Use of MatriDerm with Split-Thickness Skin Graft in Post-traumatic Full-Thickness Wound Defects in Orthopedic Cases: A Case Report and Systematic Review of the Literature

The management of complex and severe lower-extremity injuries is challenging for the orthopedic surgeon. When the primary or secondary closure of the defect is not feasible, complex procedures with graft (split-thickness or full-thickness) or flap (pedicled or free) are required. These procedures are performed by specialized plastic surgeons and are at high risk for adverse effects, even high morbidity among both the donor and acceptor sites. Furthermore, split-thickness skin grafts (STSGs) often lead to unsatisfactory results in terms of mechanical stability, flexibility, and aesthetics due to the lack of underlying dermal tissue. Consequently, dermal substitutes, such as MatriDerm (MedSkin Solutions Dr Suwelack AG, Billerbeck, Germany), have been proposed and further developed as a treatment option addressing the management of full-thickness wound defects in conjunction with STSGs. We aimed to present a case of post-traumatic full-thickness wound defect of the left foot after traumatic amputation of the digits that was treated with MatriDerm combined with autologous STSG. In addition, we performed a systematic review of the literature to delineate the efficacy of the use of MatriDerm combined with STSGs in orthopedic cases exclusively.

Treating peri-trochanteric hip fractures with intramedullary nail, when a second anti-rotational screw is necessary?

INTRODUCTION

Fragility fractures around the proximal end of the femur have increased in recent years due to an aging population, adding to the pressure on national health care systems and to hospital expenses. Peri-trochanteric fractures have historically been treated successfully with anatomic intramedullary nails, giving stable fixation in order to allow early for mobilisation of these frail patients. Some of these nails allow a second (anti-rotational) screw through the nail into the femoral head. We assessed the use of this additional screw in terms of quality of reduction, post-operative mobilization and complications.

MATERIALS & METHODS

All patients who were treated in the same hospital for peri-trochanteric fracture between January 2017 and December 2019 were included in the study. The patients were randomly assigned into group A, where the treatment included intramedullary nailing using one femoral hip screw, and group B, where the treatment additionally included a second anti-rotational screw. The patients were followed up clinically and radiologically, for at least 3 months post-operatively. Demographic and operative data were collected alongside radiographic and clinical data.

RESULTS

A total of 118 patients with an average age of 82.7 years were included in the study after exclusion criteria was applied. There were no statistically significant differences between the two groups regarding the ASA grade, Nottingham Hip fracture score, Koval score, Mental score, operation time, transfusion requirements, and operative radiation dose and time (p > 0.05). In group A, more complications were observed (p < 0.05). The radiographic measurements were statistically significantly different. CART analysis revealed that the use of a single screw in the femoral head for the subgroup of the unstable peri-trochanteric fractures (Jensen Type 4-5 - AO31A2.2 and above), has a tendency toward developing more post-operative complications, though this was not statistically significant.

CONCLUSION

The use of an additional anti-rotational screw for unstable peri-trochanteric fractures (Jensen Type 4-5 and AO 31A2.2 and above) could prevent complications such as varus collapse and cut-out.

Endoscopic Plantar Fasciotomy as an Effective and Reliable Treatment for Plantar Fasciitis: An Overview of the Literature

Plantar fasciitis is a common cause of heel pain. The aim of this study was to review the current literature and attempt to clarify whether endoscopic plantar fasciotomy (EPF) is an effective and reliable treatment for plantar fasciitis in comparison with other invasive or noninvasive treatments. We performed an electronic search of the medical literature in PubMed database using combinations of the following keywords: plantar fasciitis, endoscopic treatment, and plantar aponeurosis. Overall, we had shown that patients had better scores following EPF/endoscopic plantar fascia release. The clinical scores were improved postoperatively and most of the patients were satisfied. Furthermore, the clinical trials showed that time to return to work or to previous activities was shorter compared with other treatments. These studies suggest that EPF/endoscopic plantar fascia release is probably an effective treatment of chronic plantar fasciitis. EPF is an efficient, safe treatment with good early postoperative results in patients with recalcitrant plantar fasciitis. There is evidence that other methods are equivalently effective for EPF, and some authors support that they should be considered as a second-line treatment because of their minimal invasive character and very low risk of complications; thus, more research is required.

Does preoperative physiotherapy improve outcomes in patients undergoing total knee arthroplasty? A systematic review

OBJECTIVE

To systematically review the scientific literature and to investigate the effectiveness of preoperative rehabilitation on subjective and objective outcomes after total knee arthroplasty (TKA) when compared with patients in a control group.

DATA SOURCES

A search was conducted in PubMed, PubMed Central, Embase, Cochrane Library and Physiotherapy Evidence Database databases in May 2021.

STUDY SELECTION

randomized controlled trials (RCTs) were reviewed if they compared a preoperative physiotherapy exercise intervention with no intervention group for patients undergoing TKA for severe Osteoarthritis (OA). A total of 24 RCTs were included at the end of the evaluation process. By the end of the evaluation process, a total of 24 RCTs were included.

DATA EXTRACTION

Two authors independently screened the literature, extracted data, and assessed the quality of included studies. The outcomes were knee extension, knee flexion, pain Visual Analogue Scale (VAS), overall Western Ontario and McMaster Universities OA Index, 6 min walking test, and Timed Up and Go test.

RESULTS

The majority of the studies included in this systemic review demonstrated a comparable trend of long-term postoperative improvement of knee extension strength, VAS, range of movement and functional scores, and those of quality of life between two groups. Many studies showed a significant improvement in terms of preoperative pain, length of hospital stay and functional performance shortly after the operation, but all studies failed to show a prolonged effect on knee motion or patient function between 3 and 12 months.

CONCLUSIONS

Low to moderate evidence from mostly small RCTs demonstrated that preoperative physiotherapy interventions reduce pain and improve functional performance for patients with knee OA prior shortly after the TKA.

Clinical significance and management of meniscal extrusion in different knee pathologies: a comprehensive review of the literature and treatment algorithm

The menisci are crescent-shaped, fibrocartilaginous structures that play a crucial role in the load transition and distribution of the contact forces along the tibiofemoral articulation. Meniscal extrusion (ME) is a radiological finding, especially in magnetic resonance imaging (MRI) scans, for which there has been growing interest in recent years. ME, in the coronary plane, is defined as the maximum distance of the most distal end of the meniscus from the border of the tibial plateau, where the tibial eminences are the most prominent, without taking into account the osteophytes. Although there is still controversy in the literature in respect of the optimal cutoff value, a threshold of 3 mm is considered significant. ME has no specific clinical finding or sign and it is encountered in many knee pathologies. It is associated with either rapidly progressive knee osteoarthritis or early onset of knee osteoarthritis and increased morbidity. In this review, we delineate the clinical significance of ME in various knee pathologies, as well as when, why and how it should be managed. To the best of our knowledge, this is the first study to elaborate on these topics.

MINIMA Short Stem Versus Standard Profemur (TL) Stem in Primary Total Hip Replacement: A Comparative Study

Background: The objective of our study was to compare a novel squared section, tapered design - with four conicity - short stem, the MINIMA® short stem with the cementless Profemur® TL standard femoral stem in primary total hip arthroplasty (THA) in terms of functional outcomes, radiologic evaluation and other peri-operative and post-operative data.

Material and methods: This is a comparative study including 46 patients undergoing primary THA. In 23 patients, the MINIMA® short stem was used. These patients were matched with another 23 patients in whom a cementless Profemur® TL standard femoral stem was used. The levels of the pain were evaluated according to the Visual Analog Scale/Numerical Rating Scale (VAS/NRS). The functional and clinical evaluation of the patients was performed with Harris Hip Score (HHS), Charnley’s Hip score, EuroQol (EQ-5D)-(EQ-100), Patient Health Questionnaire (PHQ-9), and neuropathic pain questionnaire (DN-4). The rest of the comparison data included demographic data, the American Society of Anesthesiologists score (ASA), Charlson Index score, the pre-operative diagnosis, radiographic evaluation, the days of hospitalization, the operating time, incision length, blood loss, and blood transfusion requirements and complication rates.

Results: The two cohorts had comparable results regarding all patients’ peri-operative data. The radiographic assessment revealed considerable higher levels of femoral offset and femoral subsidence for the MINIMA group, but within acceptable limits for both cohorts. The majority of the functional and other scores did not give strong prominence to one specific femoral stem.

Conclusion: Our comparative study underlined the efficacy of the MINIMA® short stem, due to the fact that it revealed comparable and, in some cases, relatively better short-term outcomes compared with the TL standard femoral stem. Yet, more well-designed long-term research is required in order to further establish its effectiveness.

Extensive Inferior Vena Cava Thrombosis Related to COVID-19 Infection in a Patient with Retrievable Filter Due to Multiple Pelvic Bone Fractures

Inferior vena cava (IVC) thrombosis is often attributed to IVC filters. Here, we describe the first case of IVC filter thrombosis associated with severe acute respiratory syndrome coronavirus-2 infection in a 34-year-old male with multiple pelvic fractures. The IVC filter was initially placed prophylactically prior to major orthopedic trauma reconstruction complicated by silent pulmonary embolism, precluding the safe transition to therapeutic anticoagulation due to the high hemorrhagic risk from pelvic fracture fixation. This case highlights the potentially increased risk of severe complications in patients receiving vascular care if they were to contract coronavirus disease-2019 (COVID-19) in the hospital. IVC filter placement in the patient resulted in complete IVC thrombosis after he acquired COVID-19 infection. Prophylactic doses of low molecular weight heparin could not prevent this complication. However, prompt initiation of therapeutic anticoagulation with rivaroxaban led to the complete resolution of IVC thrombosis over weeks after viral negativization and discharge.

The Efficacy of High-Intensity Preoperative Physiotherapy Training on Postoperative Outcomes in Greek Patients Undergoing Total Knee Arthroplasty: A Quasi-Experimental Study

Purpose: Several studies have shown that patients with severe osteoarthritis (OA) of the knee can reduce their knee pain, improve their quadriceps strength, and improve their functional ability through regular exercise training. The purpose of this study was to investigate the efficacy of a six-week supervised high-intensity preoperative training program on muscle strength, functional performance, and patient-reported outcomes in patients undergoing total knee arthroplasty (TKA).

Methods: Ninety-eight patients scheduled for unilateral TKA for severe OA were allocated to an intervention group (N = 49) who completed a six-week preoperative training program, five days per week prior to surgery, and a control group (N=49) who did not follow any preoperative training program. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Physical Functioning Scale of the Short Form-36 questionnaire (SF-36), Knee Injury and Osteoarthritis Outcome Score (KOOS), quadriceps strength, 20-meter walk test, and 30-second chair stand test were assessed at six weeks before surgery (T0), just before surgery (T1), four weeks (T2) and finally 12 weeks (T3) after TKA.

Results: Of 98 patients included in our study, 10 individuals withdrew from the study at different stages. Finally, 44 patients were allocated to the intervention group and 44 patients to the control group. When comparing the changes from baseline to the primary test points at T1, T2, and T3, we found a significant group difference in favor of the intervention group for quadriceps strength (<0.001, 0.001, 0.009), 20-meter walk test (<0.001, 0.023, 0.032), 30-second chair stand test (0.001, <0.001, <0.001) and all patient-reported outcomes WOMAC (<0.001, 0.001, 0.007) except from KOOS that showed significant difference only at T1 (<0.001) at T2 (0.048) but not at T3 (0.087).

Conclusions: Our study demonstrated that a six-week preoperative physiotherapy training program supervised by a physiotherapist before TKA is efficacious for decreasing knee pain, improving knee function, and enhancing daily living activities.

IMPACT-Global Hip Fracture Audit: Nosocomial infection, risk prediction and prognostication, minimum reporting standards and global collaborative audit. Lessons from an international multicentre study of 7,090 patients conducted in 14 nations during the COVID-19 pandemic

Aims

This international study aimed to assess: 1) the prevalence of preoperative and postoperative COVID-19 among patients with hip fracture, 2) the effect on 30-day mortality, and 3) clinical factors associated with the infection and with mortality in COVID-19-positive patients.

Methods

A multicentre collaboration among 112 centres in 14 countries collected data on all patients presenting with a hip fracture between 1st March-31st May 2020. Demographics, residence, place of injury, presentation blood tests, Nottingham Hip Fracture Score, time to surgery, management, ASA grade, length of stay, COVID-19 and 30-day mortality status were recorded.

Results

A total of 7090 patients were included, with a mean age of 82.2 (range 50–104) years and 4959 (69.9%) being female. Of 651 (9.2%) patients diagnosed with COVID-19, 225 (34.6%) were positive at presentation and 426 (65.4%) were positive postoperatively. Positive COVID-19 status was independently associated with male sex (odds ratio (OR) 1.38, p = 0.001), residential care (OR 2.15, p < 0.001), inpatient fall (OR 2.23, p = 0.003), cancer (OR 0.63, p = 0.009), ASA grades 4 (OR 1.59, p = 0.008) or 5 (OR 8.28, p < 0.001), and longer admission (OR 1.06 for each increasing day, p < 0.001). Patients with COVID-19 at any time had a significantly lower chance of 30-day survival versus those without COVID-19 (72.7% versus 92.6%, p < 0.001). COVID-19 was independently associated with an increased 30-day mortality risk (hazard ratio (HR) 2.83, p < 0.001). Increasing age (HR 1.03, p = 0.028), male sex (HR 2.35, p < 0.001), renal disease (HR 1.53, p = 0.017), and pulmonary disease (HR 1.45, p = 0.039) were independently associated with a higher 30-day mortality risk in patients with COVID-19 when adjusting for confounders.

Conclusion

The prevalence of COVID-19 in hip fracture patients during the first wave of the pandemic was 9%, and was independently associated with a three-fold increased 30-day mortality risk. Among COVID-19-positive patients, those who were older, male, with renal or pulmonary disease had a significantly higher 30-day mortality risk.

Efficacy of Bioelectrical Impedance Analysis for the Evaluation of Physical Impairment in Chronic Low Back Pain. Results from a Cohort Study

Introduction: Determining the effect of body composition on chronic low back pain seems to have the potential to improve our understanding of its mechanism and to develop novel preventive and therapeutic approaches.&nbsp;

Aim: The purpose of the present study was to assess by electrical impedance the composition of lower extremities of individuals with chronic low back pain.

Materials and methods: One hundred and twenty-one adult participants with diagnosed chronic low back pain were recruited in this study. The study activities were divided into three phases: phase 1 &ndash; self-administered questionnaires, phase 2 &ndash; biomedical examination (including anthropometric measurements and physical function performance tests), and phase 3 &ndash; bioimpedance analysis.

Results: Our results showed that chronic low back pain differentiates the circumference of thigh and calf of the symptomatic leg. Besides, patients experience pain also in hip, thigh, and calf, which act as a barrier to patient&rsquo;s personal, professional, social, and recreational activities. Furthermore, patients appear with &lsquo;unstable&rsquo; walking, reduced balance, and reduced general physical condition that affect all of the neuromuscular structures of the locomotor system. Interestingly, patients seem to be characterized by a tendency to deposit fat and to decrease muscle mass in the symptomatic limb regardless of the gender.

Conclusions: In the present study, we determine the profile of a patient with chronic low back pain through a variety of measurements. Chronic low back pain causes several structural changes to the symptomatic leg of the patients leading to &lsquo;unstable&rsquo; walking, reduced balance, and reduced general physical condition. It is clear that further studies using bioimpedance analysis are needed to address the concerns raised by investigating a multifactorial condition such as chronic low back pain.

Can the exercise-based and occupational therapy improve the posture, strength, and mobility in elderly Greek subjects with hip fracture? A non-randomized control trial

Objectives

The effects of a rehabilitation program on static balance, mobility, and strength of lower limbs in elderly fallers operated after a hip fracture and non-operated were studied.

Methods

Ninety-one elderly (>65 years) were divided in two groups, the Operated Group (OG, 43 fallers) and the Non-Operated Group (NOG, 48 fallers). Posture during bipedal stance (30s), mobility (Up-and-Go, Falls Efficacy Scale, Berg Balance Scale) and isokinetic strength of several muscular groups in both limbs were evaluated before and after a rehabilitation intervention, consisting in 20 sessions (3 sessions/week) including kinesiotherapy and occupational therapy.

Results

After intervention, the average velocity of Center of Pressure displacement decreased significantly for OG and NOG (p<0.005). Similarly, all other variables describing static balance, mobility (p<0.05) and isokinetic strength (p<0.005) were improved significantly for both groups.

Conclusions

The applied intervention led to improvement in static balance, mobility, and strength of lower limbs after hip fracture. Physical and Rehabilitation Medicine physicians should prescribe evidence-based rehabilitation protocols in elderly fallers because they could show just as remarkable improvements as non-operated patients when the program is carefully designed.

Hand disorders demographics in rural areas: A 15-year analysis of demographic characteristics overtime in a stable population

OBJECTIVE

The aim of this study was to determine the incidence of hand disorders in a general rural area, record the demographic characteristics for each condition, and evaluate the tendencies overtime in the incidence of these conditions.

METHODS

Using nationwide census data, we identified a health network system serving a geographic area with stable population. Subsequently, we retrospectively analyzed all the patient records (n=731 patients) with hand disorders documented between 2001 and 2015. We performed a retrospective review and collected demographic data for the patients and disorders treated surgically. We calculated the incidence of these conditions based on the census data and performed qualitative and categorical analysis with different demographic and disease-related variables.

RESULTS

We reviewed surgically treated 204 male and 527 female patients with hand disorders. The mean annual incidence was 222.5 cases per 100,000 individuals per year. More than 55% of the patients were between 50 and 69 years old. Trigger finger (TF) accounted for approximately 42% of patients, followed by 35% with carpal tunnel syndrome (CTS). TF and CTS were related to hand dominance, and right hand was affected in 53.4% of the patients.

CONCLUSION

Hand disorders in a rural area seem to correlate with the occupational sector activities, such as farming and agriculture. CTS was the most common disorder in the past; however, the dramatic increase in the incidence rate of TF made it the most common hand disorder in the last decade. Incidence rates in both males and females showed an increasing trend.

Oblong Sesamoid Bone Appearance into the Nuchal Ligament. A Case Report

Radio-opaque formations behind the spinous processes of the cervical spine are really rare. They were described in 1929 for the first time. Sesamoid ossicles are found close to a bone or a joint and are usually small. Some sesamoids form part of normal human anatomy, while others are normal anatomical variants. We report a case of a 73-year-old Caucasian male who visited the outpatient clinic complaining about chronic cervical pain. An oblong sesamoid accidentally discovered during routine anteroposterior (AP) and lateral x-ray, within the nuchal ligament (NL) at the C3-C6 spinous processes level. A cervical MRI scan was performed and the result showed 'fabella nuchae'. This type of sesamoids are rarely symptomatic, but it should be differentially diagnosed anyway. We review its morphology, the mechanical factors of the region acting throughout life and last, but not least, the differential diagnosis.

Immunoporosis: A New Role for Invariant Natural Killer T (NKT) Cells Through Overexpression of Nuclear Factor-κB Ligand (RANKL)

Background

Osteoporosis affects millions of postmenopausal women worldwide. Invariant natural killer T cells (iNKT) are important cells for bone homeostasis. The sim of this study was to investigate the contribution of invariant natural killer T cells (iNKT) in the increased receptor activator of the nuclear factor-κB ligand (RANKL) pool and bone resorption, a characteristic of patients with osteoporosis.

Material/Methods

Whole blood was collected from 79 female patients. The dual energy x-absorptiometry scan was performed in all patients, and the T-score was calculated in order to classify our patients according to the World Human Organization (WHO) criteria for diagnosis and classification of osteoporosis. Eleven patients had a T-score <−1.0 and were encompassed in our normal donors (ND) group, 46 patients had a T-score between −1 and −2.5 and were included in the osteopenia group, while 22 patients had a T-score > −2.5 and were included in the osteoporosis group. We performed a-galactosylceramide activation of iNKT cells in vitro. Surface RANKL expression was detected by multicolor flow cytometry in naive and activated lymphocytes. Beta-Crosslaps (β-CTx) levels were measured in whole blood plasma by ELISA (enzyme-linked immunosorbent assay).

Results

Although iNKT cells were not clonally expanded in patients with osteoporosis, iNKT cells from osteoporotic patients overexpressed RANKL compared to ND and osteopenic patients. This is a distinctive feature of iNKT cells and is not seen in conventional T-lymphocytes. RANKL expression in iNKT cells was not related to β-CTx levels in the blood. Finally, iNKT cell activation by the prototypal glycolipid ligand α-galactosylceramide increased by 8 times their RANKL expression.

Conclusions

In patients with osteoporosis, iNKT cells specifically overexpress RANKL, a cytokine that regulates osteoclast activity. It seems that iNKT cells have a long-standing effect of on the bone physiology, which plays an important role in the bone loss of patients with osteoporosis.

Validity of Nottingham Hip Fracture Score in Different Health Systems and a New Modified Version Validated to the Greek Population

Background

The Nottingham Hip Fracture Score (NHFS) is validated as a predictive mortality tool in patients with hip fracture. However, it has not been modified or validated widely other than in the UK NHS health systems.

Material/Methods

We assessed the predictive capability of the NHFS for 30-day mortality after surgery for hip fracture in the Greek population and then compared the original model to a modified one. We applied the NHFS to the Greek population and created a modified model of the NHFS by including the New Mobility Score (NMS) (Parker and Palmer, 1993) to the evaluated parameters and excluding the parameter of institution.

We ran a prospective study over a period of 3 years in our institution, collecting full data from 349 patients. All data were analyzed using SPSS, version 20.

Results

From all 349 patients, with a mean age of 80.82 years, only 85 (24.4%) were men. All patients were followed up for at least 30 days and the NHFS and modified NHFS prediction were compared with the mortality rate of patients. The area under the ROC curve for both models suggested acceptable accuracy (original NHFS 0.83, modified NHFS 0.84). Calibration was acceptable for both models (Hosmer-Lemeshow p=0.31 and 0.11, respectively).

Conclusions

Both the original and the modified NHFS were significant predictors of 30-day mortality. A higher-power study might be able to show superiority of the modified one for the Greek population in the future.

A Rare Case of Tibioperoneal Arterial Trunk Entrapment Caused by a Fibular Osteochondroma

BACKGROUND

Osteochondromas or exostoses are the most common benign tumors of the bones, which appear during the growth period. The involvement of lower extremities is common, particularly in metaphyseal structures of the femur and humerus and around the knee joint. However, the incidence of the development of the tumor at the proximal fibula is rare. The most common signs and symptoms of the disease are pain, pulsatile mass, limb swelling, neurologic sequelae, bursa formation with subsequent bursitis, and impairment of the developmental growth. Vascular complications are rare, yet osteochondromas can cause catastrophic arterial complications threatening the life of the patient if they occur and can include vessel perforation and thrombosis, arterial thromboembolic events, and pseudoaneurysm formation.

METHODS

We report a case of a 24-year-old male patient presenting with tibioperoneal arterial trunk entrapment caused by a massive osteochondroma derived from the proximal fibula. A combined vascular-orthopedic approach was initiated with the excision of the tumor, in which the neurovascular structures (tibial nerve, popliteal artery and vein, anterior tibial artery, and tibioperoneal trunk) were carefully recognized and protected.

RESULTS

The postoperative course of the patient was uneventful.

CONCLUSIONS

High clinical suspicion of a vascular complication should be raised by physicians when investigating a young patient with a suspected osseous tumor in the popliteal fossa and symptomatology of concurrent peripheral arterial disease. Prompt surgical management is crucial for the salvage of the affected limb in cases of arterial involvement. Furthermore, quick surgical exposure of the mass and regular postoperative follow-up check minimizes the risk of irreparable impairments and tumor recurrence.

Simultaneous Periprosthetic Fractures of the Femur and the Acetabulum After Bipolar Hip Arthroplasty

Patient: Female, 68

Final Diagnosis: Periprosthetic fractures of the acetabulum and femur after bipolar hip arthroplasty

Symptoms: Inability to walk

Medication: —

Clinical Procedure: Revision cup and internal fixation femur

Specialty: Orhopedics and Traumatology

Prophylactic antibiotic administration for post cardiothoracic surgery sternal wounds: a retrospective study

BACKGROUND

Cardiothoracic surgery sternal infections are difficult to treat situations. Until now there are no clear guidelines which or if an antibiotic could be used as prophylactic treatment.

PATIENTS AND METHODS

We collected retrospectively data from 535 patients from our hospital which underwent cardiothoracic surgery and recorded several biological parameters and technical aspects of the surgery.

RESULTS

It was observed that patients to whom vancomycin was administered had less post surgery infection than those to whom begalin was administered. Male who were treated with vancomycin it was observed that they had 1.67 chances to be treated properly than female. Patients which were hospitalized for more than 7 days before surgery had 62.6% higher chances for post surgery infection.

CONCLUSIONS

It was observed that vancomycin can be used as a prophylactic treatment for cardiothoracic surgeries acting efficiently against sternal wounds.

Local antibiotic delivery systems in diabetic foot osteomyelitis: time for one step beyond?

In patients with diabetes mellitus, osteomyelitis is a severe, difficult-to-treat form of foot infection. In the management of diabetic foot osteomyelitis, carriers for local delivery of antimicrobial agents have begun to be tried, in an attempt to provide high local antibiotic concentrations. Randomized clinical trials are now expected to clarify when this new approach should be used and how it can be integrated into the overall therapeutic strategy for diabetic foot osteomyelitis.

Vitamin D status in patients with knee or hip osteoarthritis in a Mediterranean country

Background

Vitamin D plays an important role in bone mineralization, remodeling, and maintenance and therefore its deficiency may be implicated in the pathogenesis of osteoarthritis (OA). Vitamin D status was evaluated in patients with knee or hip OA scheduled for joint replacement. The impact of anthropometric parameters such as gender, age, and body mass index on vitamin D levels was also examined. The study was conducted in a Mediterranean country (Greece).

Materials and methods

We included 164 patients with knee or hip OA scheduled for joint replacement in this study. Serum levels of 25-hydroxyvitamin D (vitamin D) were measured in routine blood samples taken from the patients at their pre-admission visit, a week before the operation, using radioimmunoassay.

Results

The majority of patients were vitamin D deficient (81.7 %); 15.2 % of them were vitamin D insufficient (hypovitaminosis). Only 3 % of patients were vitamin D sufficient. There was a significantly positive association between vitamin D levels and male gender.

Conclusion

These findings indicate a large percentage of vitamin D deficient patients with knee or hip OA, which is unexpected considering the high annual insolation in northern Greece. Many other possible predisposing factors for OA should be taken into consideration. Whether treatment with vitamin D supplements may provide beneficial effects to these patients and the stage of disease in which this treatment should commence remains an issue for further scientific investigation.

Level of evidence

Level IV.

Juxtacortical clavicular chondrosarcoma: diagnostic dilemmas: case report and review of literature

Juxtacortical chondrosarcoma is a rare primary malignant cartilaginous tumor accounting for 0.2% of all bone tumors. Wide surgical resection is the treatment of choice for juxtacortical chondrosarcomas. Accurate preoperative diagnosis is important in ensuring appropriate management, staging, and treatment of the patient. A combination of radiographs, three-dimensional imaging with computerized tomography (CT) scan and magnetic resonance imaging (MRI) can typically allow accurate diagnosis of juxtacortical chondrosarcomas. Bone scan and chest x-ray or CT chest scans are indicated for appropriate staging of the patient. Pet scan, ultrasound, bone scan, etc. are not typically needed for the diagnosis. Certainly, pulmonary imaging and bone scan are required for staging and could be commented upon.

The association of adipokine levels in plasma and synovial fluid with the severity of knee osteoarthritis

OBJECTIVE

We sought to determine the association between plasma and SF levels of leptin and adiponectin in patients with knee OA.

METHODS

Plasma and SF levels of adipokines and soluble leptin receptor (sOB-R) were determined by ELISA in 96 patients with knee OA at different stages, according to Ahlback's classification.

RESULTS

Levels of adiponectin, leptin, sOB-R and free leptin in plasma and SF did not differ significantly across categories of OA severity. However, the ratio of SF to plasma leptin was significantly lower in the advanced OA stage compared with early stages of the disease (P = 0.02). After adjustment for sex and BMI, plasma leptin positively correlated with categories of OA severity (r = 0.23, P = 0.02), whereas SF/plasma leptin negatively correlated with OA stage (r = -0.27, P = 0.01). Cluster analysis showed that all men were included in one cluster and distributed in different stages of OA, whereas women formed three clusters with similar BMI, but those who were older and had the highest plasma leptin levels suffered from advanced OA.

CONCLUSION

Plasma leptin positively correlated with the severity of knee OA. The ratio of SF to plasma leptin might be a marker related to the severity of knee OA. Further studies should investigate whether similar associations exist in other joints affected by OA.

Feature extraction of osteoporosis risk factors using artificial neural networks and genetic algorithms

A hybrid model that consists of an Artificial Neural Network and Genetic Algorithm is used in order to select the most significant osteoporosis risk factors. The results indicated that just 8 to 10 parameters, out of a total 34, are essential in order of high performance to be achieved.

Anterior cruciate ligament reconstruction: outcome using a patellar tendon bone (PTB) autograft (one bone block technique)

OBJECTIVE

The aim of this study was to determine the outcome of anterior cruciate ligament (ACL) reconstruction using a patellar tendon bone autograft (one bone block technique).

METHOD

We retrospectively evaluated a case series of patients who had received arthroscopic ACL reconstructions using patellar tendon bone autograft. Fifty-four (54) ACL reconstructions were evaluated at a mean of 38 months (range 25-62 months). Clinical assessment was made using a modified Lysholm score, documentation of International Kappanee Documentation Committee (lKappaDC), the anterior knee pain questionnaire of Shelbourne and Trumper, and by KappaTau-Rolimeter arthrometric analysis. Radiographic assessments were also performed.

RESULTS

Arthrometric analysis showed that 51 knees (94%) were graded Alpha or Beta with a median laxity of 2 mm, postoperatively. The Lysholm score improved postoperatively from 70 to 89. The patellar position in terms of congruence angle did not show any significant change, and the final shortening of the patellar tendon using the Insall-Salvati ratio was 6.07%. Only three patients complained of moderate pain on kneeling, one patient was unable to participate in strenuous works and one patient complained of harvest-site tenderness.

CONCLUSION

It is concluded that the use of patellar tendon autograft with a single tibial-tubercule bone block and a strip of patellar periosteum have the advantages of being available and comparable in terms of graft size and strength and shows satisfactory results with reduced anterior knee pain.

Vacuum-assisted closure downgrades reconstructive demands in high-risk patients with severe lower extremity injuries

BACKGROUND

Primary soft tissue reconstruction in complex leg injuries is mandatory in order to protect exposed tissues; however, it may be precluded by the patient's clinical status or by local wound conditions. This retrospective study aims to evaluate the use of negative pressure as an adjunct to delayed soft tissue reconstruction in patients with complex lower limb trauma.

MATERIAL AND METHODS

Forty-two patients with 49 complex lower limb injuries were treated with Vacuum assisted closure (VAC) 48 hours after bone fixation, vascular repair and surgical debridement. Wound swab cultures were obtained before and after every VAC application. Duration of therapy, wound flora, final reconstructive technique required, outcome and follow-up period were retrieved from medical records.

RESULTS

Twenty-four male and eighteen female patients were recruited, with a mean age of 47 years. All were treated with VAC therapy for 15-42 days. Reconstruction was delayed due to the patients' critical condition, advanced age, medical co-morbidities, heavily exuding wounds and questionable viability of soft tissues. Patients were followed up for 90-895 days. Two wounds healed spontaneously, 6 were managed with delayed direct suture, 31 with split thickness skin grafts and 9 required local cutaneous, fasciocutaneous or muscular flaps. One patient died due to fat embolism. Wound bacterial flora progressively decreased in all but one patient. Scar formation was aesthetically acceptable by the patients while function depended on the initial injury.

CONCLUSIONS

Negative pressure is a safe and effective adjunct to delayed soft tissue reconstruction in high-risk patients with severe lower extremity injuries, minimizing reconstructive requirements and therefore postoperative morbidity.

Pyomyositis. A literature review

Pyomyositis is a primary bacterial infection of the skeletal muscles. It is known as tropical myositis as most cases have been reported in patients living in tropical areas and, until recently, it was considered unusual in the temperate zone. The condition is usually diagnosed late, and for this reason it is followed by an increased morbidity and sometimes a significant mortality rate. A review of the literature indicates a possibly rising incidence in non-tropical areas. This condition should be considered in patients with muscle pain, fever, leucocytosis, elevated ESR and CRP, in tropical and non-tropical countries, in previously healthy patients as well as in patients suffering other health problems, particularly HIV infection. An MRI investigation should be performed early as it is the imaging technique of choice during the first stage of the disease. A case of a primary iliopsoas pyomyositis diagnosed during the initial stage using MRI is presented as an illustration.

Initial rotational stability of distal tibial fractures nailed without proximal locking: the importance of fracture type and degree of cortical contact

Although distally locked (dynamic) nailing is generally recommended for fractures below the isthmus of the tibia in the presence of adequate proximal nail-bone contact, rotational stability in the above situation appears to be a major concern and can increase the risk of malunion. However, there is no published experimental evidence to quantify this mechanical parameter or to relate factors such as the fracture pattern with the final clinical outcome. This in-vitro biomechanical experimental study was set out to measure the initial rotational stability of dynamically nailed fractures of the distal tibial diaphysis. Using a composite tibial model, three non-comminuted types (spiral, oblique and transverse) and various comminuted patterns (comminution, 0-85%) of dynamically nailed fractures of the distal tibial diaphysis were tested. Using a special rig to simultaneously apply axial and torsional loading measurements of torsional stiffness and the previously described "spring-back angle" were carried out. Our results showed that in terms of torsional stiffness and the "spring-back" angle oblique fractures are the most stable followed by transverse and spiral fractures. Furthermore, when testing of the above parameters against the degree of comminution was carried out, a significant reduction of rotational stability was evident with comminution of 50% or above. It is concluded that oblique fractures of the distal tibial third that can be reduced with at least 50% cortical apposition present the optimal rotational stability following dynamic nailing.