The Outcomes of Distraction Osteogenesis over an Intramedullary Nail for the Treatment of Bone Defects in Infectious Nonunions.

Objectives: The concurrent utilization of an external fixator and intramedullary nail (IMN) for segment transportation may potentially decrease the duration of external fixator implementation and reduce associated complications. This study aimed to report the outcomes of bone transport utilizing a combination of IMN and Ilizarov frame in a cohort of individuals who had tibia or femur critical-sized bone deficiency resulting from nonunion. Methods: The present research used a single-arm clinical trial design to enroll a series of patients presenting with critical-sized bone defects resulting from infectious nonunion of the tibia or femur. The study was conducted during the period of 2017-2020 in a referral Orthopedic Surgery Center located in Tehran, Iran. The management of patients with infectious nonunion was carried out through two main stages, including infection eradication and bone transportation. The process of bone healing and segment transportation was evaluated by radiographic assessment throughout the follow-up period. Results: A total of 39 patients with bone defects in the tibia (19 cases) or femur (20 cases) with a mean age of 31.44 (±11.95, range=18-60) were included in this study. Twenty-nine (74.3%) patients had open fractures. The bone defect exhibited an average size of 6.31 ± 1.95 cm. The mean of the consolidation index (CI) was 0.97 (range=0.51-1.32) mo/cm, and the mean of the external fixator index was 0.67 (range=0.41-1.10). Although the CI was longer in patients with open fracture compared to those with closed fracture, the difference was not statistically significant (P=0.353). After the end of the two-year follow-up, complete union was observed in 35 patients (89.7%). Conclusion: Intercalary segmental bone transportation using the Ilizarov technique over an IMN, as well as preserving the advantages of the conventional callotasis method, reduces the complications of long-term use of the Ilizarov frame and increases patient adherence to treatment.

Primary seronegative intermuscular hydatidosis in a child, an infection that should be approached like a tumor: a case report and review of the literature.

INTRODUCTION: Intermuscular hydatid cyst is one of the rarest types of hydatid cyst, and as far as we know, only nine cases were reported in the literature before this study. CASE PRESENTATION: We present a 10-year-old Iranian child with an intermuscular cystic mass in the medial-distal thigh. Despite the typical imaging findings, the patient's serological and hematological tests were negative for hydatid cyst. The cyst underwent wide excision accompanied by neoadjuvant and adjuvant chemotherapy with Albendazole. No evidence of recurrence was detected during the one-year follow-up. CONCLUSION: Hydatid cysts should always be considered in the differential diagnosis of soft tissue cystic masses in endemic areas, and aspiration or drainage should be avoided as much as possible, even when serological tests are negative and imaging is non-diagnostic. In cases where the diagnosis of a hydatid cyst has been confirmed before the surgery, it is recommended to approach the cyst, like a tumor with chemotherapy using Albendazole both before and after wide cyst excision.

Treatment options and outcomes for delayed scapular anatomical neck fractures: a case report and review of the literature.

INTRODUCTION: Scapular anatomical neck fractures are among the most infrequent shoulder girdle fractures. Only seven radiologically confirmed cases of scapular anatomical neck fractures have been documented in the literature to date, of which only one case underwent delayed surgery. CASE PRESENTATION: A 34-year-old male Persian patient with morbid obesity was diagnosed with a scapula anatomical neck fracture after a motor vehicle collision. The radiographic assessment of the patient indicated an increase in the scapular glenopolar angle (73.9°). Due to concurrent chest and head injuries, surgical intervention was deferred until 6 weeks following the injury. The posterolateral limited Dupont-Evrard approach was used because of the patient's extremely high body mass index. Two plates were utilized to achieve stable fixation of the glenoid neck fracture. Following a 1 year follow-up period, complete fracture union was successfully attained, resulting in a constant score of 79. CONCLUSIONS: The most accurate radiographic indicators of these fractures are a superior fracture line located laterally to the coracoid process, a small inferior spike, and an elevated glenopolar angle. The only tendon attached to the glenoid is the long head of the triceps, making these fractures unstable; therefore, surgery is required in the majority of instances. The small size of the fractured component makes stabilization more difficult. Overall, anatomical scapular neck fractures are extremely uncommon and distinguished from other scapular fractures by their unique radiological and biomechanical characteristics. This case highlights the challenges encountered when managing scapular fractures in patients with morbid obesity. The delayed surgical intervention and the choice of surgical approach tailored to the patient's specific anatomical and physiological considerations proved to be effective in achieving a favorable outcome.

Antibiotic-loaded spacer arthroplasty in a terrible triad injury with unreconstructable radial head fracture: a case report.

BACKGROUND: Radial head arthroplasty is a viable option in cases with terrible triad injuries of elbow, wherein the radial head sustains significant comminution that precludes reconstruction. Nevertheless, this alternative is not recommended for individuals with poor elbow skin conditions, accompanied neuropsychiatric disorders, or low patient compliance. This case report presents a patient with bilateral terrible triad injury, along with the aforementioned conditions. The report outlines the treatment challenges of such a case and proposes potential solutions. CASE PRESENTATION: A 37-year-old Persian male patient presenting with a bilateral terrible triad fracture-dislocation and a history of psychoactive substance abuse, was admitted to our emergency department. The patient underwent radial head replacement using a cement spacer containing antibiotics, due to the comminuted radial head in the presence of a contaminated wound on the left elbow. The fracture of the right side was successfully fixed. Subsequent to discharge, the patient did not attend any follow-up appointments. After a period of 6 months, he was admitted to the psychiatric ward and orthopedic consultation was requested to evaluate the patient. CONCLUSION: In acute terrible triad injuries with unreconstructable radial head fractures where arthroplasty with metallic prostheses may not be suitable due to contaminated wounds, unstable psychiatric condition, and low patient cooperation, temporary orthopedic cement spacers can maintain elbow biomechanics, stability, and sterility.

A comparative analysis of suture-augmented and standard hamstring autograft single-bundle ACL reconstruction outcomes: short-term functional benefits without long-term impact.

BACKGROUND: Augmentation of the biologic graft with nonabsorbable suture material during anterior cruciate ligament reconstruction (ACLR) is a relatively new technique to enhance its biomechanical properties and add additional support to the critical process of healing. We aimed to compare the short-term functional patient-reported outcome measures (PROMs) and complication rates of patients treated with either standard single-bundle four-strand hamstring ACLR or added suture augmentation (SA). METHODS: Patients undergoing arthroscopic ACLR between February 2015-January 2017 and in the standard ACLR group, and between February 2017-September 2019 in the SA-ACLR group operated by adding a no.5 FiberWire® (Arthrex, Naples, FL, USA) braided suture to the hamstring autograft, were retrospectively reviewed and the PROMs were compared. Patients were followed up for a 24-month period and PROMs were assessed by the International Knee Documentation Committee (IKDC) Subjective Knee Form and Tegner-Lysholm knee score. Patients' demographic and clinical characteristics, and postoperative complications including graft retear requiring revision surgery, deep vein thrombois, and surgical site infection were recorded and analyzed. RESULTS: We included 79 patients with mean age of 31.6 ± 8.3 years in the standard ACLR group, and 90 patients with mean oge of 30.5 ± 7.6 in the SA-ACLR group. There was no statistically significant difference between the two groups in terms of age, sex, body mass index, and medical comorbidities. The values of the IKDC scores increased to 75.8 ± 18.9 in the standard ACLR group, and 85.6 ± 12.6 in the SA-ACLR group, 24 months after the operation (P < 0.05). The 24-month postoperative Tegner-Lysholm scores escalated to 79.3 ± 21.0 in the standard ACLR group and 91.0 ± 13.7 in the SA-ACLR group (P < 0.05). Four (5.1%) patients in the standard ACLR group and 4 (4.4%) in the SA-ACLR group experienced graft retear requiring revision surgery (P > 0.05). Incidence of surgical site infection and deep vein thrombosis showed no significant differences between the two groups, 24 months after ACLR. CONCLUSION: SA-ACLR is associated with improved short-term functional PROMs compared to the standard hamstring ACLR. Although SA did not reduce the retear rate, and infection and DVT rates did not differ between study groups, superior improvement of PROMs in SA approach, leverages this method for ACLR.

Concurrent ipsilateral fractures of acetabular posterior wall and femoral shaft associated with posterior hip dislocation: A case report and literature review of a rare injury.

INTRODUCTION: A floating hip injury involving the acetabulum and femur, often complicated by hip dislocation, necessitates a timely and appropriate management strategy to preserve the extremity and patient well-being. CASE PRESENTATION: We present a case of a 20-year-old male with concurrent fractures of the acetabular posterior wall, a comminuted femoral shaft, and posterior hip dislocation. Reduction of the dislocated hip posed a challenge due to the femoral shaft fracture. We successfully employed an innovative technique, using pins proximal and distal to the shaft fracture in conjunction with a temporary external fixator, later replaced by an interlocking nail after hip reduction. Subsequently, we addressed the acetabular fracture through a posterior hip approach, enabling the patient to regain full weight-bearing capacity within a few months. DISCUSSION: In managing concurrent injuries in a floating hip, particularly when a femoral shaft fracture is involved, innovative approaches, such as the one described in this study, are crucial for timely hip reduction. Following hip reduction, a series of surgeries are required to address the multiple lower extremity injuries, prioritizing those with the highest risk of adverse events and neurovascular complications. CONCLUSION: Urgent procedures for multiple fractures in orthopedic trauma surgery are pivotal for the best long-term outcomes. Prioritizing these urgent procedures, even through unconventional transient methods when conventional means are unavailable, can prevent long-term complications such as avascular necrosis. Effective and timely management is paramount for optimal patient recovery.

Evaluation of quality of life and associated factors in patients with intertrochanteric femoral fracture.

BACKGROUND: Intertrochanteric fracture is a common injury among the elderly, causing fundamental lifestyle derangements, influencing the patients' social and psychological functioning. We aimed to study the quality of life (QoL) and its different parameters in patients with this type of injury. MATERIALS AND METHODS: In this cross-sectional study, all patients hospitalized with intertrochanteric fracture aged above 50 from 2020 to 2022 at the Shahid Beheshti Hospital in Babol, Iran, were included. Patients were primarily managed surgically and, in exceptional cases non-surgically, were followed up for at least 12 months after receiving treatment. During the follow-up period, patients were dialled and completed a questionnaire to assess the patient's QoL by the 36-item Short Form Health Survey (SF-36). QoL parameters were analyzed based on patients' sex, age, type of treatment, and height of fall causing fracture. RESULT: A total number of 200 patients, including 101 (50.5%) males and 99 (49.5%) females, with a mean age of 74.76±11.36 years (range: 50-99), were included. Regarding the received treatment, 192 (96.0%) patients underwent surgery, and 8 (4.0%) underwent non-surgical treatment. In the study of SF-36 scores, the mean score of male patients was 42.31±14.58, and females scored 37.83±15.35, and the difference was statistically significant (P = 0.04). The mean score of QoL and its subscales among the 50-75 group patients was significantly higher than the 76-99 group (P<0.001). The average score of QoL was considerably higher in patients who had surgery (40.75±14.57) compared to those who had non-surgical treatment (24.30±19.85) (P = 0.01). Patients having a fall from a higher height had higher QoL after treatment. CONCLUSION: This study revealed that patients with an intertrochanteric femoral fracture had poor QoL in all aspects. The overall QoL was significantly higher among male patients, younger patients, those who underwent surgical treatment, and the falls from higher heights. These findings highlight the necessity of long-term follow-up and support in patients with intertrochanteric fractures.

Arthroscopic management of ankle primary synovial chondromatosis (Reichel's syndrome): A case report with literature review.

INTRODUCTION AND IMPORTANCE: Primary Synovial chondromatosis is a rare disease characterized by metaplastic cartilaginous nodules originating from the synovium, which rarely involves the ankle joint. To date, there has been a limited number of reported cases regarding the arthroscopic treatment of this disease, which can be attributed to its rare incidence. This article aims to illuminate the advantages and challenges of this technique by presenting a case study. Furthermore, we delve into the existing literature to assess the different treatments used for this disease and their outcomes. CASE PRESENTATION: A 59-year-old male patient presented with ankle pain, swelling and limited dorsiflexion. Subsequent imaging findings led to the diagnosis of anterior ankle primary synovial chondromatosis. Following this, the patient underwent arthroscopic assisted loose body removal and partial anterior synovectomy, conducted via anteromedial and anterolateral portals. During the five-year follow-up period, no recurrence was observed, and the American Orthopedic Foot and Ankle Score (AOFAS) was assessed as 88. CLINICAL DISCUSSION: Given the uncommon occurrence of this disease, no standardized treatment approach has been established in the literature. While many researchers advocate for surgical intervention to alleviate symptoms and prevent potential complications like osteoarthritis and malignancy, there exists a diversity of perspectives concerning the specific strategies and techniques to employ. CONCLUSION: Partial anterior synovectomy and loose body removal using arthroscopy via anteromedial and anterolateral portals demonstrate a notably efficacious and low-risk technique for addressing primary synovial chondromatosis affecting the anterior chamber of the ankle.

Fixed-Bearing Posterior-Stabilized Implant versus Constrained Condylar Knee in One-Stage Bilateral Primary Arthroplasty of the Varus Knee: A Randomized Controlled Trial with Minimum 2-year Follow-Up.

Background: Severe varus deformity of the knee poses a technical challenge in balancing the flexion-extension gaps. The use of a varus-valgus constrained prosthesis is a solution to achieve coronal plane stability. The results of constrained condylar knee (CCK) implants in primary total knee arthroplasty are not well known. This study aims to compare the functional outcomes of posterior-stabilized (PS) and CCK implants for primary arthroplasty of the varus knee. Materials and Methods: Twenty patients with bilateral severe osteoarthritis and genu varum of more than 10° were enrolled in this study. One knee was randomly implanted with a fixed-bearing PS implant, whereas the other was implanted with a CCK prosthesis. Pre- and postoperative Knee Society Score (KSS) and Oxford Knee Score (OKS) questionnaires were completed, and knee flexion was measured and compared. Results: The patients were followed for 32 months on average (24-36 months). On the KSS and OKS, both the groups improved significantly, but the difference between them was not statistically significant. Postoperative knee flexion was also not different between the two groups. Furthermore, 18 patients could not distinguish the difference between the two prostheses, whereas two patients preferred the PS one. Conclusion: We demonstrated that a PS prosthesis can achieve comparable functional results to the CCK one in the short term.

Intraoperative Chertsey Test, is it a Reliable Alternative to Computed Tomography Scan for Diagnosing Syndesmotic Injuries of the Ankle?

Background: The present study aims to evaluate the diagnostic exactitude of the intraoperative Chertsey test in tibiofibular syndesmotic injuries in patients with malleolar fractures, in comparison with a computed tomography (CT) scan. Materials and Methods: In this study, patients with malleolar fractures operated between 2018 and 2020 were examined. Thirty-nine patients were enrolled in the study. A three-dimensional preoperative CT scan was obtained. The opposite unfractured ankle was also scanned and considered as the control group. The Chertsey test was performed during the operation to assess the syndesmosis injury. Then, patients were partitioned into two distinct groups, considering the condition of their ankle, namely the Chertsey positive (unstable syndesmosis) group and the Chertsey negative (stable syndesmosis) group. Results: The outcomes of the present survey illustrated that the Chertsey test was positive in 16 patients (41.03%) and negative in 23 patients (59.07%). The median of all CT scan parameters (anterior tibiofibular distances (TFD), middle TFD, posterior TFD, and maximal TFD and volume) before surgery in the group of patients with a positive Chertsey test was significantly higher, measured against the unfractured control group (P < 0.001 for all parameters). Furthermore, a comparison of CT scan parameters and syndesmosis space volume before surgery between the two groups of patients with positive and negative Chertsey test results showed that the measurement of parameters in Chertsey-positive patients was significantly higher than the Chertsey-negative patients (P < 0.001). Conclusion: Chertsey test could be used to diagnose syndesmosis injuries in patients with malleolar fractures due to its high importance in the outcome of patients.

Acute Onset of Guillain-Barré Syndrome after Multiple Spine Surgeries: A Rare Case Report.

Guillain-Barré syndrome is an autoimmune disorder presented by ascending paralysis and areflexia. The condition has been reported after many infections, but Guillain-Barré syndrome after spine surgery is rare. We, herein, present a case of Guillain-Barré syndrome after multiple spine surgeries for degenerative lumbar scoliosis. A 60-year-old woman with degenerative scoliosis underwent surgery for the third time and developed Guillain-Barré syndrome 3 weeks after the final operation. The patient received intravenous immune globulin therapy and needed mechanical ventilation and intensive care. She was discharged in good condition after 5 weeks.

Candida albicans Prosthetic Joint Infection After Total Knee Arthroplasty: A Rare Case Report.

In this article, a 75-year-old patient with pain in left knee and restricted range of motion following total knee arthroplasty (TKA) is presented. Serological evaluation and aspiration of knee joint suggested a fungal prosthetic joint infection. After the diagnosis was confirmed, treatment started with antifungal drugs, removing prosthesis, exhaustive debridement, and revision of TKA after efficient antifungal treatment. At one-year follow-up, she has a painless motion range of 10 to 90 degrees, and there was no recurrence of infection observed.