OUTCOMES OF SURGICAL TREATMENT FOR DISPLACED BOTH-COLUMN ACETABULAR FRACTURES

Complex both-column acetabulum fractures are severe injuries, often with associated injuries and complications with uncertain clinical and functional outcome. Modern traumatological protocols point to early surgical treatment, with anatomical reduction and stable internal fixation of fragments as a prerequisite for achieving a good treatment outcome. This retrospective-prospective multicenter cohort study was conducted during the 2014-2020 period and included 24 cases that met the input parameters, using the Letournel and Judet classification, and application of a combined surgical approach, a modified Stoppa and Kocher-Langenbeck approach. The results of treatment with complications, associated injuries and functional outcome are described. Fractures were caused by high kinetic energy trauma, and the cause was traffic accident in 17/24 (70.84%), fall from a height in 5/24 (20.83%) and crash injuries in 2/24 (8.33%) cases. The sample included 18 (75.00%) male and 6 (25.00%) female, with 10/24 (41.67%) right sided and 14/24 (58.33%) left sided fractures. Their mean age was 45.06 (range, 24-62) years. The mean follow-up time was 2.8 (range, 1-5) years. Postoperative complications were detected in 14/24 (58.33%) cases, including wound infection in 4/24 (16.67%), deep vein thrombosis in 2/24 (8.33%), heterotopic ossification in 2/24 (8.33%), hip osteoarthrosis in 3/24 (12.50%), avascular necrosis of femoral head in 2/24 (8.33%), total hip arthroplasty procedures in 3/24 (12.50%), abdominal complications in 2/24 (8.33%), urologic complications in 2/24 (8.33%), iatrogenic nerve lesion in 3/24 (12.50%), and fatal pulmonary embolism in 2/24 (8.33%) cases; there was no loss of reduction or non-union acetabular fracture. Associated injuries that we recorded as major trauma were presented in 13/24 (54.17%) study patients. The final functional results according to the Harris Hip Score (HHS) were excellent in 7/22 (31.82%), good in 10/22 (45.45%), moderate in 4/22 (18.18%) patients, and poor in 1/22 (4.55%) patient. The mean HHS was 84 (range 34-98). Complications and results have led us to a conclusion that primary injuries significantly affect the clinical and functional results. A good diagnostic procedure, assessment of the general condition and application of the trauma scoring system, surgical treatment that includes early hip reduction, open reduction internal fixation and physical rehabilitation are necessary.

IMPACT OF CEMENTLESS ZWEYMÜLLER STEM ANTEVERSION ON RESISTANCE TO PERIPROSTHETIC FRACTURE IN TOTAL HIP ARTHROPLASTY

Total hip arthroplasty implies proper orientation of both acetabular and femoral components with a range of 25-40° of combined anteversion. The aim of the study was to examine resistance to periprosthetic fracture of the axially loaded cross section rectangular femoral stem (Zweymüller) with respect to different degrees of anteversion, implanted in the artificial bone model, in laboratory conditions. Femoral bone models with implanted femoral stems were divided into 3 groups depending on the degree of stem anteversion (A, control group 13-17°; B, stem retroverted 0°-4°; and C, stem anteverted 26-30°). The amount of axial load leading to periprosthetic fracture (PPFx) of the artificial bone model was determined experimentally for each construct. The results showed that the load at which the PPFx occurred significantly increased with the increase of the endoprosthesis anteversion angle. In our clinical practice, we are often unable to place the acetabular component in an ideal grade of anteversion for intraoperatively determined reasons. The results of this experimental study suggested that increasing rectangular femoral (Zweymüller) stem anteversion lowered the risk of PPFx. This study was limited by experimental design (laboratory conditions, artificial bone) and should be clinically verified.

Hip Arthroscopy: Residual Cam Deformity Combined with Loose Bony Fragment in Hip Capsule

Hip arthroscopy is a minimally invasive, effective and innovative orthopedic procedure with a relatively low rate of complications. In our patient, residual cam deformity and a bone fragment that remained in the front hip capsule after hip arthroscopy performed three years before caused thigh numbness, muscle fasciculations, and paresthesia. It was assumed that the loose bony fragment remained following burring on prior procedure. During hip flexion, neural structures were compressed and caused the mentioned symptoms. Revision hip arthroscopy was performed and the loose fragment in addition to residual cam deformity was removed. Resolution of pain and anterior thigh numbness was reported after the revision surgery.

TREATMENT OF HUMERAL SHAFT FRACTURES: ANTEGRADE INTERLOCKING INTRAMEDULLARY NAILING WITH ADDITIONAL INTERLOCKING NEUTRALIZATION SCREWS THROUGH FRACTURE SITE

The aim of this study was to compare union time between two different nail designs for the treatment of humeral shaft fracture, i.e. antegrade interlocking intramedullary nail with and without additional interlocking neutralization screws. The retrospective study included 51 patients treated with antegrade humeral intramedullary nailing between January 2015 and December 2017. The inclusion criteria of the study were proximal and middle third humeral shaft fractures. Fifty-one patients met the inclusion criteria; 23 patients were treated with antegrade intramedullary nail with additional interlocking neutralization screws through fracture site (group A) and 28 patients were treated with antegrade intramedullary nail without additional interlocking neutralization screws (group B). Medical documentation and radiographic images taken preoperatively and postoperatively were reviewed. Radiological union was defined as cortical bridging of at least three of four cortices in two-plane radiographs, with disappearance of the fracture gap. There were no significant differences in union time between the groups (p>0.05). To our knowledge, this is the first report of antegrade interlocking humeral nailing with additional interlocking neutralization screws through fracture site. Hypothetical advantages of fracture gap reduction by additional interlocking neutralization screws to promote union were not confirmed by this first clinical trial.

TREATMENT OF UNICAMERAL BONE CYSTS IN CHILDREN: A COMPARATIVE STUDY

Unicameral bone cysts (UBC) are benign bone tumor-like lesions. Mostly they are located in the metaphyseal-diaphyseal region of long bones in children and adolescents. The etiology of UBC is still unclear. There is no consensus about the protocol of UBC treatment. The aim of this study was to evaluate the effectiveness of three different techniques for the treatment of UBC. This study included 129 pediatric patients with UBC treated at University Children’s Hospital in Belgrade during the 8-year period. The mean follow up was 7.14 years. The following parameters were observed: gender, age, site, length of cyst, cyst index, cortical thickness, presentation of pathologic fracture, healing of cyst, treatment complications and length of hospitalization. These parameters were correlated to three treatment modalities, i.e. intracystic methylprednisolone acetate injection (group 1), curettage with bone grafting (group 2) and osteoinductive procedure using demineralized bone matrix (group 3). We found statistically significant differences in healing of the cysts and length of hospital treatment between groups 1 and 2, and between groups 2 and 3. In conclusion, complete healing of UBC can be achieved only using open surgery procedure. Intracystic methylprednisolone acetate instillation can be considered a good option for initial treatment of UBC.

Treatment of Periprosthetic Femoral Fractures after Total Hip Arthroplasty Vancouver Type B

The rate of periprosthetic femoral fractures following total hip replacement has been growing steadily in the last 20 years and ranges from 0.1% to 2.1%. These fractures are mostly related to older patients with the presence of chronic diseases and frequently poor bone quality. The treatment is surgically very complex and demanding, followed by a series of complications. The evaluation in this retrospective study included 23 patients who were medically treated from January 2004 to December 2015 with the mean follow-up of 14.5 (range, 9-25) months. There were 17 patients with cement total hip arthroplasty (THA) and 6 with cementless THA. During treatment of fractures, different techniques were implemented including the use of wire cerclage, dynamic compression plates (DCP), a locking compression plate (LCP) system, and long revision stem. For the purpose of distinguishing fractures, we used the Vancouver classification by Duncan and Masri. For clinical evaluation, we used the modified Merle d'Aubigne score system and monitored complications during treatment. The aim is to show treatment results of the type B periprosthetic femoral fractures by using different operative treatment techniques. According to the Vancouver classification within type B, 10 (43.47%) patients had type B1 fractures, another 10 (43.47%) patients had type B2 fractures, and three (13.04%) patients had type B3 fractures. According to gender distribution, there were eight (34.8%) male and 15 (65.2%) female patients, mean age 59.5 (range, 47-86) years. Twelve (52.2%) and 11 (47.8%) patients had left- and right-sided fractures, respectively. The mean length of hospital stay was 16 (range, 9-26) days. According to the Merle d'Aubigne score system, 10 patients with type B1 fractures had the mean score of 11.5 points, which is poor result. Poor result was also recorded in patients with type B2 fractures, with the mean score of 10.6 points. The three patients with type B3 fractures had the mean score of 12 points, which is considered fair score. In conclusion, Vancouver classification has been widely accepted and using the protocols makes decision making during treatment much easier. During treatment of this type of fracture, we used various implants, wire cerclage, DCP and LCP, as well as long stem revision. In certain cases, we applied surgical techniques, implants that are not recommended by the Vancouver protocol by which we treated periprosthetic femoral fractures; in these case, we recorded nonunion bone, malunion and breaking of implants, which resulted in poor treatment outcome.

Surgical Treatment of Metastatic Disease of the Vertebral Column

Spinal metastatic disease is a rather common occurrence and definitely warrants attention and treatment due to the high likelihood of leaving cancer patients severely disabled in their final months of life. Recent developments in the understanding of the behavior of different tumor types, as well as advances in surgical treatment, are allowing for the evolution of treatment algorithms, especially when surgical treatment is to be considered. This paper gives an overview of the decision-making process and the array of surgical options currently available.

Association of TGFB1 29C/T and IL6 -572G/C polymorphisms with developmental hip dysplasia: a case-control study in adults with severe osteoarthritis

PURPOSE

Developmental dysplasia of the hip (DDH) increases the risk of severe adult hip osteoarthritis (OA). Transforming growth factor-β1 (TGF-beta1) and interleukin-6 (IL-6) are included in pathogenesis of OA, as well as in development of the musculoskeletal system. We investigated the association of single nucleotide polymorphisms (SNPs) known to reflect on the circulating levels of the two cytokines, specifically, 29 T → C transition in the TGFB1 signal sequence (rs1800470) and -572G → C transversion in the IL6 promoter (rs1800796), with DDH.

METHODS

We conducted a case-control study in consecutive unrelated adults with severe hip OA scheduled for total hip arthroplasty. Cases, patients with OA secondary to DDH (n = 68) and controls, patients with OA unrelated to DDH (n = 152) were genotyped at the two loci.

RESULTS

With adjustment for age, sex and genotype at the concurrent locus, cases were more likely (OR = 2.42, 95%CI 1.08-5.43; p = 0.032) to be transition homozygous at TGFB1 locus 29, and also more likely (OR = 6.36, 95%CI 2.57-15.7; p < 0.001) to be transversion homozygous at IL6 locus -572 than controls. Cases were also more likely (OR = 11.3, 95%CI 4.25-29.8; p < 0.001) than controls to carry one of the three genotypes combining transition/transversion homozygosity at both loci, or transition/transversion homozygosity at one and heterozygosity at the concurrent locus.

CONCLUSIONS

Data suggest association between TGFB1 29 T → C transition (rs1800470) and IL6 -572G → C transversion (rs1800796) with DDH, and also a possibility of TGF-beta1 and IL-6 interaction in DDH pathogenesis.