a was 14.3 and 50%, respectively. Furthermore, CNA decreased to more than 20° in 6 hips (four were ARCO 2 and two were ARCO 3a).There was no significant difference in the VAS and HHS (P = 0.052 and P = 0.535, respectively). Total hip arthroplasty was performed in 4 hips.

CONCLUSION

CD with culture-expanded autologous BM-MSCs showed promising results for the treatment of early stage ONFH.

Identification of steroid-induced osteonecrosis of the femoral head biomarkers based on immunization and animal experiments

BACKGROUND

Steroid-induced osteonecrosis of femoral head (SONFH) is a severe health risk, and this study aims to identify immune-related biomarkers and pathways associated with the disease through bioinformatics analysis and animal experiments.

METHOD

Using SONFH-related datasets obtained from the GEO database, we performed differential expression analysis and weighted gene co-expression network analysis (WGCNA) to extract SONFH-related genes. A protein-protein interaction (PPI) network was then constructed, and core sub-network genes were identified. Immune cell infiltration and clustering analysis of SONFH samples were performed to assess differences in immune cell populations. WGCNA analysis was used to identify module genes associated with immune cells, and hub genes were identified using machine learning. Internal and external validation along with animal experiments were conducted to confirm the differential expression of hub genes and infiltration of immune cells in SONFH.

RESULTS

Differential expression analysis revealed 502 DEGs. WGCNA analysis identified a blue module closely related to SONFH, containing 1928 module genes. Intersection analysis between DEGs and blue module genes resulted in 453 intersecting genes. The PPI network and MCODE module identified 15 key targets enriched in various signaling pathways. Analysis of immune cell infiltration showed statistically significant differences in CD8 + t cells, monocytes, macrophages M2 and neutrophils between SONFH and control samples. Unsupervised clustering classified SONFH samples into two clusters (C1 and C2), which also exhibited significant differences in immune cell infiltration. The hub genes (ICAM1, NR3C1, and IKBKB) were further identified using WGCNA and machine learning analysis. Based on these hub genes, a clinical prediction model was constructed and validated internally and externally. Animal experiments confirmed the upregulation of hub genes in SONFH, with an associated increase in immune cell infiltration.

CONCLUSION

This study identified ICAM1, NR3C1, and IKBKB as potential immune-related biomarkers involved in immune cell infiltration of CD8 + t cells, monocytes, macrophages M2, neutrophils and other immune cells in the pathogenesis of SONFH. These biomarkers act through modulation of the chemokine signaling pathway, Toll-like receptor signaling pathway, and other pathways. These findings provide valuable insights into the disease mechanism of SONFH and may aid in future drug development efforts.

Femoral nailing associated with bone marrow emboli in pigs induced a specific increase in blood IL-6 and broad inflammatory responses in the heart and lungs

Introduction

Bone marrow embolization may complicate orthopedic surgery, potentially causing fat embolism syndrome. The inflammatory potential of bone marrow emboli is unclear. We aimed to investigate the inflammatory response to femoral intramedullary nailing, specifically the systemic inflammatory effects in plasma, and local tissue responses. Additionally, the plasma response was compared to that following intravenous injection of autologous bone marrow.

Methods

Twelve pigs underwent femoral nailing (previously shown to have fat emboli in lung and heart), four received intravenous bone marrow, and four served as sham controls. Blood samples were collected hourly and tissue samples postmortem. Additionally, we incubated bone marrow and blood, separately and in combination, from six pigs in vitro. Complement activation was detected by C3a and the terminal C5b-9 complement complex (TCC), and the cytokines TNF, IL-1β, IL-6 and IL-10 as well as the thrombin-antithrombin complexes (TAT) were all measured using enzyme-immunoassays.

Results

After nailing, plasma IL-6 rose 21-fold, compared to a 4-fold rise in sham (p=0.0004). No plasma differences in the rest of the inflammatory markers were noted across groups. However, nailing yielded 2-3-times higher C3a, TCC, TNF, IL-1β and IL-10 in lung tissue compared to sham (p<0.0001-0.03). Similarly, heart tissue exhibited 2-times higher TCC and IL-1β compared to sham (p<0.0001-0.03). Intravenous bone marrow yielded 8-times higher TAT than sham at 30 minutes (p<0.0001). In vitro, incubation of bone marrow for four hours resulted in 95-times higher IL-6 compared to whole blood (p=0.03).

Discussion

A selective increase in plasma IL-6 was observed following femoral nailing, whereas lung and heart tissues revealed a broad local inflammatory response not reflected systemically. In vitro experiments may imply bone marrow to be the primary IL-6 source.

Utility of 2.0 mm diameter Kirschner wires assembled with Wu's Tension Traction Bows in calcaneal skeletal traction

The 3.5 mm diameter or thicker Steinmann pins were commonly used in skeletal traction, which are so highly invasive that may result in severe complications such as pin tract infection and iatrogenic calcaneus fractures. Accordingly, Xirui Wu designed a new type of tension traction bow that can be assembled with 2.0 mm diameter Kirschner wires, but its effectiveness is unclear. We aim to evaluate the effectiveness of 2.0 mm diameter Kirschner wires assembled with Wu's Tension Traction Bows in calcaneal skeletal traction. Data of 65 patients who were admitted to our department with tibia fractures from January 2021 to June 2022 and underwent preoperative calcaneal skeletal traction were collected retrospectively. 36 patients treated with 2.0 mm diameter Kirschner wires assembled with Wu's Tension Traction Bows were assigned into Group 1, and 29 patients treated with 3.5 mm diameter Steinmann pins assembled with Bohler's traction bows were assigned into Group 2. Pins loosening, breakage, and calcaneus fractures occurred in neither group. No statistical differences were observed in traction weight, swelling reduction efficacy, and traction duration (P > 0.05). Statistically significant differences were found between the two groups in term of post-traction bleeding incidence, average bleeding duration, and mean size and healing time of traction wounds (P < 0.05). Though VAS pain score before traction and on the first two days after traction in Group 1 didn't differ from Group 2 (P > 0.05), it was significantly lower in Group 1 compared to Group 2 on the third day after traction (P = 0.030). This study demonstrates that 2.0 mm diameter Kirschner wires assembled with Wu's Tension Traction Bows produce satisfied traction outcomes with less invasion and are recommended in calcaneal skeletal traction.

Low avascular necrosis rates in femoral neck fractures: efficacy of cannulated screw fixation

PURPOSE

Cannulated screw fixation for femoral neck fractures is often limited by concerns of avascular necrosis (AVN) occurring, historically seen in 5-40% of fixed intracapsular fractures. This study aims to assess the outcomes, particularly the AVN rate, associated with current surgical techniques within our unit.

METHODS

We conducted a single-center cross-sectional study, manually searching operative records between July 14, 2014, and December 1, 2018, identifying patients with intracapsular fractured neck of femur fixed with cannulated screws, with a minimum of two years follow-up. Patient records and radiographs were reviewed for clinical and radiographic diagnoses of AVN, non-union, post-operative metalwork infection, and screw penetration of the head. Additionally, fracture pattern and displacement, screw configuration, reduction techniques, and adequacy of reduction were recorded, with radiographs independently analyzed by four orthopedic surgeons.

RESULTS

Fifty-six patients were included; average age of 67 years (range 30-100). Forty-two patients (75%) sustained displaced fractures and 14 patients (25%) had undisplaced fractures. Two (4%) patients developed AVN, with no cases of non-union, post-operative metalwork infection or screw penetration of the head. Eight patients (14%) sustained a high-energy injury, though none of these patients developed AVN. All fractures required closed reduction; no open reductions performed. Twenty-seven (64%) of reductions were adequate.

CONCLUSION

Our observed AVN rate is notably lower than the widely reported figures, even among a significant proportion of displaced fractures that were fixed. This study underscores that with adequate fixation, cannulated screws represent an excellent option for treating intracapsular neck of femur fractures, even in cases of displaced fracture patterns with imperfect reduction.

Evaluation of the Tensor Fascia Lata Muscle Pedicle Bone Grafting Technique in the Management of Avascular Necrosis of the Femoral Head: An Observational Clinical Study

BACKGROUND

Osteonecrosis of the hip is defined as necrosis of the bone tissue due to some form of vascular insult, subsequently leading to the collapse of the femoral head and secondary osteoarthritis, which leads to pain and impaired joint function. This disease is widely known to affect middle-aged groups; however, in the Indian population, even younger people are more commonly affected. The disease has a debilitating effect on the activities of daily living (ADL) and the productivity of individuals and has financial consequences. With the increased utilization of magnetic resonance imaging (MRI) in society, the disease is diagnosed in its early stages. Hip-preserving surgery like tensor fascia lata (TFL) muscle pedicle iliac bone grafting should be given a chance to preserve the native femoral head.

METHODOLOGY

At a tertiary care teaching hospital in Gorakhpur, India, an observational clinical study was carried out. This study comprised 40 patients, ages 18-50 years, with femoral head osteonecrosis (stages II and III of the Ficat-Arlet staging system), who came to our institute's orthopedic outpatient department. Patients were treated with multiple drillings, curettage, and cheilectomy of the femoral head, in addition to TFL muscle pedicle bone grafting. The Harris hip score (HHS) was utilized to assess the clinical results, and the radiological assessment focused on signs of revascularization.

RESULT

In our study, the most prevalent age group was 20-30 years (67.5%), with a male predominance (85%). Among our cohort of 40 patients, the HHS indicated excellent outcomes (90-100) in 14 cases (35%), good outcomes (80-89) in 19 cases (47.5%), fair outcomes (70-79) in six cases (15%), and poor outcomes (<70) in one case (2.5%), at the time of the final follow-up. The final follow-up period varied from one to 10 years.

CONCLUSION

TFL muscle pedicle bone grafting procedure provides excellent clinical and radiological outcomes, especially in young patients in whom femoral head-preserving surgery is preferred over total hip arthroplasty. This procedure is effective in both early and advanced stages of femoral head osteonecrosis, provided there are no arthritic changes. It reduces symptoms and improves functional outcomes.

Combined articular and ligament reconstructions in neglected fracture-dislocation of the knee

Background

The management of neglected traumatic knee dislocations is challenging and is commonly associated with suboptimal outcomes. In this article we present two cases of neglected knee dislocations in two young trauma victims who presented late due to restrictions during the COVID-19 pandemic.

Methods

Two young patients presented at our center with neglected knee fracture-dislocations after eight weeks and six months of trauma. Comprehensive evaluation was performed using radiographs, computed tomography scans, and magnetic resonance imaging. Surgical intervention included open reduction and internal fixation of the mal-aligned intra-articular fracture fragments. Additionally, articular congruency was restored and repair or reconstruction of the posterior cruciate ligament, anterior cruciate ligament, and meniscus was conducted using suitable tendinous autografts and implants. Following surgery, the knees were immobilized for six weeks, followed by aggressive physical therapy.

Results

After three months of surgical intervention, fracture union and joint stability were achieved. At the >36-month follow-up appointments, both patients were pain-free at rest with a stable knee joint, achieving ≥90 degrees of knee flexion and without extensor deficits. Concurrent with radiographic evidence of osteoarthritic changes in the knee joint, there was mild pain (VAS 2) after prolonged knee movement activities and walking for long distances (>1 km).

Conclusion

Open reduction and internal fixation, along with simultaneous menisco-ligamentous reconstructions in neglected fracture-dislocations of the knee result in satisfactory clinical outcomes. This approach proves to be an effective joint preservation procedure in young patients, even in delayed and neglected conditions.

Anterior peri-sacroiliac joint osteotomy in the treatment of malunion and nonunion of complex pelvic ring fracture: techniques and preliminary results

PURPOSE

To introduce anterior peri-sacroiliac joint osteotomy (APSJO) through the lateral-rectus approach (LRA) for treating pelvic fracture malunion and nonunion, and to evaluate the safety, feasibility, and potential effectiveness.

METHODS

Data of 15 patients with pelvic fracture malunion and nonunion who underwent treatment by APSJO were selected and analyzed. The reduction quality was assessed using the Mears and Velyvis criteria, while the pre-operative and post-operative function was revealed by the Majeed scoring system. The British Medical Research Council (BMRC) grading system was recruited for the evaluation of lumbosacral plexus function.

RESULTS

The average operative duration was 264.00 ± 86.75 min, while the intra-operative blood loss was 2000 (600, 3000) mL. Anatomical reduction was complete in three cases, satisfactory in ten cases, and unsatisfactory in two cases. Among the seven patients with lumbosacral plexus injury, the pre-operative Majeed grades were good in two cases, fair in two cases, and poor in three cases, while the post-operative Majeed grades were excellent in three cases, good in three cases, and fair in one case. Muscle strength recovered to M5 in two cases, M4 in three cases, and showed no recovery in two cases. The pre-operative Majeed grades were good in five cases, fair in two cases, and poor in one case of the series without lumbosacral plexus injury, while the post-operative Majeed grades were excellent in seven cases and good in one case.

CONCLUSION

APSJO through LRA may be a feasible strategy for treating pelvic fracture malunion and nonunion with promising application.

Thirty-Day Surgical Morbidity and Mortality in Pelvic and Acetabular Fracture Patients Presenting to a Tertiary Care Hospital in Karachi, Pakistan

INTRODUCTION

Pelvic fractures, encompassing a spectrum from minor to life-threatening injuries, pose challenges in trauma management. This study focuses on short-term outcomes, exploring morbidity and mortality within 30 days postoperative, among pelvic fracture patients at a tertiary care hospital in Karachi, Pakistan. The majority of pelvic injuries result from intense blunt trauma, with associated risks of concomitant injuries. Pelvic fractures are linked to early complications such as hemorrhage, thromboembolism, and infections, influencing mortality rates.

METHODOLOGY

A prospective cohort study involving 53 surgically managed pelvic fracture patients was conducted at Aga Khan University Hospital, Karachi. Variables such as age, gender, comorbidities, mechanism of injury, associated injuries, and presenting vitals were documented. Thirty-day morbidity included surgical site infections, hemorrhagic shock, nerve injuries, and others. Statistical analyses assessed associations between patient characteristics and morbidity.

RESULTS

The study revealed a median age of 37 years, with 77% male patients. Most fractures result from motor vehicle accidents. Morbidity occurred in 31.6% of cases, primarily associated with the presence of associated injuries. Postoperative complications included neurological deficits (15.1%) and pulmonary complications (9.4%). No 30-day mortality was reported.

DISCUSSION

The study highlights the importance of a multidisciplinary approach in managing pelvic fractures, emphasizing the association between associated injuries and postoperative morbidity. Comorbidities did not significantly impact morbidity, emphasizing the traumatic nature's independent contribution. Timely presentation (median 20 hours) and efficient trauma systems are crucial for optimal outcomes.

CONCLUSION

This research contributes insights into short-term outcomes following pelvic fracture fixation in a Pakistani tertiary care setting. By exploring a range of parameters, the study emphasizes the need for comprehensive management strategies to minimize complications and improve patient outcomes. Bridging critical knowledge gaps, this research informs clinical decision-making for pelvic fracture patients in this region.

ARTHROSCOPIC ANKLE JOINT AND ARTIFICIAL BONE GRAFTING FOR TREATMENT BONE CYSTS OF THE TALAR: A CASE REPORT

ABSTRACTS Bone cysts of the talar body are a benign, rare condition. Remove bone cysts, autologous bone grafting is a treatment method many authors recognize. Approaching the calcaneal bone cysts of the talar body encounters difficulties due to the narrow surgical field, poor blood supply, and the entire surface of the talar body being covered with cartilage. Endoscopic talar joint surgery to remove cysts bone, autologous bone grafting in the treatment of calcaneal bone cysts of the talar body is a progressive step, with many advantages, overcoming the mentioned difficulties, albeit being a challenging technique. We report a case of bone cysts of the talar body treated with endoscopic ankle joint surgery to remove cysts bone and autologous bone grafting at Viet Duc University Hospital, with good postoperative results, and no recurrence after 8 months of follow-up.

Relationship to the superficial radial nerve and anatomic variations of the first extensor compartment in Thai population: a basis for successful de Quervain tenosynovitis treatment

Knowledge of the superficial radial nerve (SRN) relationship and anatomic variations of the first extensor compartment (1st EC) will contribute to a better outcome of de Quervain tenosynovitis treatment. We dissected 87 embalmed cadaveric wrists to determine the relationship of the SRN, the 1st EC length, distance from the proximal and distal 1st EC borders to radial styloid process (RSP), abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendon slip numbers, and the presence of septum. Our results revealed SRN crossing over the 1st EC in 59.5%. The lateral branch of the superficial radial nerve to the 1st EC midline in most cases (61.9%) except for one specimen, where lateral antebrachial cutaneous nerve was the closest. Distances from proximal and distal 1st EC borders to the RSP were 19.7±4.1 mm and 7.6±1.8 mm, respectively. Extensor retinaculum (ER) width over 1st EC (1st EC length) was 14.8±3.2 mm. Complete and incomplete septa were found in 17.2%, and 42.5%, respectively. The most frequent APL tendon slip number in the compartment was two in overall 47 specimens (54.0%). Almost all compartments (85 specimens; 97.7%) contained one EPB tendon slip. We detected bilateral EPB absence in one cadaver. Moreover, we recorded a tendon slip from extensor pollicis longus traveling into 1st EC bilaterally in one cadaver and observed the EPB muscle belly extension into 1st EC in 9 wrists. Awareness of 1st EC anatomic variations would be essential for successful surgical and nonsurgical outcomes.

Malassezia restricta as an unexpected cause of infectious osteomyelitis diagnosed by metagenomic sequencing: a case report and literature review

BACKGROUND

Malassezia restricta, a lipophilic and lipodependent yeast belonging to the basidiomycetes group, is an opportunistic fungal pathogen associated with various skin diseases, including seborrheic dermatitis and dandruff. Typically, Malassezia infection in neonates manifests as fungemia or hematogenous dissemination to the bone or lungs. However, vertebral osteomyelitis caused by these fungi is rarely reported owing to non-specific clinical presentations and laboratory/imaging findings. The Pathogen Metagenomics Sequencing (PMseq) technique enables direct high-throughput sequencing of infected specimens, facilitating the rapid and accurate detection of all microorganisms in clinical samples through comprehensive reports.

CASE PRESENTATION

A 52-year-old male was admitted to our hospital on July 20, 2022 with a 3-month history of ambulatory difficulties and localized low back pain. Magnetic Resonance Imaging (MRI) examination of the spinal column revealed irregular bone destruction affecting the L2, L3, and L5 vertebral bodies. Additionally, low T1 and high T2 intensity lesions were observed at the intervertebral discs between L3 and L5. The presumptive diagnosis of tuberculous spondylitis was made based on the imaging findings, despite negative results in all mycobacterium tests. However, the patient exhibited no improvement after receiving regular anti-tuberculosis treatment for 3 months. Subsequent MRI revealed an expansive abnormal signal within the vertebral body, leading to progressive bone destruction. The absence of spinal tuberculosis or other infective microorganisms was confirmed through culture from blood and pathological tissue from the L4 vertebral body. Subsequently, PMseq was performed on the specimens, revealing M. restricta as the predominant pathogen with the highest relative abundance value. The pathological examination revealed the presence of fungal mycelium in the L4 vertebral body, with positive findings on periodic Schiff-methenamine and periodic acid-Schiff staining. The anti-tuberculosis treatment was discontinued, and an antifungal combination of fluconazole and voriconazole was administered. All symptoms were resolved after 7 consecutive months of treatment, and the patient was able to ambulate autonomously. Vertebral lesions were reduced on MRI during the 13-month follow-up.

CONCLUSIONS

M. restricta is not a commonly recognized pathogen associated with infectious vertebral osteomyelitis. However, PMseq can aid in diagnosis, timely treatment, and decision making for some non-specific infectious diseases.

Similar Medium-Term Revision Rates Following Acute Total Hip Arthroplasty Versus Open Reduction and Internal Fixation for Acetabular Fractures in the Elderly

BACKGROUND

The management of elderly acetabular fractures is complex, with high rates of conversion total hip arthroplasty (THA) after open reduction and internal fixation (ORIF), but potentially higher rates of complications after acute THA.

METHODS

The California Office of Statewide Health Planning and Development database was queried between 2010 and 2017 for all patients aged 60 years or older who sustained a closed, isolated acetabular fracture and underwent ORIF, THA, or a combination. Chi-square tests and Student t tests were used to identify demographic differences between groups. Multivariate regression was used to evaluate predictors of 30-day readmission and 90-day complications. Kaplan-Meier (KM) survival analysis and Cox proportional hazards model were used to estimate the revision surgery-free survival (revision-free survival [RFS]), with revision surgery defined as conversion THA, revision ORIF, or revision THA.

RESULTS

A total of 2,184 surgically managed acetabular fractures in elderly patients were identified, with 1,637 (75.0%) undergoing ORIF and 547 (25.0%) undergoing THA with or without ORIF. Median follow-up was 295 days (interquartile range, 13 to 1720 days). 99.4% of revisions following ORIF were for conversion arthroplasty. Unadjusted KM analysis showed no difference in RFS between ORIF and THA (log-rank test P = 0.27). RFS for ORIF patients was 95.1%, 85.8%, 78.3%, and 71.4% at 6, 12, 24 and 60 months, respectively. RFS for THA patients was 91.6%, 88.9%, 87.2%, and 78.8% at 6, 12, 24 and 60 months, respectively. Roughly 50% of revisions occurred within the first year postoperatively (49% for ORIF, 52% for THA). In propensity score-matched analysis, there was no difference between RFS on KM analysis ( P = 0.22).

CONCLUSIONS

No difference was observed in medium-term RFS between acute THA and ORIF for elderly acetabular fractures in California. Revision surgeries for either conversion or revision THA were relatively common in both groups, with roughly half of all revisions occurring within the first year postoperatively.

LEVEL OF EVIDENCE

III.

Proteomic profiling of extracellular vesicles derived from human serum for the discovery of biomarkers in Avascular necrosis

BACKGROUND

Avascular necrosis (AVN) is a medical condition characterized by the destruction of bone tissue due to a diminished blood supply. When the rate of tissue destruction surpasses the rate of regeneration, effective treatment becomes challenging, leading to escalating pain, arthritis, and bone fragility as the disease advances. A timely diagnosis is imperative to prevent and initiate proactive treatment for osteonecrosis. We explored the potential of differentially expressed proteins in serum-derived extracellular vesicles (EVs) as biomarkers for AVN of the femoral head in humans. We analyzed the genetic material contained in serum-derived exosomes from patients for early diagnosis, treatment, and prognosis of avascular necrosis.

METHODS

EVs were isolated from the serum of both patients with AVN and a control group of healthy individuals. Proteomic analyses were conducted to compare the expression patterns of these proteins by proteomic analysis using LC-MS/MS.

RESULTS

Our results show that the levels of IGHV3-23, FN1, VWF, FGB, PRG4, FCGBP, and ZSWIM9 were upregulated in the EVs of patients with AVN compared with those of healthy controls. ELISA results showed that VWF and PRG4 were significantly upregulated in the patients with AVN.

CONCLUSIONS

These findings suggest that these EV proteins could serve as promising biomarkers for the early detection and diagnosis of AVN. Early diagnosis is paramount for effective treatment, and the identification of new osteonecrosis biomarkers is essential to facilitate swift diagnosis and proactive intervention. Our study provides novel insights into the identification of AVN-related biomarkers that can enhance clinical management and treatment outcomes.

Effect of Patient Age on Total Hip Arthroplasty Outcomes in Patients Who Have Osteonecrosis of the Femoral Head Compared to Patients Who Have Hip Osteoarthritis

BACKGROUND

Osteonecrosis of the femoral head (ONFH) affects both young and old patients. However, outcomes following total hip arthroplasty (THA) for these patients may vary with age. This study aimed to examine the effect of age on THA outcomes for non-traumatic ONFH patients, an area currently lacking research.

METHODS

Patients who had non-traumatic ONFH undergoing THA with at least 2 years of follow-up were identified using a database and divided into four groups by age. Then, 4 matched control groups of patients who had hip osteoarthritis (OA) were created. Multivariate logistic regression analyses were used to evaluate the rates of medical and surgical complications. Additionally, cohorts with a minimum 5-year follow-up were filtered to obtain further data on surgical outcomes. The study analyzed 85,462 non-traumatic ONFH and 80,120 hip OA patients undergoing THA.

RESULTS

Multiple medical complications in ONFH patients increased with age. Periprosthetic fracture within 2 years increased with age, while 90-day wound complications, 2-year periprosthetic joint infections, dislocations, and revisions decreased. The trends for complications continued at the 5-year follow-up. Compared to OA patients, those who had ONFH had higher risks of most complications, but this discrepancy decreased with age.

CONCLUSIONS

In ONFH patients undergoing THA, medical complications generally rise with age, while most surgical complications, including revisions, decrease. It is notable that ONFH patients experienced more complications than those who had OA, but this difference diminished with age.

Can the Achilles tendon regenerate completely following percutaneous tenotomy in older children with clubfoot?

PURPOSE

The aims of the study were to document the outcomes of percutaneous Achilles tenotomy (pAT) performed in older children with clubfoot, by assessing the clinical, functional and ultrasonographic evidence of Achilles tendon regeneration.

METHODS

A retrospective case series of older children with clubfoot treated between August 2011 and July 2020 was studied. Clinical assessment of ankle range of motion and calf strength, functional assessment of triceps surae muscle endurance by single leg heel-rise test, and ultrasonographic assessment of Achilles tendon echotexture and dimensions to assess tendon regeneration were performed.

RESULTS

Percutaneous Achilles tenotomy was performed on 31 children (48 clubfeet) at a mean age of 5.24 ± 2.14 years (1-10.2 years). At a mean follow-up of 4.86 ± 1.97 years, all children demonstrated normal calf strength with mean dorsiflexion range of 13.64° (0-25°) and mean plantarflexion range of 37.95° (10-40°). The heel-rise endurance test was completed by 27 children with mean 25.85 heel rises/minute (range 17-30) and mean height of heel rise of 6.29 cm (range 4-10 cm). Normal fibrillar tendinous echotexture with homogenous echogenicity was seen on ultrasonography in 41 feet (85.4%) with mean tendon width of 9.7 mm (3.3-16 mm) and thickness of 5.1 mm (1.8-15 mm), comparable with unaffected feet.

CONCLUSIONS

Clinical, functional and ultrasonographic parameters unequivocally demonstrate complete regeneration of the Achilles tendon, when pAT is performed in older children with delayed-presenting idiopathic clubfoot treated using Ponseti principles.

Symptomatic Heterotopic Bone Formation after 1,2 ICSRA in Scaphoid Nonunions

Background  We observed several cases of heterotopic bone formation after a 1,2 intercompartmental supraretinacular artery (1,2 ICSRA) distal radius vascularized bone graft (VBG) for the treatment of scaphoid nonunion. This adverse event seems underreported. Knowledge about factors associated with the formation of heterotopic bone after VBGs might help reduce this adverse event. Purpose  What factors are associated with resected heterotopic bone formation after 1,2 ICSRA distal radius graft for the treatment of scaphoid nonunion? Patients and Methods  We retrospectively reviewed all patients with a scaphoid nonunion treated with a 1,2 ICSRA distal radius graft between 2008 and 2019 in an urban level 1 trauma center in the Netherlands. We included 42 scaphoid nonunions in 41 people treated with the 1,2 ICSRA graft. We assessed potential correlation with patient, fracture, and treatment demographics. Results  Heterotopic bone developed in 23 VBGs (55% [23/42]), of which 5 (12% [5/42]) were resected. Heterotopic bone was located radially (at the pedicle side) in all participants. Except a longer follow-up time ( p  = 0.028), we found no variables associated with the development of heterotopic bone formation. Conclusion  The location of the heterotopic bone at the pedicle site in all cases suggests a potential association with the periosteal strip. Surgeons might consider not to oversize the periosteal strip as a potential method to prevent heterotopic ossification after VBG. Level of Evidence  Level II, prognostic study.

Post-traumatic Total Hip Arthroplasty After Acetabular Fractures: Benefits of the Hardinge Approach

Post-traumatic arthritis is a common sequelae after undergoing open reduction and internal fixation (ORIF) of acetabular fractures. This often necessitates conversion to total hip arthroplasty (THA) to help alleviate pain and improve function for these patients. Unfortunately, dislocation rates for post-traumatic THA have been alarmingly high especially when the posterior approach has been used. In the setting of prior soft tissue disruption, the theoretical risk of dislocation is even greater. Conversely, the lateral or the abductor-split approach (Hardinge) is associated with decreased dislocation rates. In this retrospective case series, we evaluated the dislocation rate of the Hardinge approach on patients who underwent THA after developing post-traumatic arthritis after acetabulum ORIF. All patients who matched CPT code 27132 (Repair, Revision, and/or Reconstruction Procedures on the Pelvis and Hip Joint), from January 2009 to December 2019, and treated by the senior author, were pulled from the electronic medical record at the University of Pittsburgh Medical Center. Thirty-one of the resultant 110 were treated with THA for post-traumatic arthrosis through a lateral, abductor-splitting Hardinge approach and met the inclusion criteria for further study. Our case series involves 31 patients who underwent post-traumatic THA through a Hardinge approach: the mean age at the time of index acetabular ORIF is 48.5 years, the mean age at the time of THA is 53.5 years, and the mean interval between ORIF and ultimate THA was five years. The mean length of follow-up after THA was 22.4 months. Overall, patients did well with an all-cause revision rate of 9.7%, with no revision performed for loosening of either the acetabular or femoral component. One patient developed an infection. No patient in our group sustained a dislocation, and all implants were stable without evidence of radiographic loosening at the final follow-up. This study found satisfactory results with patients undergoing THA via lateral or abductor split approach (Hardinge) for post-traumatic arthritis after acetabular ORIF. The use of a Hardinge approach for post-traumatic reconstruction of the hip may be protective against dislocation without increasing baseline risks in this difficult patient population.

Ulnar Buttress Arthroplasty without Ulnar Stump Stabilization for Giant Cell Tumor of Distal Ulna

Purpose  Reconstruction and stabilization of ulnar stump after distal ulna tumor resection is still a matter of debate. We present the outcomes of ulnar buttress arthroplasty without stabilization of the ulna stump in giant cell tumor of bone (GCTB) of the distal ulna. Methods  Evaluation of functional outcome was performed using Musculoskeletal Tumor Society 93 (MSTS93) score, Modified Mayo Wrist score (MMWS), and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. We also assessed the hand grip strength, range of motion at the wrist, and ulnar carpal translation. Results  The study included 8 patients with Campanacci grade 3 GCTB of the distal ulna with a mean follow-up of 35.5 ± 9.1 months. The mean resection length was 7.7 ± 1.3 cm. The mean hand grip strength on the operated side was noted to be 90 ± 0.04% of the contralateral side. Mean MSTS93 score was 27.9 ± 1.25, mean MMWS was 86.9 ± 4.58%, and the mean DASH score was 4.9 ± 1.67, depicting a good to excellent functional outcome with low degree of disability. No radiocarpal instability, ulnar carpal translation, prominence, or instability of the proximal ulnar stump was noted in any patient. Conclusion  Reconstruction of the distal radioulnar joint using iliac crest bone graft for ulnar buttress without stabilization of the ulnar stump after resection of the distal ulna is an effective reconstruction option with good functional outcome and preservation of good hand grip strength. Level of Evidence  Level IV, Therapeutic study.

V-Y Quadricepsplasty for Knee Stiffness Post Total Knee Arthroplasty: A Case Report and Literature Review

Introduction

Knee stiffness post-total knee arthroplasty (TKA) represents a common and challenging complication. Standard treatment protocols primarily include physical therapy, manipulation under anesthesia (MUA), fibrotic tissue release, lysis of adhesions (LOA), and in refractory cases, revision arthroplasty. However, these interventions often show minimal improvement in refractory cases. This report introduces V-Y quadricepsplasty as an innovative approach for addressing knee stiffness post-TKA, particularly in cases unresponsive to MUA and LOA, without any evidence of prosthetic component malposition or failure.

Case Report

We present a case involving a middle-aged woman experiencing persistent knee stiffness post-TKA, unresponsive to both MUA and LOA. Diagnostic evaluations confirmed no malposition or failure of the prosthetic component. The patient underwent a successful V-Y quadricepsplasty, which resulted in significant improvement in her condition.

Conclusion

This case underscores the efficacy of V-Y quadricepsplasty in managing knee stiffness post-TKA, especially in cases where traditional treatments such as MUA and LOA are ineffective and there is no evidence of prosthetic component failure or malposition. This approach potentially offers a new avenue for treatment in similar clinical scenarios.

Comparison of single and double incision leg fasciotomy in disaster settings-Experience from 2023 Türkiye earthquakes

INTRODUCTION

Although there are studies comparing methods for leg fasciotomy in compartment syndrome after fractures, choice of single or double fasciotomies in disasters was not investigated. The aim of this study was to compare the efficacy of single and double incision leg fasciotomy in the setting of disaster.

METHODS

Patients that have undergone fasciotomy after 2023 Kahramanmaraş earthquakes were retrospectively analyzed. The cases were separated into two groups as single incision and double incision according to the method of the first fasciotomy. The number of debridements after each fasciotomy, muscle group excisions, completion time of treatment, presence of amputation, the method of closure (primary closure or graft/flap) and positive results of wound cultures were analyzed and compared between two groups.

RESULTS

62 legs of 52 patients (22 females, 30 males, age 36.9 ± 11.2 years) with compartment syndrome that have undergone fasciotomy after 2023 Kahramanmaraş earthquakes were included in the study. Single-incision group included 27 legs and double incision group included 35 legs. Amputation was needed in 15 patients (%24.2), six in single incision group and nine in double incision group. (p = 0.75). Compartment excision (eight patients in single incision, nine patients in double incision groups, p = 0.81), number of debridements (median 4 in both groups, p = 0.55), wound closure time (median 17 days in single incision, 22 days in double incision groups, p = 0.52), graft or flap requirement (11 patients in single incision, 16 patients in double incision groups, p = 0.53), positive culture results (15 patients in single incision, 16 patients in double incision groups, p = 0.44) were not different statistically between two groups.

CONCLUSION

Single and double incision fasciotomy methods are equally effective and safe in treatment of compartment syndrome of the leg in disaster situations. To our knowledge, this is the first study comparing outcomes of single and double incision fasciotomy in disaster settings.

Late surgical correction after complex unstable pelvic fracture 61 C3 (OTA/AO) of an 18-year-old woman

Surgical fixation of pelvic fractures is often necessary to restore fracture stability and improve patient outcomes. However, early operative management of pelvis fractures is not widely available in many health systems, resulting in conservative treatment approaches. Conservative approaches can lead to uncorrected pelvic deformities, which are challenging to treat and increase the risk of serious complications such as malunion. Treatment of pelvic malunion requires specialized care, access to necessary equipment, and a clearly defined treatment protocol. However, there is a lack of literature describing treatment algorithms for pelvic fracture malunion. This case report aims to incrementally fill this gap in the literature and highlight a logical step-by-step approach for reconstruction of pelvic malunion. This report is a single case of an 18-year-old woman who sustained complex unstable pelvic fracture, indicated for a 3-step reconstruction at a hospital with limited resources but access to computed tomography scan and some specialized pelvis reduction instruments. Postoperative imaging of the pelvis indicated satisfactory reduction and stable fixation of the pelvic reconstruction. After surgery, the patient was able to perform full axial load with no reported pain. This report provides a detailed description of each step of the operative management of a pelvic malunion case with clearly defined sequences, reduction tools, and positioning maneuvers necessary. Demonstrated in this case report, strategic preoperative planning is critical to successfully treating pelvic malunion and improving patient outcomes. This case report provides the necessary information on the management of pelvic reconstruction to inform other surgeons in underserved regions.

Sacral fracture associated with a Tarlov cyst causing an anterior sacral CSF fistula and intraventricular fat emboli - a case report and review of the literature

BACKGROUND

Sacral fractures are rare and either associated with high-energy trauma or osteoporosis in most cases. A search of the current literature on sacral fractures and cerebrospinal fluid fistula identified only few cases. Pathological fractures are uncommon and exceedingly rare in case of Tarlov cysts. Sacral fractures can be missed in oligosymptomatic patients. However, severe complications may emerge as shown by this case report.

METHODS

We present the case of a pathological sacral fracture at the level S2/3 following a low-impact trauma, associated with a Tarlov cyst, which was complicated by an anterior CSF fistula and intraventricular fat emboli.

RESULTS

The patient was treated conservatively with strict bedrest and a CT-guided blood patch. Postponed mobilization was successful with decreasing orthostatic symptoms. Follow-up MRI and CT imaging showed a complete resolution of the ventral CSF fistula and ossification of the fracture. The intraventricular fat did not resolve, however, there was no radiological sign of hydrocephalus with excellent clinical outcome at 6-months follow-up.

CONCLUSION

Although exceedingly rare, sacral Tarlov cysts may be associated with pathological fractures of the sacrum. Relevant complications can emerge and need to be properly addressed.

Relevance of the Watson-Jones anterolateral approach in the management of Pipkin type II fracture-dislocation: a case report and literature review

Femoral head fractures with associated hip dislocations substantially impact the functional prognosis of the hip joint and present a surgical challenge. The surgeon must select a safe approach that enables osteosynthesis of the fracture while also preserving the vascularization of the femoral head. The optimal surgical approach for these injuries remains a topic of debate. A 44-year-old woman was involved in a road traffic accident, which resulted in a posterior iliac dislocation of the hip associated with a Pipkin type II fracture of the femoral head. Given the size of the detached fragment and the risk of incarceration preventing reduction, we opted against attempting external orthopedic reduction maneuvers. Instead, we chose to perform open reduction and internal fixation using the Watson-Jones anterolateral approach. This involved navigating between the retracted tensor fascia lata muscle, positioned medially, and the gluteus medius and minimus muscles, situated laterally. During radiological and clinical follow-up visits extending to postoperative month 15, the patient showed no signs of avascular necrosis of the femoral head, progression toward coxarthrosis, or heterotopic ossification. The Watson-Jones anterolateral approach is a straightforward intermuscular and internervous surgical procedure. This method provides excellent exposure of the femoral head, preserves its primary vascularization, allows for anterior dislocation, and facilitates the anatomical reduction and fixation of the fracture.

Delayed Fixation of Acetabular Fractures Affects Functional Outcomes and Health-Related Quality of Life, Not Just Quality of Reduction

Background

Delayed operative fixation of acetabular fractures remains a major problem in many parts of the world. No previous studies have reported the effect of fixation delay on health-related quality of life (HRQOL). We aimed to investigate the effect of delayed operative fixation of acetabular fractures on health-related quality of life, EuroQol-5 Dimension questionnaire (EQ-5D), and other related outcomes.

Methods

We retrospectively analysed 117 patients who underwent open reduction internal fixation for displaced acetabular fractures between 2014 and 2021. Patients were divided into groups based on the admission-to-surgery time (interval between injury and definitive surgery): 1-14, 15-21, and >21 days. Patients were analysed for associations between admission-to-surgery time and postoperative outcomes, including operative time, estimated blood loss, blood transfusion, postoperative complication, and quality of reduction. Eighty-five patients with a mean follow-up time of 3.94 ± 1.84 years were analysed for the association between admission-to-surgery time and conversion to total hip arthroplasty, the Modified Merle d'Aubigné and Postel score, EQ-5D score, ability to sit cross-legged, and ability to sit squat. Multivariable linear regression was used for continuous outcomes and logistic regression for categorical outcomes associated with delayed operative fixation.

Results

An admission-to-surgery time > 14 days was associated with significantly higher blood loss [785 mL (236-1335), p = 0.006]. For associated fractures, an admission-to-surgery time > 21 days increased the risk of poor reduction [odds ratio (OR), 5.21 (1.42-19.11), p = 0.013]. Further, admission-to-surgery time > 21 days was associated with poor Modified Merle d'Aubigné and Postel scores [OR, 8.46 (1.48-48.29), p = 0.016], EQ-5D pain domain [OR, 3.55 (1.15-11), p = 0.028], and EQ-5D usual activity domain [OR, 4.24 (1.28-14), p = 0.018].

Conclusion

Delayed operative fixation of acetabular fractures after 21 days affected the functional outcomes and HRQOL, independent of the reduction status. Surgical interventions and patient referrals should occur at the earliest and within 21 days from the time of injury.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43465-024-01163-x.

Combined anatomical reduction plate for quadrilateral acetabular fractures via a posterior approach: an anatomical-morphological study

OBJECTIVE

To digitally measure the fixation trajectory of anatomical plates used in the combined reduction of quadrilateral acetabular fractures via the posterior approach, and to develop anatomical plates that align with the characteristics of the pelvis in the Chinese population.

METHODS

Pelvic computed tomography (CT) data from 102 adult patients were collected at the Affiliated Hospital of Zunyi Medical University. This group included 51 males and 51 females, aged between 20 and 60 years. Using Mimics software (version 21.0), a three-dimensional model of each pelvic data point was reconstructed. The fixation path for the combined reset anatomical steel plate was drawn, where the curves on the fixation path were approximated as arcs. The radius of curvature and length of these curves were measured, and an anatomical steel plate was designed to best fit the pelvic structure.

RESULTS

The combined anatomical reduction plate fixation system for quadrilateral acetabular fractures using a posterior approach consisted of two parts: a locking plate and a reduction plate. The posterior wall region (r2), ischial region (r3), quadrilateral region (r4), and bending region (r5), and the total length of the reduction plate were significantly smaller in females (P < 0.05). Similarly, the posterior wall region (R3), distal posterior wall region (R4), and the total length of the locking plate were significantly smaller in females (P < 0.05). Additionally, the anterior superior iliac spine side (r1) and the total length of the T-shaped auxiliary plate were significantly smaller in females (P < 0.05). The bending angle (< A) was also significantly smaller in females (P < 0.05).

CONCLUSIONS

The pelvic surface structure is irregular and varies greatly among individuals.Compared to the traditional steel plate, The combined reduction anatomical plate designed in this study demonstrated high precision and improved conformity to the anatomical structure of the pelvis.

Comparative study of retrograde intramedullary nailing versus locking extramedullary plating in complete articular fractures with metaphyseal comminution of the distal femur

INTRODUCTION

Fractures of the distal femur with metaphyseal comminution and complete intra-articular involvement (AO/OTA classifications 33C2 and 33C3) present challenges for reduction and fixation. However, an optimal fixation method remains unknown. This study aimed to compare the clinical and radiographic outcomes of locking extramedullary plating (LEP) and retrograde intramedullary nailing (RIN) for complete distal femoral intra-articular fractures with metaphyseal comminution.

MATERIALS AND METHODS

Between January 2016 and May 2022, 80 patients (45 men and 35 women; average age, 56.7 years) diagnosed with AO/OTA 33C2 and 33C3 were treated with either LEP or RIN and followed up for at least one year. Post-operative evaluations included radiographic assessments of bone union rate, timing, and alignment. Clinically, the knee joint range of motion (ROM), lower extremity functional scale (LEFS), and Kellgren and Lawrence (KL) grade were analyzed. The complications were also compared.

RESULTS

36 underwent LEP and 44 underwent RIN. Bone union was observed in 69.4% and 63.6% of the patients in the LEP and RIN groups, respectively (p = 0.64). The average union time was 6.9 months for the LEP group and 6.6 months for the RIN group (p = 0.51). A tendency toward varus deformity was observed in the RIN group, although the difference was not statistically significant. No significant differences were observed in knee ROM, LEFS, or KL grade. Complications included non-union (33.8%; RIN, 11; LEP, 16), varus deformity (5%; RIN, 4; LEP, 0), infection (1.3%; RIN, 0; LEP, 1), heterotrophic ossification (1.3%; RIN, 0; LEP, 1), and wound dehiscence (2.5%; RIN, 2; LEP, 0).

CONCLUSIONS

The surgical fixation methods, RIN and LEP, for complete distal femoral intra-articular fractures with metaphyseal comminution showed similar clinical and radiological outcomes. However, regardless of the type of fixation device used, there was a reduced rate of bone union owing to high energy and a less favorable prognosis.

Epidemiology of acetabular fractures in elderly patients and the effect of various management options on the outcomes. A comprehensive narrative review

Owing to the expected increase in the world's elderly population (>65 years old), and the concomitant osteoporosis in this particular population, fragility fractures of the pelvis and the acetabulum is becoming a real concern, which could be life-threatening. In the current review, we aimed to discuss the various epidemiological characteristics of geriatric acetabular fractures, management options, and the outcomes. For the review synthesis, we searched PubMed to select the most relevant and updated articles published from various areas and institutions. Geriatric acetabular fractures are mainly caused by trivial trauma, constitute about 1.5%-3% of all skeletal injuries, and showed a 2.4-fold increase over the past three decades. Furthermore, these fractures' associated one-year mortality rate ranges from 14% to 25%. Management options differ largely according to the type and severity of the injury if there is an associated skeletal or non-skeletal injury, and preexisting patient comorbidities. These options could be nonoperative or operative (including surgical fixation and acute total hip arthroplasty), and both carry a specific risk in this vulnerable age group. There is controversy among various reports regarding the best management option leading to better function and health-related quality of life (HRQoL) outcomes. In conclusion, the incidence of acetabular fractures in elderly patients is rising. The decision-making on the best management option should consider the patient's fragility, injury severity, poor bone quality, and multiple medical comorbidities. The outcomes related to function, quality of life, and mortality are comparable between operative and nonoperative management options.

Health-related quality of life after total knee arthroplasty and unicompartmental knee arthroplasty for unicompartmental osteoarthritis: A systematic review and meta-analysis

BACKGROUND

While previous research has demonstrated potential advantages of unicompartmental knee arthroplasty (UKA) over total knee arthroplasty (TKA), particularly in terms of clinical outcomes such as function and pain relief, the specific impact on health-related quality of life (HRQOL) remains unclear. This systematic review and meta-analysis aim to address this gap by comparing HRQOL outcomes between UKA and TKA, providing valuable insights for clinical decision-making.

METHODS

We conducted a literature search in the PubMed, Embase, Cochrane Controlled Register of Trials (CENTRAL), and Web of Science databases up to July 15, 2023. Eligible studies assessed HRQOL using EQ-5D, SF-36, or SF-12 and were assessed for methodological quality using the Newcastle-Ottawa Scale (NOS).

RESULTS

Seven eligible studies were included, comprising a total of 64,585 patients with 35,809 undergoing TKA and 28,776 undergoing UKA. Patient age ranged from 52.0 to 67.7 years with an average BMI ranging from 27.2 to 31.0 kg/m2. Follow-up periods ranged from 6 months to 10 years. Five studies (63,829 patients) that evaluated HRQOL using EQ-5D showed significantly better outcomes for UKA compared to TKA (MD -0.04, 95% CI -0.05 to -0.02). Two studies (756 patients) that evaluated HRQOL using SF-36 showed no significant difference between TKA and UKA. Five studies (63,286 patients) that evaluated functional outcomes using Oxford Knee Score (OKS) showed significantly better functional scores for UKA compared to TKA (MD -1.29, 95% CI -1.86 to -0.72). Four studies (24,570 patients) that reported patient satisfaction showed no statistically significant difference between TKA and UKA (MD 0.97, 95% CI 0.90 to 1.05). Further subgroup analysis did not affect the conclusions.

CONCLUSIONS

Our meta-analysis suggests that UKA is associated with better HRQOL and knee function, as well as similar patient satisfaction, compared to TKA for patients with unicompartmental osteoarthritis.

Saw-box osteotomy versus reamer-box osteotomy in posterior stabilized total knee arthroplasty: a retrospective study of an average five year follow-up

PURPOSE

The purpose of this study is to compare the difference of results between two methods of femoral box osteotomy adopted by two designs of posterior stabilized total knee prostheses.

PATIENTS AND METHODS

Retrospective analysis of the results of two groups of patients operated upon using two primary PS TKA systems, PFC Sigma (DePuy Synthes, Johnson and Johnson®) and Genesis II prosthesis (Smith and Nephew®), with an average of five year follow-up was done. Group 1 included 152 knees in 121 patients and group 2 included 122 knees in 111 patients. The average follow-up period in both groups was five years. The box osteotomy method depends on bone saw in group 1, and bone reamer in group 2.

RESULTS

The KSS score of group 2 was better in the first six months postoperatively. Then, no significant differences were seen in the remaining follow-up visits. The risk of periprosthetic fractures was significantly higher in group 1 (p-value 0.040). Survival analysis showed a significantly shorter time for reoperation in group 1 than in group 2 as described by log-rank test, (p < 0.006).

CONCLUSION

The method of box cutting has an impact on the function and longevity of posterior stabilized primary knee implants. The risk of periprosthetic fractures can be reduced by proper patient selection, decreasing the box sizes, and development of more "controlled" box osteotomy instruments.

Unicompartmental knee arthroplasty improves mental health in patients with single compartment knee osteoarthritis

PURPOSE

The purpose of this study was to determine if preoperative mental health status improves following unicompartmental knee arthroplasty (UKA) in patients with single compartment knee osteoarthritis (OA).

METHODS

A total of 163 patients underwent UKA [115 (71%) medial, 48 (29%) lateral] (mean age = 65 ± 11) completed preoperative and minimum 2-year postoperative veterans RAND 12 item health survey (VR-12) mental component score (MCS). VR-12 MCS was the primary outcome measure. Secondary measures included VR-12 physical component summary score (PCS), knee osteoarthritis outcome score (KOOS) and KOOS patient acceptable symptom state at the final follow-up.

RESULTS

The median VR-12 MCS improved from 50.5 [interquartile range (IQR): 43.7-56.8] to 55.0 [IQR: 52.3-57.0] (p < 0.001) at a mean follow-up of 9.5 ± 4 years (range 2-19 years) following UKA. Preoperative VR-12 MCS was significantly correlated with patients postoperative VR-12 PCS (ρ = 0.294, p < 0.01), KOOS pain (ρ = 0.201, p = 0.012), KOOS ADL (ρ = 0.243, p = 0.002) and KOOS quality of life (ρ = 0.233, p < 0.01). Sixty-three (39%) patients improved from low VR-12 MCS (<50) to normal VR-12 MCS (≥50). One hundred forty-two (87%) achieved a normal VR-12 MCS score (≥50) postoperatively.

CONCLUSION

At a mean of 10-year follow-up, patients who underwent UKA for single compartment osteoarthritic knee pain demonstrated significant improvement in mental health scores. UKA resulted in normal mental health in a majority of patients (87%). The resultant improved mental health scores were associated with improved patient pain and activities of daily living.

LEVEL OF EVIDENCE

Level III retrospective cohort study.

Uncemented hip revision cup as an alternative for T-type acetabular fractures: A cadaveric study

BACKGROUND

The current rise in elderly patients with compromised bone quality complicates the surgical treatment of acetabular T-type fractures (AO type 62B2 fractures). There is on ongoing discussion about the treatment options, mostly consisting of an open reduction and internal fixation (ORIF) with or without primary or secondary total hip arthroplasty (THA). Yet, these patients are oftentimes unable to fulfil weight-bearing restrictions and mostly present with an unavailability of a stable anchor site. Consequently, this study investigates the feasibility of a cementless hip revision cup for acetabular T-type fractures and compares its biomechanical properties to ORIF.

HYPOTHESIS

The cementless hip revision cup provides sufficient biomechanical stability under the simulation of full weight-bearing.

PATIENTS AND METHODS

The study compared two groups of human cadaveric hip bones with T-type fractures, of whom 6 subjects were treated with ORIF (6 male; mean age: 62±17years; mean body weight: 75±15) versus 6 subjects treated with a cementless hip revision cup (2 male; 69±12 years; 73±15kg). The group-assignment was controlled for comparable BMD results (mean BMD: ORIF 110±37 mg Ca-Ha/mL versus hip revision cup 134±32 mg Ca-Ha/mL). To compare for biomechanical stability cyclic loading was applied measuring the force and dislocation of the fracture gap at standardized bone loci using an all-electric testing machine and a 3D-ultrasound measuring system.

RESULTS

Comparing superior pubic ramus versus iliac wing (cementless hip revision cup versus ORIF [mean±standard deviation]: 5.8±2.0 versus 7.0±3.2; p=0.032) as well as sacral ala versus iliac wing (4.6±2.2 versus 6.4±3.7; p=0.002), the cementless revision cup achieved a significantly higher stability than the plate osteosynthesis.

CONCLUSION

Revision cup and ORIF withstood biomechanical loading forces exceeding full weight-bearing in this biomechanical study. The results of our study suggest that the cementless hip revision cup might be promising alternative to the current standard care of ORIF with or without primary THA.

LEVEL OF EVIDENCE

III; case control experimental study.

Rare Case of Open Comminuted Scaphoid Fracture Dislocation: Treatment With Free Bone Graft and Locking Plate

To the best of our knowledge, there are no reports in the literature of an open comminuted scaphoid fracture dislocation. We present such a rare case. The case report illustrates the case of a 58-year-old right-handed press operator who injured his left wrist when his hand got caught in a press machine. He received initial treatment at another hospital and was subsequently referred to our hospital. Eight days after the injury, surgery was performed under the brachial plexus block. Successful bone fusion was achieved through volar locking plate fixation, primary free bone grafting from the radius, and Kirschner wire fixation. Our case report may be a valuable resource for the treatment of similar injuries.

Intelligent robot-assisted fracture reduction system for the treatment of unstable pelvic fractures

BACKGROUND

Precise and minimally invasive closed reduction is the premise of minimally invasive internal fixation. This paper aims to explore the safety and efficacy of a robot-assisted fracture reduction system (RAFR) in the treatment of pelvic fractures and to analyze its clinical advantages and existing problems.

METHODS

The RAFR system intelligently designed the optimal reduction path and target position based on a preoperative three-dimensional(3D) CT scan of the patient. The reduction robotic arm automatically reduced the affected hemipelvis according to the pre-planned reduction path.

RESULTS

The average residual displacement was the 6.65 ± 3.59 mm. According to Matta's criteria, there were 7 excellent, 10 good, and 3 fair, and the excellent and good rate was 85%. No postoperative complications occurred.

CONCLUSION

In our study, the RAFR system could complete accurate and minimally invasive closed reduction for most patients with unstable pelvic fractures, which could achieve good fracture reduction quality and short-term efficacy.

Critical distance of the sacroiliac joint for open reduction using screw fixation for traumatic sacroiliac joint diastasis: a retrospective study

BACKGROUND

Osteosynthesis for sacroiliac joint (SIJ) diastasis using an iliosacral screw (ISS) and a trans-iliac-trans-sacral screw (TITSS) can be performed using a closed or an open method. However, no clear indication for open reduction has been established.

METHODS

Data on patients with unilateral traumatic SIJ diastasis who underwent ISS and TITSS fixation were retrospectively collected and separated into groups according to the reduction method: closed reduction group (C group) and open reduction group (O group). Demographic data and perioperative image assessments were compared between the groups. The critical distance of the SIJ was identified to elucidate the indication for open reduction of the diastatic SIJ.

RESULTS

Fifty-six patients met the inclusion criteria over a 3-year period. There was no significant difference in the reduction quality of pelvic ring injuries between the groups, according to Matta's and Lefaivre's criteria. The improvement in the SIJ distance was significantly greater in the O group than in the C group in the axial plane on multiplanar computed tomography (p = 0.021). This model predicted that a difference of > 3.71 mm between the injured and healthy SIJ was a recommended indication for open reduction, with an area under the curve of 0.791 (95% confidence interval 0.627-0.955, p = 0.004).

CONCLUSIONS

Open reduction for SIJ diastasis might achieve better reduction quality than does closed reduction in the axial plane in selected cases. When the difference between the injured and healthy SIJ was wider than 3.71 mm, open reduction was recommended for satisfactory radiological outcomes.

Serum gonadal hormones levels and hypogonadism in ART naïve newly diagnosed HIV infected adult males in Mwanza, Tanzania

BACKGROUND

Human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) is an endemic chronic disease which is characterized with progressive depletion of CD4 T cells and increased susceptibility to opportunistic infections. Previous studies have associated HIV infection with increased hypogonadism. However, the prevalence of hypogonadism remained poorly defined and widely ranging in various studies. This study aims to evaluate the serum gonadal hormonal levels and hypogonadism in antiretroviral therapy (ART) naïve newly diagnosed HIV infected-males in Mwanza, Tanzania.

METHODS

This was a comparison study involving 81 ART naïve newly diagnosed HIV-infected adult males as study group and 81 apparently healthy HIV-negative males as comparison group. The participants in the study group and comparison group were matched by body mass index and age. Serum hormones [Total testosterone (TT), follicle stimulating hormone (FSH), luteinizing hormone (LH) and estradiol (E) were estimated. Serum testosterone < 300 ng/dl, or testosterone > 300 ng/dl with high LH and FSH (compensatory hypogonadism) were taken as markers of hypogonadism. Data were analyzed using STATA version 15.

RESULTS

The median serum testosterone level among ART naïve newly diagnosed HIV-infected adult males was significantly lower as compared to their comparison group (447 [259-534] versus 517 [396-605]; p = 0.0074) and shown to decrease with decreasing CD4 level. The median [IQR] serum FSH level among ART naïve newly diagnosed HIV-infected adult males was significantly higher than among their comparison group (3.8 [2.1-6.5] versus 2.6 [1.8-4.2]; p = 0.0086). The differences in serum LH and Estradiol were not statistically significant. Furthermore, the proportion of hypogonadism was significantly higher among ART naïve newly diagnosed HIV-infected adult males than in their comparison group (37.0% [30/81] versus 14.8% [12/81]; p = 0.0006). Out of these 30, 24 HIV-infected males had secondary hypogonadism, one had primary, and the remaining five had compensatory hypogonadism.

CONCLUSION

Serum testosterone was lower and follicle stimulating hormone was higher among ART naïve HIV-infected males as compared to the HIV negative controls. Hypogonadism, mainly secondary, is common endocrine abnormality among ART naïve HIV-infected male patients in this study. HIV is associated with variations in gonadal hormones which may lead to sexual dysfunction in infected individuals.

Determination of the ideal plate for medial femoral condyle fracture fixation: an anatomical fit and biomechanical study

BACKGROUND

The aim of this study is to determine the best plate to use as a substitute to fix a medial femoral condyle fracture.

MATERIALS AND METHODS

The first part is to measure the best fit between several anatomical plates including the Proximal Tibia Anterolateral Plate (PT AL LCP), the Proximal Tibia Medial Plate (PT M LCP), the Distal Tibia Medial Locking Plate (DT M LCP) and the Proximal Humerus (PHILOS) plate against 28 freshly embalmed cadaveric distal femurs. Measurements such as plate offset and number of screws in the condyle and shaft shall be obtained. The subsequent part is to determine the compressive force at which the plate fails. After creating an iatrogenic medial condyle fracture, the cadavers will be fixed with the two plates with the best anatomical fit and subjected to a compression force using a hydraulic press.

RESULTS

The PT AL LCP offered the best anatomical fit whereas the PHILOS plate offered the maximal number of screws inserted. The force required to create 2 mm of fracture displacement between the two is not statistically significant (LCP 889 N, PHILOS 947 N, p = 0.39). The PT AL LCP can withstand a larger fracture displacement than the PHILOS (LCP 24.4 mm, PHILOS 17.4 mm, p = 0.004).

DISCUSSION AND CONCLUSION

Both the PT AL LCP and the PHILOS remain good options in fixing a medial femoral condyle fracture. Between the two, we would recommend the PT AL LCP as the slightly superior option.