Candida spondylodiscitis: a systematic review and meta-analysis of seventy two studies

OBJECTIVES

Knowledge of Candida spondylodiscitis is limited to case reports and smaller case series. Controversy remains on the most effective diagnostical and therapeutical steps once Candida is suspected. This systematic review summarized all cases of Candida spondylodiscitis reported to date concerning baseline demographics, symptoms, treatment, and prognostic factors.

METHODS

A PRISMA-based search of PubMed, Web of Science, Embase, Scopus, and OVID Medline was performed from database inception to November 30, 2022. Reported cases of Candida spondylodiscitis were included regardless of Candida strain or spinal levels involved. Based on these criteria, 656 studies were analyzed and 72 included for analysis. Kaplan-Meier curves, Fisher's exact, and Wilcoxon's rank sum tests were performed.

RESULTS

In total, 89 patients (67% males) treated for Candida spondylodiscitis were included. Median age was 61 years, 23% were immunocompromised, and 15% IV drug users. Median length of antifungal treatment was six months, and fluconazole (68%) most commonly used. Thirteen percent underwent debridement, 34% discectomy with and 21% without additional instrumentation. Median follow-up was 12 months. The two year survivorship free of death was 80%. The two year survivorship free of revision was 94%. Younger age (p = 0.042) and longer length of antifungal treatment (p = 0.061) were predictive of survival.

CONCLUSION

Most patients affected by Candida spondylodiscitis were males in their sixties, with one in four being immunocompromised. While one in five patients died within two years of diagnosis, younger age and prolonged antifungal treatment might play a protective role.

Return to sports following discectomy: does a consensus exist?

INTRODUCTION

In the USA, lumbar discectomy is one of the most commonly performed spinal procedures. As certain sports are considered to be major risk factors for disc herniation, the question remains as to when highly active patients should return to their previous level of activity. This study aimed to analyze spine surgeons' opinions on when patients may return to activities following discectomy as well as their underlying rationale for their decision.

METHODS

A questionnaire was designed by five different fellowship-trained spine surgeons for the 168 members of the Spine Society of Australia. Questions on the surgeons experience, decision making, preferred surgical technique, the postoperative rehabilitation and the response to patient expectations were included.

RESULTS

In total, 83.9% of surgeons discuss the postoperative level of activity with their patients. Sport is considered as an important contributor for good functional outcome by 71.0% of surgeons. Surgeons recommend avoiding, often permanently, weightlifting (35.7%) of the time, rugby (21.4%), horseback riding (17.9%) as well as martial arts (14.3%) postoperatively even with previous training. The return to high levels of activity is considered as a major risk factor for disc herniation recurrence by 25.8% of surgeons. Return to high level of activity is typically recommended after 3 months by 48.4% of surgeons.

CONCLUSION

So far no consensus on the rehabilitation protocol and return to level of activity exists. Recommendations depend on personal experience as well as the individuals' training, and typically, a period of avoidance of sport for up to 3 months is recommended.

LEVEL OF EVIDENCE

Level III, therapeutic and prognostic study.

Combining radiographic and CT measurements to rival MRI for the diagnosis of acute isolated syndesmotic injury

BACKGROUND

Acute isolated syndesmotic injuries (AISIs) have a high potential to be misdiagnosed or underdiagnosed at initial presentation to the hospital. Although magnetic resonance imaging (MRI) is the gold standard in noninvasive diagnostics, it is not always available immediately and is much more expensive than other imaging modalities. This study identifies improvements in conventional radiography and computed tomography (CT) to diagnose AISI and aims to reduce the number of MRI scans needed to verify the diagnosis.

METHODS

A retrospective case match control study was conducted by searching our trauma database between 2008 and 2022. A study group of patients with AISI (n = 64) and a control group of patients without AISI (n = 76) were formed to generate an equal number of images from both groups (62 radiographs and 22 CT scans). A total of 16 parameters that quantify the distal tibiofibular relation in injured and uninjured ankles were analyzed. For statistical analysis, a two-sided t-test was applied to calculate significant differences (p < 0.05). In a further step, a receiver operating characteristic curve (ROC) was used to determine cut-off values for the most significant parameters.

RESULTS

The most significant measurement (p < 0.001) on axial CT scans was the syndesmotic area (SA). The ROC curve revealed an area under the curve (AUC) of 0.94 (95% CI 0.86-1.0) and a cut-off value of 71.68 mm2 that shows a sensitivity and specificity of 95.5% and 81.8%, respectively.

CONCLUSION

This study suggests that radiographic imaging could represent an equally accurate alternative to MRI. These methods might generate the correct diagnosis faster due to their availability and inexpensiveness. By applying our new cut-off values in a clinical setting, the number of underdiagnosed and untreated unstable syndesmotic injuries could be reduced.

LEVEL OF EVIDENCE

III, retrospective comparative study.

Total hip arthroplasty in acute acetabulum fractures: a systematic review

INTRODUCTION

The incidence of acetabular fractures has increased significantly in recent years due to demographic change. It can be divided into high-energy acetabular fractures primarily seen in adult patients versus geriatric patients mostly suffering from low-energy trauma. Historically, acetabular fractures have been treated either non-operatively or surgically following open reduction and internal fixation (ORIF), whereas nowadays total hip arthroplasty (THA) provides a true alternative. Aim of this study was to perform a systematic review on the outcome following THA in acute acetabulum fractures.

METHODS

PubMed/MEDLINE, Cochrane and Google databases were systematically searched on December 9, 2021. The key terms were [acetabular fracture] AND [[arthroplasty] OR [fixation]]. All retrospective and prospective original studies in English and German were analyzed the outcome following THA in acute acetabulum fractures were included.

RESULTS

A total of 2459 studies were screened, which includes 15 studies that met the inclusion criteria with a total of 590 patients at a mean age of 61.3 years (SD 11.48). Most studies described good to excellent results. Especially, THA allows elderly patients quicker mobilization and rehabilitation as well as symptomatic relief, as compared to ORIF or non-operative treatment. Patients who underwent non-operative treatment showed better results compared to those who underwent ORIF initially.

CONCLUSION

In acetabulum fractures, THA provides a good alternative with very good results when patients are carefully selected. Good to excellent outcomes are reported for both acute and delayed use of THA in elderly patients.

LEVEL OF EVIDENCE

Level 2, systematic review.

Spinal fractures in fused spines: nonoperative treatment is a reliable alternative

INTRODUCTION

Spinal fractures in fused spines such as in ankylosing spondylitis or DISH are typically of type B or C fractures where operative treatment is recommended. The mortality rate in non-operatively treated patients is reported to be 51%. The purpose of this study was to investigate the mortality rate, complication rate and demographics of patients following non-operatively treatment in fused spine injuries.

METHODS

Between 2019 and 2021, a retrospective study was conducted including all patients who presented to our trauma center with a spinal fracture of a fused spine. Radiology and patient charts were analyzed for fracture pattern, complications, neurological deficit, comorbidities, and mortality rate.

RESULTS

A total of 49 patients were found at a mean age was 79.8 ± 10.9 years and primarily males were affected in 65.3%. All fractures were of type B and the thoracic spine was involved in 85.7%. The mean follow-up was 6.3 ± 8.2 months and fusion was obtained in all patients. No neurological deficit was observed in any. A total of 13 patients died at a mean age of 86.5 ± 10.0 years after 157.1 ± 158.1 days. 6 patients (10.2%) deceased within the first 6 weeks at a mean age of 91.8 ± 3.8 years. One patient each suffered from heart failure, an acute delirium, end stage colon cancer and subdural hemorrhage.

CONCLUSION

This study shows that the mortality rate in the first 6 weeks following a fracture in a fused spine is 10.2% for patients above the age of 90 years. Therefore, non-operative treatment should be taken into consideration as the mortality rate in other studies may be overestimated.

LEVEL OF EVIDENCE

III, retrospective study.

Subacute Posttraumatic Ascending Myelopathy: Case Report and Systematic Review of the Literature

STUDY DESIGN

Case report and literature review.

OBJECTION

Aim of this study was to summarize the current evidence base behind subacute posttraumatic ascending myelopathy (SPAM) including the epidemiology, presentation, diagnosis, prognosis, and etiology.

SUMMARY OF BACKGROUND DATA

SPAM is a rare, potentially fatal disorder which is not attributable to ongoing mechanical instability, syrinx formation, or iatrogenic causes.

METHODS

A systematic literature search on SPAM was performed on Medline, Ovid, Cochrane, Embase, and PubMed databases between 1969 and 2021. Cases were reviewed and the findings summarized. Further evidence was reviewed to support the hypothesis that disruption of cerebrospinal fluid (CSF) circulation is the underlying etiology of the condition.

RESULTS

It is estimated to occur in 0.4%-0.7% of spinal cord injuries and may have a mortality of up to 10%. The most likely etiology disruption of CSF circulation leading to further damage to the spinal cord presumably through pressure mediated effects such as a reduction in cellular perfusion.

CONCLUSION

There is effectively no treatment of this condition, however, with interest developing in monitoring of CSF pressures during spinal cord injury this may help confirm the etiology, and allow the suggestion of therapies such as drains or expansion duraplasty to reduce spinal cord pressures.

LEVEL OF EVIDENCE

Level II-case report and systematic review.

Cure rate of infections is not an argument for spacer in two-stage revision arthroplasty of the hip

INTRODUCTION

 A devastating complication after total hip arthroplasty (THA) is chronic periprosthetic joint infection (PJI). Most frequently spacers (Sp) with or without antibiotics are implanted in a two-stage procedure even though not always indicated due to unknown pathogen, femoral and acetabular defects or muscular insufficiency.

MATERIALS AND METHODS

 A retrospective analysis of a prospectively collected database was conducted, analyzing the treatment of 44 consecutive cases with chronic PJI undergoing two-stage revision using a Girdlestone situation (GS) in the interim period between 01/2015 and 12/2018. Diagnostics included intraoperative microbiological cultures, histological analysis, sonication of the initial implant, analysis of hip aspiration, as well as laboratory diagnostics and blood cultures. We analyzed the general and age-group-specific success rate of treatment using GS. Furthermore, we compared our data with the current literature on spacer implantation regarding common complications.

RESULTS

In total, 21 female and 23 male patients at a mean age of 59.3 ± 9.6 years were included. Age groups were divided into young, mid-age, and elderly. In most patients, microbiology revealed Staphylococcus epidermidis in 39.1% of cases, following Staphylococcus lugdunensis and Staphylococcus aureus in 10.9% after THA explantation. For histology, Krenn and Morawietz type 2 (infectious type) was diagnosed in 40.9%, type 3 (infectious and abrade-induced type) in 25.0%. With GS, the total cure rate was 84.1% compared to 90.1% (range 61-100%) using Sp as described in the literature. Among age-groups, cure rate varied between 77.8 and 100%. Other complications, which only occurred in the mid-age and elderly group, included the necessity of transfusion in 31.1%, and in total, one periprosthetic fracture was identified (2.3%).

CONCLUSION

GS shows an acceptable cure rate at a minimum of 2 years when compared to the cure rate reported in the literature for Sp without major complications. For patients with increased risks for treatment failure using spacer, GS seems to be an alternative for chronic PJI when looking at the success rate of treatment.

LEVEL OF EVIDENCE

III, Retrospective trial.

Mechanical failure of total hip arthroplasties and associated risk factors

INTRODUCTION

Mechanical failure of total hip arthroplasties is a rare but devastating complication. With increasing numbers in primary arthroplasty implantation, revision surgeries are indicated more often. Therefore, understanding the mechanism and the location of failure is essential in determining proper treatment. Aim of this study was to identify mechanical failures of all total hip arthroplasties performed in a major academic center as well as the associated risk factors such as BMI and sports.

METHODS

A retrospective trial was conducted using our prospective arthroplasty database. Database was searched for all patients presenting with mechanical failures of total hip arthroplasty (THA) to the emergency department between 2011 and 2019. All medical charts and radiographs as well as surgical reports were analyzed to identify demographics, implant choice in addition to location of failure and subsequent treatment.

RESULTS

In total, 13 patients suffering from mechanical total hip implant failure were found. The femoral neck (conus) was broken in four patients, the stem in five cases, one broken inlay, two cup failures and one conus dislocation. The mean BMI was 31.42 ± 5.29 kg/m² including five patients who have obesity class II. In all cases, revision surgeries were indicated. No structural causes or underlying risk factors such as repeated physical load (i.e. in sports) were identified.

CONCLUSION

Implant failure does not seem to correlate with participation in sports or BMI. Catastrophic failure of implants is a technical challenge requiring special extraction instruments that can be difficult even for experienced surgeons. It should be noted that functional outcome is often worse for this group of patients after surgery than comparing against those revised for loosening.

LEVEL OF EVIDENCE

III, Retrospective Trial.

Cervical immobilization in trauma patients: soft collars better than rigid collars? A systematic review and meta-analysis

INTRODUCTION

Rigid cervical spine following trauma immobilization is recommended to reduce neurological disability and provide spinal stability. Soft collars have been proposed as a good alternative because of the complications related to rigid collars. The purpose of this study was to perform a systematic review on soft and rigid collars in the prehospital management of cervical trauma.

METHOD

A systematic review was performed following the PRISMA guidelines. Search terms were (immobilization) AND (collar) AND ((neck) OR (cervical)) to evaluate the range of motion (ROM) and evidence of clinical outcome for soft and rigid collars.

RESULTS

A total of 18 studies met eligibility criteria including 2 clinical studies and 16 articles investigating the range of motion (ROM). Four hundred and ninety-six patients at a mean age of 32.5 years (SD 16.8) were included. Measurements were performed in a seated position in twelve studies. Eight articles reported the ROM without a collar, 7 with a soft collar, and 15 with a rigid collar. There was no significant difference in flexion/extension, bending and rotation following immobilization with soft collars compared to no collar. Rigid collars provided significantly higher stability compared to no collar (p < 0.005) and to soft collars in flexion/extension and rotation movements (p < 0.05). The retrospective clinical studies showed no significant differences in secondary spinal cord injuries for soft collar (0.5%) and for rigid collar (1.1%). One study, comparing immobilization without a collar compared to that with a rigid collar, found a significant difference in neurologic deficiency and supraclavicular nerve lesion.

CONCLUSION

Although rigid collars provide significant higher stability to no collar and to soft collars in flexion/ extension and rotation movements, clinical studies could not confirm a difference in neurological outcome.

LEVEL OF EVIDENCE

II, Systematic Review.

Defining Operative Indications in Lisfranc Injuries

Category:

Trauma; Midfoot/Forefoot

Introduction/Purpose:

Injuries to the midfoot, especially subtle, primarily ligamentous ones, have historically been under- recognized. The literature surrounding midfoot injuries has also evolved as understanding has improved. Earlier studies focused on non-subtle midfoot dislocations and fracture dislocations, injuries in which the need for operative intervention was perhaps obvious. However, in more subtle injuries, there is some lack of clarity amongst orthopaedic surgeons as to what constitutes an operative indication. The purpose of this study was to perform a literature review of Lisfranc injuries to answer the simple question of what the operative indication was in the given study.

Methods:

A literature search [MEDLINE (PubMed), EMBASE, Google Scholar, and Cochrane databases] was performed to identify studies on Lisfranc injuries. Given that the purpose was to assess surgical indications for Lisfranc injuries, all studies that included a surgical indication for Lisfranc injuries, including case reports and review articles, were included. Studies that were not relevant to that question (i.e. biomechanical studies, anatomic studies, etc.) were excluded. PRISMA guidelines were followed where applicable, although since this study did not involve the synthesis of outcome data, some aspects were not relevant. Studies were classified as having no operative indication, a vague operative indication, or an explicit operative indication. A vague operative indication is one that referenced displacement or instability without explicitly defining those terms, i.e. displacement between which bones (M1-M2, C1-M2, or otherwise) and to what degree (any displacement, >1mm, >2mm, or otherwise) with or without stress exam.

Results:

737 studies were identified with the search term 'Lisfranc injury.' After review of the titles, 389 were felt to be potentially relevant to the question at hand. The papers were then reviewed to establish whether the indication for surgery was explicitly stated. We were unable to access 31 of these studies, and a further 51 were felt not to be relevant, leaving 307 studies that were assessed. 63.2% of these studies (194/307) did not give any specific indication for surgery. While 113 studies did give an indication for surgery, 59.3% of these studies (67/113) gave only a vague indication for surgery. Only 15.0% of studies assessed (46/307) had a clear, explicit operative indication.

Conclusion:

It is a basic tenet of any surgical discipline that one must understand what does and does not require surgery. The answering of this question perhaps becomes more difficult when the pathology is subtle and difficult to define. However, establishing clear guidelines is a necessity in this setting. There appears to be a relative lack of clear and explicit operative indications in the literature with respect to Lisfranc injuries. Surgeons and authors should be clear and consistent about which injuries require surgery; as we move forward, better outcome data will allow us to refine our indications.

App-Based Rehabilitation in Back Pain, a Systematic Review

Smartphones and their associated applications are used frequently by patients and clinicians alike. Despite the technology being widely accessible, their use to aid in rehabilitation is yet to be adopted. The SARS CoV-2 pandemic has presented an opportunity to expedite their integration given the difficulty patients currently have in accessing healthcare. The aim of this study was to perform a systematic literature review on the use of smartphone rehabilitation applications compared to standard physiotherapy for back pain. We conducted a search of Medline/Pubmed and google databases using the search terms [APP] AND [[Orthopaedic] OR [Neurosurgery]], following the PRISMA guidelines. All prospective studies investigating rehabilitation applications for back pain or following spine surgery were included. A total of nine studies met the inclusion criteria which investigated 7636 patients, of which 92.4% were allocated to the interventional group (n = 7055/7636) with a follow up of 4 weeks to 6 months. All except one study reported on patients experiencing back pain on average for 19.6 ± 11.6 months. The VAS-pain score was presented in all studies without significance between the interventional and control group (p = 0.399 before and p = 0.277 after intervention). Only one research group found significantly higher improvement in PROMs for the application group, whereas the remaining showed similar results compared to the control group. Using application-based rehabilitation programs provides an easily accessible alternative or substitute to traditional physiotherapy for patients with back pain. Given that smartphones are so prevalent in activities in our daily lives, this will enhance and improve rehabilitation if patients are self-dedicated and compliant.

The Impact of Hip Dysplasia on CAM Impingement

Predisposing factors for CAM-type femoroacetabular impingement (FAI) include acetabular protrusion and retroversion; however, nothing is known regarding development in dysplastic hips. The purpose of this study was to determine the correlation between CAM-type FAI and developmental dysplastic hips diagnosed using X-ray and rotational computed tomography. In this retrospective study, 52 symptomatic hips were included, with a mean age of 28.8 ± 7.6 years. The inclusion criteria consisted of consecutive patients who suffered from symptomatic dysplastic or borderline dysplastic hips and underwent a clinical examination, conventional radiographs and rotational computed tomography. Demographics, standard measurements and the rotational alignments were recorded and analyzed between the CAM and nonCAM groups. Among the 52 patients, 19 presented with CAM impingement, whereas, in 33 patients, no signs of CAM impingement were noticed. For demographics, no significant differences between the two groups were identified. On conventional radiography, the acetabular hip index as well as the CE angle for the development of CAM impingement were significantly different compared to the nonCAM group with a CE angle of 21.0° ± 5.4° vs. 23.7° ± 5.8° (p = 0.050) and an acetabular hip index of 25.6 ± 5.7 vs. 21.9 ± 7.3 (p = 0.031), respectively. Furthermore, a crossing over sign was observed to be more common in the nonCAM group, which is contradictory to the current literature. For rotational alignment, no significant differences were observed. In dysplastic hips, the CAM-type FAI correlated to a lower CE angle and a higher acetabular hip index. In contrast to the current literature, no significant correlations to the torsional alignment or to crossing over signs were observed.

The Impact of the Laterality on Radiographic Outcomes of the Bernese Periacetabular Osteotomy

The purpose of this study was to compare the pre and postoperative radiographic findings and analyze the complication rate with respect to the laterality in periacetabular osteotomy in right-handed surgeons. Satisfaction rate and radiographic findings were prospectively collected between 2017 and 2019 and retrospectively reviewed. For analysis, all measurements of the CT scans were performed by a musculoskeletal fellowship-trained radiologist. Complications were classified into two categories: perioperative or postoperative. All surgeries were performed by three right-hand dominant hip surgeons. A total of 41 dysplastic hips (25 right and 16 left hips) in 33 patients were included. Postoperatively, a significantly lower acetabular index angle on the left side was observed at −2.6 ± 4.3 as compared to the right side at 1.6 ± 6.5 (p < 0.05). The change in Center edge (CE) angle was significantly lower for the left side 13.7 ± 5.5° than on the right side, measured at 18.4 ± 7.3 (p < 0.001); however, the overall CE angle was comparable at 38.5 ± 8.9° without any significant difference between the operated hips (left side at 37.8 ± 6.1° versus right side at 39.0 ± 10.3; p = 0.340). No significant differences in other radiographic measurements or surgical time were observed. For complications, the right side was more commonly affected, which may also explain a higher satisfaction rate in patients who were operated on the left hip with 92.3%. The change in lateral CE angle was significantly lower for the left side and the right hip seems to be predisposed to complications, which correlate with a lower satisfaction rate in right-handed surgeons.

Rotational abnormalities in dysplastic hips and how to predict acetabular torsion

OBJECTIVES

The aim of this study was to investigate the degree to which conventional radiography can represent the acetabular and femoral rotational alignment profile between dysplastic and borderline-dysplastic hips.

METHODS

A retrospective trial was conducted including 56 borderline-dysplastic and dysplastic hips at a mean age of 28.9 years (range from 18 to 46). Inclusion criteria consisted of symptomatic patients with hip dysplasia undergoing 2-dimensional radiography as well as computed tomography. On radiography, the lateral center edge angle, acetabular hip index, hip lateralization index, acetabular index angle, and the Sharp angle were measured, and the presence of a crossover sign was noted. In computed tomography, the full rotational profile of the lower limb was measured.

RESULTS

Significant correlations were observed in the overall analysis between the anteversion of the acetabulum and the hip lateralization index (mean 0.56, coefficient of regression (CoR) -32.35, p = 0.011) as well as the acetabular index angle with a mean of 11.50 (CoR 0.544, p = 0.018). Similar results were found in the subgroup of dysplastic hips with an acetabular index angle of 13.9 (p = 0.013, CoR 0.74). For the borderline-dysplastic group, no significant correlations between the pelvis radiography and rotational CT were seen.

CONCLUSION

Although the femoral and acetabular torsion cannot be predicted from x-rays, the anteversion of the acetabulum correlates with the acetabular index angle, the hip lateralization index, and eventually the beta angle in dysplastic hips. For borderline-dysplastic hips, such results did not show up, which strongly illustrates the need for computed tomography in these cases.

KEY POINTS

• Much of the current literature focuses on rotational alignment especially with respect to the femur and tibia in healthy patients, although little is known about the acetabular, femoral, and tibial torsion in dysplastic hips. • This is the first study showing significant correlations between the anteversion of the acetabulum and the hip lateralization index as well as the acetabular inclination angle. Also, it is the first study to provide a mechanism for estimation of the torsion of the acetabulum with plain radiography in dysplastic hips. • In borderline-dysplastic hips, no significant correlation was found, which raises the question if a simple x-ray has enough validity to address the acetabular deformity with surgery.

Breakage of intramedullary femoral nailing or femoral plating: how to prevent implant failure

Introduction

Intramedullary (IM) fixation is the dominant treatment for pertrochanteric and femoral shaft fractures. In comparison to plate osteosynthesis (PO), IM fixation offers greater biomechanical stability and reduced non-union rates. Due to the minimally invasive nature, IM fixations are less prone to approach-associated complications, such as soft-tissue damage, bleeding or postoperative infection, but they are more prone to fat embolism. A rare but serious complication, however, is implant failure. Thus, the aim of this study was to identify possible risk factors for intramedullary fixation (IMF) and plate osteosynthesis (PO) failure.

Materials and methods

We searched our trauma surgery database for implant failure, intramedullary and plate osteosynthesis, after proximal—pertrochanteric, subtrochanteric—or femoral shaft fractures between 2011 and 2019. Implant failures in both the IMF and PO groups were included. Demographic data, fracture type, quality of reduction, duration between initial implantation and nail or plate failure, the use of cerclages, intraoperative microbiological samples, sonication, and, if available, histology were collected.

Results

A total of 24 femoral implant failures were identified: 11 IMFs and 13 POs. The average age of patients in the IM group was 68.2 ± 13.5 years and in the PO group was 65.6 ± 15.0 years, with men being affected in 63.6% and 39.5% of cases, respectively. A proximal femoral nail (PFN) anti-rotation was used in 7 patients, a PFN in one and a gamma nail in two patients. A total of 6 patients required cerclage wires for additional stability. A combined plate and intramedullary fixation was chosen in one patient. Initially, all intramedullary nails were statically locked. Failures were observed 34.1 weeks after the initial surgery on average. Risk factors for implant failure included the application of cerclage wires at the level of the fracture (n = 5, 21%), infection (n = 2, 8%), and the use of an additional sliding screw alongside the femoral neck screw (n = 3, 13%). In all patients, non-union was diagnosed radiographically and clinically after 6 months (n = 24, 100%). In the event of PO failure, the placement of screws within all screw holes, and interprosthetic fixation were recognised as the major causes of failure.

Conclusion

Intramedullary or plate osteosynthesis remain safe and reliable procedures in the treatment of proximal femoral fractures (pertrochanteric, subtrochanteric and femoral shaft fractures). Nevertheless, the surgeon needs to be aware of several implant-related limitations causing implant breakage. These may include the application of tension band wiring which can lead to a too rigid fixation, or placement of cerclage wires at the fracture site.

Effect of total hip arthroplasty on brake reaction time and braking force

INTRODUCTION

The correct moment for return to driving after total hip arthroplasty (THA) remains unclear. Until today no uniform recommendation exists on the ability to perform an emergency brake.The aim of this prospective study was to investigate the braking ability of patients before and after THA implantation based on brake reaction time in milliseconds (BRT) and braking force in N (BF).

METHODS

In total, 25 patients (15 men, 10 women, mean age 51.3 ± 10.1 years) were treated with THA on the right side. Inclusion criteria consisted of a valid driving licence, frequent road participation and at least 2 years of driving experience. Exclusion criteria were underlying neurological disorders as well as severe complaints in the lumbar spine and the right knee joint. The brake ability was evaluated for emergency braking with a car simulator and a measuring sole. Measurements were performed preoperatively, 6 days, 2, 4 and 6 weeks after surgery.

RESULTS

Preoperatively, the mean BRT was 671.3 ± 123.5 ms and the BF 455.4 ± 185.0 N. Significant differences were observed at 6 days and 2 weeks after surgery, (BRT 836.4 ± 219.7 ms, respectively, BRT 735.0 ± 186.7 ms, and BF 302.6 ± 154.9 N, respectively, BF 375.5 ± 149.3 N, p < 0.05). Only 4 weeks after, no significant differences were seen compared to pre-operative with a BRT of 647.0 ± 91.9ms (p = 0.354) and BF of 435.9 ± 177.4 (p = 0.843). Furthermore, the BRT improved significantly after 6 weeks (607.4 ± 87.6; p = 0.005).

CONCLUSIONS

The braking force is significantly reduced, and the brake reaction time is prolonged directly after surgery for at least 2 weeks. After 4 weeks, no statistically significant differences were measured, although special care should still be taken during return to activity.

Weightbearing Radiography and MRI Findings in Ankle Fractures

Background. Static weightbearing radiography can be used to assess stability in ankle fractures by measuring lateral talar shift (medial clear space; MCS). However, the correlation of a stable ankle joint under weightbearing load and the structural integrity of the deltoid ligament has not been shown. In this study, we assessed deltoid ligament integrity on magnetic resonance imaging (MRI) and correlated that with weightbearing and gravity stress test radiography. Methods. Thirty-four patients with supination external rotation II-IV (SER) fractures underwent MRI, weightbearing radiography, and gravity stress test. On MRI, the deep anterior and posterior tibiotalar deltoid, tibionavicular and tibiocalcaneal ligaments, as well as the syndesmosis were assessed as intact, partial rupture, or complete rupture. The MCS was measured as the distance between the lateral border of the medial malleolus and the medial border of the talus at the level of the talar dome on the mortise view. Results. Twenty-three patients suffered a deep anterior tibiotalar ligament rupture (16 partial; 7 complete) and 2 a deep posterior tibiotalar ligament tear (1 partial; 1 complete). For MCS on weightbearing radiography, no statistically significant differences were identified between any of the individual groups. With gravity stress radiography, only a complete tear of the tibiocalcaneal ligament showed a significantly higher MCS than a partial tear or intact tibiocalcaneal ligament (P < .005). No other ligament disruption showed a significant difference between the complete rupture versus intact or partial tear. Conclusion. Weightbearing radiography does not show much variation in terms of MCS even with ligamentous disruption and fibula fracture. The talus often centers itself underneath the tibia with weightbearing radiography.Levels of Evidence: Level III: Retrospective cohort study.

A novel treatment for prevention of post-traumatic elbow stiffness using onaBotulinum toxin type A: a prospective placebo controlled randomized trial

Approximately 30% of all upper extremity fractures are elbow fractures which may result elbow stiffness. This study aimed to investigate the efficacy of onaBotulinum Toxin type A injection to prevent post-traumatic pain and elbow-stiffness. All patients were included who presented to a single surgeon with supracondylar/ intraarticular distal humerus fractures, proximal ulna and radius fractures. The study was developed in a randomized placebo controlled study between 2003-2007. The Disabilities of the Arm, Shoulder, and Hand (DASH) score as well as the arc-of-motion (AOM) were assessed after three, six, twelve-months and final follow up for evaluation. Of the 31-patients included, 15-patients (48.4%) received Botox injections. In all patients no complication was observed when injecting a dosage 100-units for the brachialis and biceps brachii muscles. Furthermore, it was an effective method to prevent post-traumatic elbow stiffness, lasting six- months. Significant differences in DASH, VAS-score and ROM after three-months between the Botox and control group (DASH 21.6±11.0 vs. 55.3±11.0 ; VAS 1.2±5.2 vs. 5.7±21.9 ; ROM 103±7.6 vs. 73±6.3 ; p>0.05) were identified in the prospective group. Botulinum toxin is a safe, reliable and effective treatment to prevent post-traumatic elbow stiffness. Our study demonstrates improved early range-of- motion (p<0.05), better extension after 6 weeks and improved functional outcome including VAS and DASH score (p<0.05).

Flexor tenosynovectomy in carpal tunnel syndrome as a screening tool for early diagnosis of amyloidosis

INTRODUCTION

Amyloidosis is a heterogeneous group of diseases that most often presents with advanced cardiac pathology. Another presentation of the disease can include symptoms consistent with carpal tunnel syndrome; however, the true incidence of amyloidosis in patients with carpal tunnel syndrome remains unclear.

METHODS

We performed a retrospective chart review on all patients who underwent an open carpal tunnel release, with tenosynovium biopsy by a single surgeon between 01/2000 and 12/2018. Samples were stored in formalin following hematoxylin-eosin or congo red staining. A total of 199 patients were excluded for incomplete records, and carpal tunnel release performed for traumatic or infectious etiologies. Histologic findings of the attending pathologist were examined and categorized as follows: amyloidosis, fibrous tissue, tenosynovitis/inflammation edematous, benign tenosynovium, and gout.

RESULTS

Exactly 898 open carpal tunnel releases were performed, and 699 patients were included for final analysis. In all patients, biopsies for histology with hematoxylin-eosin (HE) staining were taken; in those HE stains where amylogenic proteins were suspected (73 or 10.4%), a subsequent congo red staining was additionally performed which confirmed the diagnosis of amyloidosis in 10 patients (1.4% of the carpal tunnel procedures). Overall, 10 patients were identified and constituted 1.4% of all HE stains (n = 10/699) and 13.7% of all congo red stains (n = 10/73).

CONCLUSION

Our results suggest that the incidence of amyloidosis in the general CTS patient population may be as high as 1.4% with routine screening by synovial biopsy and the diagnosis should be considered as a potential cause. Level of Evidence: III, retrospective study.

A novel treatment for prevention of post-traumatic elbow stiffness using onaBotulinum toxin type A: a prospective placebo controlled randomized trial

Approximately 30% of all upper extremity fractures are elbow fractures which may result elbow stiffness. This study aimed to investigate the efficacy of onaBotulinum Toxin type A injection to prevent post-traumatic pain and elbow-stiffness. All patients were included who presented to a single surgeon with supracondylar/ intraarticular distal humerus fractures, proximal ulna and radius fractures. The study was developed in a randomized placebo controlled study between 2003-2007. The Disabilities of the Arm, Shoulder, and Hand (DASH) score as well as the arc-of-motion (AOM) were assessed after three, six, twelve-months and final follow up for evaluation. Of the 31-patients included, 15-patients (48.4%) received Botox injections. In all patients no complication was observed when injecting a dosage 100-units for the brachialis and biceps brachii muscles. Furthermore, it was an effective method to prevent post-traumatic elbow stiffness, lasting six- months. Significant differences in DASH, VAS-score and ROM after three-months between the Botox and control group (DASH 21.6±11.0 vs. 55.3±11.0 ; VAS 1.2±5.2 vs. 5.7±21.9 ; ROM 103±7.6 vs. 73±6.3 ; p>0.05) were identified in the prospective group. Botulinum toxin is a safe, reliable and effective treatment to prevent post-traumatic elbow stiffness. Our study demonstrates improved early range-of- motion (p<0.05), better extension after 6 weeks and improved functional outcome including VAS and DASH score (p<0.05).

Functional Outcomes of Insertional Achilles Tendinopathy Treatment: A Systematic Review

BACKGROUND

Achilles tendinopathy is a common clinical problem that can be either insertional or noninsertional, and effective treatment of each type can vary. We sought to investigate the current evidence on different treatment methods for insertional Achilles tendinopathy with a focus on functional outcomes.

METHODS

We performed a systematic review of the available literature using the PubMed/MEDLINE and Cochrane Central Register of Controlled Trials databases. Data from included studies were categorized according to treatment method and reported with respect to functional outcomes and complications.

RESULTS

A total of 1,457 abstracts were reviewed; 54 studies with 2,177 patients met the inclusion criteria. Among the 54 studies, 6 operative techniques and 6 nonoperative treatments were evaluated.

CONCLUSIONS

Eccentric exercises and low-energy extracorporeal shockwave therapy (ESWT) have the greatest evidence for the initial management of insertional Achilles tendinopathy. ESWT has been increasingly studied in recent years, but more high-quality evidence is needed. Operative treatment with tenotomy, debridement, retrocalcaneal bursectomy, and calcaneal exostectomy is effective. Flexor hallucis longus tendon transfer may benefit cases of more severe disease. Minimally invasive procedures have a potential role in the treatment algorithm and require more rigorous study.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Dual-Energy Computed Tomography in Spine Fractures: A Systematic Review and Meta-Analysis

BACKGROUND

The purpose of this study was to perform a systematic literature review and meta-analysis to evaluate the sensitivity, specificity, and accuracy of dual-energy computed tomography (DE-CT) of bone marrow edema and disc edema in spine injuries.In vertebral injuries, prompt diagnosis is essential to avoid any delays in treatment. Conventional radiography may only reveal indirect signs of fractures, such as when it is displaced. Therefore, to detect the presence of bone marrow or disc edemas, adjunctive tools are required, such as magnetic resonance imaging (MRI) or DE-CT.

METHODS

Search terms included ((DECT) OR (DE-CT) OR (dual-energy CT) OR "Dual energy CT" OR (dual-energy computed tomography) OR (dual energy computed tomography)) AND ((spine) OR (vertebral)), and the PubMed, EMBASE, and MEDLINE databases and the Cochrane Library and Google were used. We found 1233 articles on our preliminary search, but only 13 articles met all criteria. Data were extracted to calculate the pooled sensitivity, specificity, and diagnostic odds ratio for analysis using R software.

RESULTS

Within the 13 studies, 515 patients, 3335 vertebrae, and 926 acute fractures (27.8%) defined by MRI were included. The largest cohort included 76 patients with 774 vertebrae. In 12 publications, MRI was reported for comparison. For DE-CT, the overall sensitivity was 86.2% with a specificity of 91.2% and accuracy of 89.3%. Furthermore, 5 studies reported the accuracy of CT with an overall sensitivity of 81.3%, specificity of 80.7%, and accuracy with 80.9%. Significant differences were found for specificity (P < .001) and accuracy (P = .023). However, significant interobserver differences were reported.

CONCLUSIONS

DE-CT seems to be a promising diagnostic tool to detect bone marrow and disc edemas, which can potentially replace the current gold standard, the MRI.

LEVEL OF EVIDENCE

2.

CLINICAL RELEVANCE

This study shows that DE-CT seems to be a promising diagnostic tool with an accuracy of 89.3%.

Intramedullary fixation of fibula fractures: A systematic review

INTRODUCTION

Distal fibula fractures are common injuries that often require open reduction internal fixation. Intramedullary fixation of the fibula has been used historically, and interest has been renewed somewhat recently, although there is limited data assessing outcomes after intramedullary fibular fixation. The purpose of this study was to systematically evaluate the literature as it relates to the clinical and functional outcome after fibular fracture fixation using an intramedullary device.

METHODS

A literature review on Medline/Pubmed, EMBASE, Cochrane and Google was performed. In total, 1994 abstracts were reviewed of which 30 articles in English, German and French were included, all of which evaluated the clinical and functional outcome after fibular nail osteosynthesis.

RESULTS

Within the 30 studies, a total of 1116/1380 patients were treated with a fibular nail between 1986 and 2018. In total 11 different devices were investigated. Six articles compared fibular nail versus plate osteosynthesis and in five cases a prospective study was performed. The complication rate varied somewhat widely based on the implants used. The mean union rate was 99.1% with a mean follow-up of 19.0 months. In comparison to plate fixation the nail was superior in terms of complication rate in most studies. No unified assessment of functional outcome was used, and so comparison between studies was difficult. However, good and excellent results were obtained in 73%-100% of patients.

CONCLUSION

Current data on intramedullary fixation of the fibula is limited and suffers significantly from inconsistency in outcome reporting. It remains to be seen whether the potential advantages of intramedullary implants can both maintain the good results of other implants and improve on some aspects of more commonly used implants.

LEVEL OF EVIDENCE

III, systematic review.

Epidemiology of proximal femoral fractures

INTRODUCTION

With increasing age, the incidence of proximal femoral fractures increases steadily. Although the different treatments are investigated frequently, little is known about the seasonal variation and predisposing factors. The purpose of this study is to investigate the epidemiology, the impact of femoroacetabular impingement, as well as the presence of osteoarthritis.

METHODS

We performed a retrospective review of all patients with pertrochanteric, lateral and medial femoral neck fractures between 2012 and 2019. Inclusion criteria consisted of patients older than 18 years old who presented with isolated proximal femoral fractures without any congenital or hereditary deformity. For analysis, we assessed the demographics, season at time of accident, Kellgren-Lawrence score and corner edge (CE) angle.

RESULTS

In total, 187 patients were identified at a mean age of 75.1 ± 12.9 years old. Females consisted of 54.5% of this cohort. Most commonly, patients tend to present in winter with pertrochanteric fractures whereas no seasonal variation was found for medial femoral neck fractures. Significant correlations between season and age (regression coefficient -0.050 ± 0.021; p < 0.05) were identified. In medial neck fractures, the Gardner score was lower and Kellgren-Lawrence score higher for both female than males (p < 0.05). Patients with lateral neck fractures were significantly younger at 68.6 ± 12.5 years old (p < 0.05). In pertrochanteric fractures, the Kellgren-Lawrence score was significantly higher at 2.1 ± 0.8 (p < 0.05) with higher CE angle at 43.0 ± 7.6° (p = 0.14).

CONCLUSION

With increasing incidences of proximal femoral fractures, it is essential to recognize potential risk factors. This allows for development of new guidelines and algorithm that can aid in diagnosis, prevention, and education for patients.

Prospective Analysis of Hand Infection Rates in Elective Soft Tissue Procedures of the Hand: The Role of Preoperative Antibiotics

Background: The purpose of this study was to evaluate the efficacy of prophylactic antimicrobial prophylaxis in elective hand surgery in preventing postoperative infection. Methods: Between 2009 and 2012, we performed a multicenter trial in which patients undergoing elective hand surgeries were categorized into an antibiotic or control group depending on the center they were enrolled in. Surgical site infections were defined according to the Centers for Diseases Control and Prevention. Results: In total, 434 patients were included: 257 did not receive antibiotics (control) and 177 received antibiotics at a mean age of 61.0 years. In the control group, comorbidities were more common with 23.7% (61/257) in comparison to the antibiotics group with 14.1% (25/177). Only one surgical site infection in each group was identified. One wound was opened surgically, and an antimicrobial treatment was indicated in both cases. In addition, we observed four complications in the control group and three complications in the antibiotics group which required conservative management. No significant differences in the two cohorts in infection rate (0.006% vs 0.003%, χ² = 0.07, P > .05) and complication rate (2.8% vs 1.6%, χ² = 0.01, P > .05) were found. Conclusions: Our prospective multicenter trial showed no significant difference in infection rate in elective hand surgery whether antibiotics were administered preoperatively or not.

Meta-analysis of Noninsertional Achilles Tendinopathy

BACKGROUND

Achilles tendinopathy is a common clinical problem that can be either insertional or noninsertional. A variety of treatment methods have been described, although little consensus exists on an optimal method or methods. We sought to investigate the current evidence on different treatment methods for noninsertional Achilles tendinopathy, with a focus on functional outcomes.

METHODS

We performed a review of the available literature in PubMed and the Cochrane Central Register of Controlled Trials. Data from included studies were categorized according to treatment method and analyzed with respect to functional outcome and complication rate.

RESULTS

In total, 1420 abstracts were reviewed, of which 72 articles containing 3523 patients met inclusion criteria. Within the 72 studies included, 6 operative techniques and 19 nonoperative treatments were evaluated.

CONCLUSION

A wide variety of treatments are available for noninsertional Achilles tendinopathy, although newer treatments and most operative methods lack high-level evidence. Eccentric exercise is the most thoroughly studied and supported nonoperative treatment, while tenotomy and debridement is the operative procedure with the most evidence of efficacy. Platelet-rich plasma injections and extracorporeal shockwave therapy have proven to be viable second-line nonoperative treatments. Gastrocnemius recession and flexor hallucis longus transfer have shown benefit in case series.

LEVEL OF EVIDENCE

Level II, systematic review.

Thumb Disability Examination (TDX) as a New Reliable Tool for Basal Joint Arthritis

Background  The general assessment of basal joint arthritis (BJA) is limited using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. This has been shown to be insensitive to pain and disability levels, leading to the development and validation of the thumb disability examination (TDX) as a specific tool for BJA in 2014. Objective  The goal of this study was to evaluate the reliability, sensitivity, and specificity of the TDX score for BJA. Methods  A multicenter BJA database was established in 2007 to collect prospective data. We evaluated the correlation between the TDX score, visual analog pain scale with activity (A-VAS), Eaton-Littler score, and grip strength using a Pearson test. Additionally, we evaluated the pre- and postintervention scores to assess their predictive values. Results  A total of 109 thumbs of 74 patients with TDX scores were evaluated. Females were more commonly affected (75.2%), and the mean age was 65.39 years (standard deviation: 10.04). The majority of participants were white (90.8%). A high correlation between TDX and A-VAS score (Pearson's correlation = 0.520; p  < 0.001) and between grip strength (Pearson's correlation = -0.336; p  < 0.005) and Eaton-Littler score (Pearson's correlation = 0.353' p  < 0.01) was identified. Additionally, when comparing pre- and post-intervention for all treatment groups and for operative intervention, significant differences in TDX scores were observed (both p ≤ 0.01). No significant differences could be identified for DASH score or A-VAS when assessing these same groups. Conclusion  The TDX score correlates to high Pearson's correlation values and p -values, especially in grip strength, Eaton-Littler score, A-VAS score, and pre-/postintervention for all treatment groups combined and when specifically assessing the surgical intervention group. As a result, it can be concluded that the TDX score is a specific tool for the assessment of BJA. Level of Evidence  This is a Level II, prospective comparative study.

Increased Synovial Inflammatory Markers in Aseptic Total Hip Arthroplasty Dislocation

BACKGROUND

In cases of total hip arthroplasty (THA) dislocation, a synovial fluid aspiration is often performed to evaluate for periprosthetic joint infection (PJI). It is currently unclear how aseptic dislocation of a THA influences synovial fluid white blood cell (WBC) count and polymorphonuclear percentage (PMN%). The primary aim of this study is to investigate the influence of THA dislocation on synovial WBC count and PMN%.

METHODS

Twenty-eight patients who underwent a synovial aspiration of a THA between 2014 and 2019 were identified and enrolled in our case-control study. Patients with an aseptic THA dislocation and synovial hip aspiration were matched against patients without dislocation, patients undergoing hip aspiration before aseptic THA revision surgery, and patients undergoing hip aspiration before septic THA revision surgery.

RESULTS

Synovial WBC count was significantly increased in the dislocation vs aseptic THA revision group (P = .015), as well as between the septic revision group vs dislocation and aseptic THA revision group (both P < .001). The PMN% did not differ significantly between the dislocation and aseptic revision groups (P = .294). Mean C-reactive protein values were 12.4 ± 14.9 mg/dL in THA dislocation, 24.1 ± 37.7 mg/dL in THA without infection compared to 85.7 ± 84.9 mg/dL in THA infection group (P < .001).

CONCLUSION

This study shows that THA dislocation has a significant impact on synovial WBC count in joint aspiration. Our data suggest that in the setting of THA dislocation, synovial WBC and PMN% may not be the best method to evaluate for PJI. Further research should be performed to establish new thresholds for these synovial inflammatory markers in the setting of THA dislocation and PJI.

LEVEL OF EVIDENCE

Level III; retrospective trial.

Functional Outcomes After Fracture-Dislocation of the Ankle

Background. Fracture dislocation of the ankle represents a substantial injury to the bony and soft tissue structures of the ankle. There has been only limited reporting of functional outcome of ankle fracture-dislocations. This study aimed to compare functional outcome after open reduction internal fixation in ankle fractures with and without dislocation. Methods. A retrospective chart review of surgically treated ankle fractures over a 3- year period was performed. Demographic data, type of fracture, operative time and complications were recorded. Of 118 patients eligible for analysis, 33 (28%) sustained a fracture-dislocation. Mean patient age was 46.6 years; 62 patients, who had follow-up of at least 12 months, were analyzed for functional outcome assessed by the Foot and Ankle Outcome Score (FAOS). The median follow-up time was 37 months. Demographic variables and FAOS were compared between ankle fractures with and without dislocation. Results. The average age of patients sustaining fracture-dislocation was greater (53 vs 44 years, P = .017); a greater percentage were female (72.7% vs 51.8%, P = .039) and diabetic (24.2% vs 7.1%, P = .010). Wound complications were similar between both groups. FAOS was generally poorer in the fracture-dislocation group, although only the pain subscale demonstrated statistical significance (76 vs 92, P = .012). Conclusion. Ankle fracture-dislocation occurred more frequently in patients who were older, female, and diabetic. At a median of just > 3-year follow-up, functional outcomes in fracture-dislocations were generally poorer; the pain subscale of FAOS was worse in a statistically significant fashion. Levels of Evidence: Therapeutic, Level III.

Foreign rectal body - Systematic review and meta-analysis

BACKGROUND

Self-inserted foreign rectal bodies are an infrequent occurrence, however they present a serious dilemma to the surgeon, due to the variety of objects, and the difficulty of extraction. The purpose of this study is to give a comprehensive review of the literature regarding the epidemiology, diagnostic tools and therapeutic approaches of foreign rectal body insertion.

METHODS

A comprehensive systematic literature review on Pubmed/ Medline and Google for 'foreign bodies' was performed on January 14th 2018. A meta-analysis was carried out to evaluate the epidemiology, diagnostics and therapeutic techniques. 1,551 abstracts were identified, of which 54 articles were included.

RESULTS

The motivation of foreign rectal body insertion is mostly sexual stimulation. Patients are typically young and predominantly male, with a male to female ratio of 6:1. Sexual devices (35.7%, n=108) and glass objects (17.5%, n=53) are the most commonly self-inserted rectal foreign bodies. Patient history should be taken sensitively after diagnostic evaluation and identification of the object. Removal was performed under general anesthesia in 45.2% (n=95) and sedation in 29.0% (n=61). The total complication rate was described to be 30.4%.

CONCLUSIONS

Diagnostics must be performed with caution in order to rule out perforation and establish a treatment algorithm. Manual transanal extraction under sedation or general anesthesia may be performed in conjunction with cautious abdominal compression. Because of the variety of objects, i.e. in form and material, each case must be treated individually. Sometimes creativity and surgeon imagination may be required, although different algorithms have been established.

Fibular Nail Fixation: Topical Review

BACKGROUND

Intramedullary implants have been used historically in long bone fractures with success. In recent years, a variety of intramedullary implants for the treatment of fibular fractures have been investigated. These various implants have not been assessed together in a cohesive manner. In this review, we assess implants used for intramedullary fixation of fibular fractures with respect to implant design and clinical results.

METHODS

A comprehensive systematic literature review for intramedullary implants in fibular fractures was performed. All publications that assessed intramedullary fibular implants were reviewed. In total, 11 different intramedullary nails were found. Clinical results obtained from these studies were reviewed.

RESULTS

The intramedullary implants used for fibular fracture fixation generally fell into one of 3 categories: an unlocked longitudinal strut, an implant roughly equivalent to a large screw, or a more traditionally locked intramedullary nail. Reported clinical results were generally good, although inconsistent outcome reporting greatly limited comparison between studies. Complication rates varied with the implants but were generally low.

CONCLUSION

Intramedullary implants for fibular fracture stabilization have changed over the years to improve stability. Although clinical results are limited, data suggest that these implants are safe and can potentially approximate more traditional implants.

LEVEL OF EVIDENCE

Level II, systematic review.

Magnetic resonance imaging (MRI) versus single photon emission computed tomography (SPECT/CT) in painful total hip arthroplasty: a comparative multi-institutional analysis

OBJECTIVE

To investigate the value of MRI in comparison to single photon emission computed tomography (SPECT)/CT in patients with painful hip arthroplasties.

METHODS

A prospective, multi-institutional study was performed. Therefore, 35 consecutive patients (21 female, 14 male, mean age 61.8 ± 13.3 years) with 37-painful hip arthroplasties were included. A hip surgeon noted the most likely diagnosis based on clinical examination and hip radiographs. Then, MRI and SPECT/CT of the painful hips were acquired. MRI and SPECT/CT were assessed for loosening, infection, fracture, tendon pathology and other abnormalities. Final diagnosis and therapy was established by the hip surgeon after integration of MRI and SPECT/CT results. The value of MRI and SPECT/CT for diagnosis was assessed with a 3-point scale (1 = unimportant, 2 = helpful, 3 = essential).

RESULTS

Loosening was observed in 13/37 arthroplasties (6 shaft only, 6 cup only, 1 combined). Sensitivity, specificity, positive predictive value and negative predictive value for loosening of MRI were 86%/88%/60%/100% and of SPECT/CT 93%/97%/90%/100%, respectively. MRI and SPECT/CT diagnosed infection correctly in two of three patients and fractures in two patients, which were missed by X-ray. MRI detected soft tissue abnormalities in 21 patients (6 bursitis, 14 tendon lesions, 1 pseudotumor), of which only 1 tendon abnormality was accurately detected with SPECT/CT. All 5 arthroplasties with polyethylene wear were correctly diagnosed clinically and with both imaging modalities. MRI and SPECT/CT were judged as not helpful in 0/0%, as helpful in 16%/49% and essential in 84%/51%.

CONCLUSION

In patients with painful hip arthroplasty SPECT/CT is slightly superior to MR in the assessment of loosening. MRI is far superior in the detection of soft tissue, especially tendon pathologies.

ADVANCES IN KNOWLEDGE

To our knowledge this is the first prospective, multiinstitutional study which compares MRI with SPECT/CT in painful hip arthroplasties. We found that MRI is far superior in the detection of soft tissue pathologies, whereas SPECT/CT remains slightly superior regarding loosening.

Strength Measurement After Achilles Tendon Repair

The goal of treatment after Achilles tendon rupture (ATR) is to restore appropriate tension to the tendon, so that normal baseline strength and functional soft-tissue length can be achieved. The assessment of plantarflexion strength has shown widespread variability. The purpose of this study is to document variations in strength assessment after the treatment of ATR in the literature. A comprehensive literature review was performed. In total, 2758 articles were found on Achilles tendon rupture and Achilles tendon strength measurement. The full text of articles including strength as a functional outcome measurement in the abstract were assessed. All objective strength measurements performed were reviewed and recorded for comparison. One-hundred articles were included in our study. In 78 articles, a dynamometer was used to measure strength, whereas in 22 articles, an endurance test (n=14) or formal gait assessment (n=8) was applied. When a dynamometer was used, there was wide variability in the various methods used including the incorporation of both isokinetic (n = 65) and isometric (n = 29) exercises utilizing varying degrees of knee flexion and patient testing position. Furthermore, the number of measurements at certain angular velocities varied. This study illustrates that no general consensus exists regarding an optimal method for measuring strength after ATR. The variability creates difficulty and challenges medical professionals' ability to formulate consistent conclusions when determining functional performance outcomes. A more uniform way of measuring strength after ATR may allow for better comparisons between studies in the literature, potentially leading to a better understanding of strength. Levels of Evidence: Therapeutic, Level II.

MRI Assessment of Degeneration of the Tendon in Achilles Tendon Ruptures

BACKGROUND

The extent of tendinosis along the entire tendon in Achilles tendon ruptures (ATRs) has not previously been assessed. MR images of acute ATRs were evaluated to assess this extent, even in areas distant from the rupture.

METHODS

Patients who had MR images for an ATR were reviewed. Each tendon was divided into a proximal, middle, and distal segment with the full tendon length defined as the length measured from the myotendinous junction to the insertion. The site of tendon rupture, presence of tendinosis and/or additional tearing, and largest anteroposterior (AP) diameter in the remaining segments were noted. In total, 45 MR iamges were included in our study.

RESULTS

The mean total tendon length was 9.93 cm, while the length from the insertion to the tear was 5.86 cm. Of the 45 ruptures, 20 (44.4%) were in the proximal third, 19 (42.2%) in the middle third, and 6 (13.3%) in the distal third. In all remaining segments where no ruptured tendon was observed, tendinosis was seen. Further, of the 90 segments of a tendon without rupture, 87 (96.7%) had an AP diameter greater than 6 mm. Of those 90 segments without rupture, 24 (26.7%) had a secondary partial-thickness tear in another third.

CONCLUSION

Tendinosis is a known precursor of an ATR that in the current study was not limited to the area of rupture. The finding of extensive tendon degeneration may have implications for the optimal surgical treatment.

LEVEL OF EVIDENCE

Level IV, case series.

Spinopelvic dissociation in patients suffering injuries from airborne sports

BACKGROUND

Spinopelvic dissociation which is also called U-type or referred to H-type sacral fractures with a transverse fracture line is an infrequent injury that results mainly from high-energy accidents. This results in an osseous dissociation of the upper central segment of the sacrum and the entire spine from the lower sacral segments. The purpose was to investigate the incidence of spinopelvic fracture in general among airborne injuries.

PATIENTS AND METHODS

Using our electronic patient records, we retrospectively investigated all sacral fractures related to airborne sports between 2010 and 2017. All injuries were classified according to the Roy-Camille, Denis, AOSpine and the Tile classification system.

RESULTS

During the period of interest, 44 patients (18.7%) were admitted with sacral fractures after accidents obtained from airborne sports, including 16 spinopelvic dissociations (36.4%). The majority of these injuries were obtained from paragliding (75.0%), followed by BASE jumping (21.4%) and parachuting (4%). The mean injury severity score (ISS) in the spinopelvic dissociation group was significantly higher compared with other sacral fracture group (38.1 vs. 20.0; p < 0.001). Six lambda-type, four T-type, four H-type and two U-type injuries were identified. In total, four patients (25%) were found to have neurological impairment. For treatment, 87.5% of patients underwent subsequent surgical stabilization.

CONCLUSION

Airborne sports have high potential for serious, life-threatening injuries with a high incidence of spinopelvic dissociation. In the literature, the prevalence of spinopelvic dissociation in sacral fractures is described to be between 3 and 5%. In our series, the prevalence is 36.4%. It is important to identify the potential injuries promptly for the further treatment. These slides can be retrieved under Electronic Supplementary Material.

Radiographic Results of Unicortical Medial Malleolar Fracture Fixation

BACKGROUND:

Medial malleolar fractures commonly occur as part of rotational ankle fractures, which often require surgery. Different fixation techniques exist, including unicortical or bicortical lag-screw fixation. Bicortical screws that engage the lateral distal tibia have been noted to be biomechanically superior to unicortical ones with a lower failure rate. The authors of this study have used unicortical screws routinely. This study was initiated to investigate the clinical results of a large series of patients with unicortical medial malleolar fixation.

METHODS:

Patients who underwent unicortical medial malleolar fracture fixation between 2011 and 2017 were reviewed. In total, 461 ankle fractures were identified with a mean follow-up of 11.4 months (range, 3-57), of which 211 had a medial malleolar fracture. Eight patients were excluded as they did not follow up with the treating surgeons after surgery, leaving 203 patients for evaluation. The primary outcome was radiographic union. Any loss of reduction, complication, or subsequent surgery was recorded. Malunion was defined as greater than 2 mm displacement.

RESULTS:

There were 2 asymptomatic nonunions (1.0%), 1 delayed union that healed using an external bone growth stimulator (0.5%), and 2 malunions of the medial malleolus (1.0%) with 1 asymptomatic. The other patient developed posttraumatic osteoarthritis but has not yet required further surgery. None of these 5 patients required revision medial malleolar surgery. Ultimately, the union rate using unicortical medial malleolar fixation was 99.0% (201/203).

CONCLUSION:

Unicortical fixation of medial malleolar fractures resulted in consistently good healing. Even though biomechanical studies have shown that bicortical screws provide stronger fixation, our clinical results indicate that the need for this stronger fixation may be questionable.

LEVEL OF EVIDENCE:

Level IV, retrospective case series.

Anatomy of the ankle capsule: A cadaveric study

Although bony and ligamentous injuries of the ankle are well understood, little is known about the degree to which injury of the ankle capsule can be a component of such injuries. The purpose of this study was to determine the dimensions of the ankle capsule and its relationship to adjacent structures. Thirteen fresh-frozen ankle specimens were systematically dissected. Methylene blue solution was injected to identify the dimensions of the ankle capsule. External dimensions were measured as the distance from the capsular reflection to the bony margin of the ankle. Internal dimensions were measured as the distance from the capsular attachment of the distal tibia, fibula, and talus to the cartilage margin. The anterior aspect of the capsule demonstrated the most proximal capsular reflection in all specimens. The most proximal reflections of the anteromedial, anterior middle and anterolateral capsule were 10.3, 13.5, and 9.8 mm, respectively. The most proximal reflections of the posteromedial, posterior middle and posterolateral region were 8.7, 6.2, and 3.5 mm, respectively. There was no capsular reflection over the medial malleolus and less than 1 mm over the posterior lateral malleolus. There was a confluence of the capsule and ligamentous complex on the medial side, and also with the transverse tibiofibular ligament about the posterolateral ankle. The most proximal attachment of the ankle capsule was located at the anterior aspect of the distal tibia. The medial and posterolateral capsules were confluent with the ligamentous complexes of the ankle in those regions. Clin. Anat. 31:1018-1023, 2018. © 2018 Wiley Periodicals, Inc.