Intra- and inter-operator reliability of three-dimensional preoperative planning in total knee arthroplasty.

PURPOSE: To characterize the intra- and inter-operator reliability of a CT-based 3D preoperative planning software. MATERIALS AND METHODS: This study analyzed 30 CT scans of de-identified knees with osteoarthritis. For each scan, a case planner segmented the bones and pre-planned the TKA. Three orthopedic surgeons then reviewed each pre-planning three times at least one week apart, in a blinded manner. During the reviews, the surgeons modified the pre-plannings until they felt the plannings matched the objectives defined collegially at the beginning of the study. Reliability was assessed using the Intraclass Correlation Coefficient (ICC) and the Standard Error of Measurement (SEM). RESULTS: The intra- and inter-operator reliabilities for implant size selection were almost perfect (ICC between 0.97 and 0.99). Implants of same sizes were selected in 67.1-90.0% of cases. For implant placements, almost perfect intra- and inter-operator reliability was observed in all degrees-of-freedom (ICC between 0.81 and 1.00), except in flexion-extension for the femur (intra-operator ICC between: 0.76 and 0.99; inter-operator ICC of 0.61) and the tibia (intra-operator ICC between 0.12 and 1.00; inter-operator ICC of 0.03). All implant placements SEM were below 1.3 mm or 1.7°. CONCLUSIONS: This study showed high intra- and inter-operator reliability for implant size selection and, in most of the degrees-of-freedom, also for implant placements. Further research is needed to evaluate the benefit of developing more precise means of describing the objectives of the surgical planning as well as to evaluate the possibility and relevance of adding features in the planning software to assist the operators.

Modified Gritti-Stokes amputation: tips and tricks.

Major amputations of the lower extremity may be required after trauma and a variety of underlying diseases such as peripheral vascular disease, diabetes, and malignancies. The goal of any major amputation is an optimal functional result with a maximum limb length in combination with optimal wound healing. The preservation of the knee joint is essential for successful rehabilitation, and this is best achieved by the Burgess below-knee amputation (BKA). Whenever a BKA is not possible, the Gritti-Stokes amputation is our first choice. This technique mainly consists of a through-knee amputation with the creation of a pedicled patella flap consisting of the patella, patellar ligament, and overlying soft tissue. After osteotomy of the distal femur and resection of the articular surface of the patella, the anterior flap is rotated in order to cover the femur defect while performing a patellofemoral arthrodesis. The aim of this paper is to describe our surgical technique and experience with GSA and to point out the important steps of this procedure. In conclusion, GSA is an excellent surgical option for patients requiring major lower limb amputations where BKA cannot be considered. Particular attention must be paid to careful preoperative evaluation and optimization of comorbidities. A meticulous surgical technique is warranted, including atraumatic tissue handling and an optimal patellofemoral arthrodesis technique.

[Antiagregants, anticoagulants and proximal femur fracture]. / Antiagrégants, anticoagulants oraux directs et fracture du fémur proximal.

Hip fractures are common in the elderly, particularly due to an increased susceptibility to falls and greater bone frailty, especially in women. The consequences of such events are potentially serious. Early management (< 48 hours) significantly reduces the mortality and postoperative complications. Because of their comorbidities, older people are often on antiplatelet therapy, anticoagulant therapy, or both. However, there are no definitive recommendations for the perioperative management of antiplatelet and anticoagulant treatment in the early surgery of hip fractures. The purpose of this article is to review the management of these patients.

Les fractures de la hanche sont fréquentes chez les personnes âgées, notamment en raison d'une prédisposition accrue aux chutes et d'une plus grande fragilité des os, principalement chez les femmes. Les conséquences de tels événements sont potentiellement graves. Une prise en charge précoce (< 48 heures) diminue de manière significative la mortalité et les complications postopératoires. En raison de leurs comorbidités, les personnes âgées sont souvent sous traitement antiagrégant, anticoagulant ou les deux. Or il n'existe pas de recommandations définitives quant à la gestion périopératoire des traitements antiagrégants et anticoagulants de la chirurgie urgente de la fracture du fémur. Le but de cet article est de faire le point sur la prise en charge de ces patients.

The use of a 30-degree radiolucent triangle during surgery in distal avulsion fractures of the patella.

BACKGROUND: Avoiding patella baja or alta after the Krackow suture technique for distal avulsion fractures of the patella can be challenging. We aim to introduce a simple and reproducible technique using a 30-degree radiolucent triangle involving the contralateral knee to ensure the correct positioning of the patella intraoperatively. METHOD: The radiolucent triangle is positioned under the contralateral knee before operating the injured knee. A strict lateral view is obtained using fluoroscopy as a reference before a Krackow technique is performed on the avulsion fracture of the patella. RESULTS: The triangle technique is straightforward and easily reproducible by surgeons of all levels. It allows the surgeon to correctly position the patella intraoperatively in avulsion fracture repair and modify tension on the patellar tendon. CONCLUSION: This method avoids millimetric mispositioning of the operated patella, thus improving the management intraoperatively and could decrease postoperative complications.

Clinical and radiological outcome of the Chimaera short nailing system in inter- and subtrochanteric fractures.

BACKGROUND: cephalomedullary devices are popular treatment for femoral intertrochanteric or subtrochanteric fractures. Various complications include post-surgical lateral thigh pain and cut-out. To prevent those complications, a new concept cephalomedullary device system was designed (Chimaera, Orthofix®). This study aimed to evaluate the clinical and radiological outcomes in patients with femoral intertrochanteric or subtrochanteric fractures treated with the proximal femoral cephalomedullary device system. METHODS: A prospective cohort study involved consecutive patients with Arbeitsgemeinschaft für Osteosynthesefragen/ Orthopaedic Trauma Association type 31-A1, 2, 3 fractures treated with the Chimaera short cephalomedullary device system from October 2016 to September 2017 at our level 1 trauma center. The Parker and Palmer mobility score and Jensen social function scores and post-surgical lateral thigh pain were assessed at 3 months post-operatively and compared to before surgery. Radiologic assessment consisted of controlling the position of the cephalic screw by using the tip-apex distance (TAD) and Cleveland zone as well as union and cut-out rates. RESULTS: We included 99 patients (79 women; 100 hips; one bilateral fracture 3 months after a first trochanteric fracture) with a mean follow-up of 2 years. The Parker and Palmer mobility score decreased by 22% at 3 months post-operatively as compared with the pre-fracture score (42/99 patients showed a return to their pre-injury level). The Jensen social function score increased by 16.5% at 3 months post-operatively as compared with the pre-fracture score (68/99 patients showed a return to their pre-injury level). No major intra-operative complication was recorded. Nine TAD scores were > 25 mm. The mean TAD was 16.5 mm (range 5-36), and the lag screw position was well positioned in most (95%) hips according to Cleveland zones. Three patients required revision surgery (one for cut-out of the lag screw, one for hip osteoarthritis and one for gluteus medius insufficiency). All patients but the one with the cut-out showed fracture union. CONCLUSION: The Chimaera short cephalomedullary device exhibited good mid-term functional and radiological outcomes.

Pelvic Chondrosarcoma Treated by En Bloc Resection with Patient-Specific Osteotomy Guides and Reimplantation of the Extracorporeally Irradiated Bone as an Osseocartilaginous Structural Orthotopic Autograft: A Report of Two Cases with Description of the Surgical Technique.

Primary tumors of the pelvis are considered difficult to treat due to the complex anatomy and the proximity of important neurovascular structures. The surgical armamentarium for the treatment of these tumors has evolved with the help of cutting-edge technology from debilitating hemipelvectomies to solutions such as precise resections guided by patient-specific instruments or computer navigation and reconstruction by modular prostheses, 3D-printed custom-made implants, or orthotopic autograft reimplantation after extracorporeal irradiation. Different combinations of these techniques have been described in the literature with various rates of success. We present two cases of pelvic chondrosarcomas successfully treated by a combination of periacetabular resection with patient-specific osteotomy guides and orthotopic reimplantation of the extracorporeally irradiated autograft resulting in retention of the native hip.

Advantages of patient-specific cutting guides with disposable instrumentation in total knee arthroplasty: a case control study.

BACKGROUND: Total knee arthroplasty (TKA) is most frequently planned using conventional two-dimensional weight-bearing lower limb radiographs and is performed with conventional femoral and tibial cutting guides. Questions have been raised about the accuracy of conventional TKA instrumentation and planning for an anatomically standard or complex joint. Use of computed tomography (CT)-based three-dimensional (3D) templating and patient-specific cutting guides printed in 3D has shown improved postoperative lower limb alignment parameters. This case-control study compared costs and operative times of using CT-based, patient-specific, single-use instruments versus conventional metal instruments for TKA. METHODS: In this case-control, retrospective chart review, all TKAs were performed by one senior surgeon, using the F.I.R.S.T. posterior-stabilised knee prosthesis (Symbios, CH), with a similar protocol and identical operating room setup. Group A included 51 TKAs performed with patient-specific cutting guides and conventional metal instruments. Group B included 49 TKAs performed with patient-specific cutting guides and patient-specific, single-use instrumentation. Operation duration, number of instrumentation trays and sterilisation costs were evaluated. RESULTS: The groups were similar for age, body mass index, hip-knee-ankle angle and operation duration. The mean number of instrumentation trays was 8.0 ± 0.8 for group A (controls) and 5.1 ± 0.9 for group B (p<0.001). The mean sterilisation costs were 380 ± 47 Swiss Francs (CHF) for group A and 243 ± 55 CHF for group B (p<0.001), for a mean cost reduction of 130.50 CHF per intervention in group B. The time interval between two consecutive surgeries was 24 min for group A and 18 min for group B. There were no adverse events or complications, instrument-related or otherwise. CONCLUSION: Compared to conventional instrumentation, use of patient-specific, single-use instruments for TKA reduced the number of instrumentation trays by more than one-third and saved 36% in sterilisation costs. If fabrication costs of single-use instruments are included by the company, the total cost is significantly diminished. There was no operative time advantage for single-use instrumentation.

Greater trochanteric pain after primary total hip replacement, comparing the anterior and posterior approach: A secondary analysis of a randomized trial.

BACKGROUND: Greater trochanteric pain (GTP) after total hip replacement is a common cause of residual lateral hip pain, regardless of the approach used. The goal of our study was to evaluate GTP after a direct anterior approach (DAA) compared to a posterior approach (PA) as well as the clinical outcomes of both approaches and answer the following: 1) What is the incidence of trochanteric pain after primary THA with two different surgical approaches? 2) What is the functional outcome of patients with GTP? 3) What proportion of patients with GTP resort to peritrochanteric injections? HYPOTHESIS: Our hypothesis is that GTP is present with both approaches but satisfaction is lower with the PA. PATIENTS AND METHODS: A secondary analysis of a previously published clinical trial with 55 total hip arthroplasty patients randomized in one of two surgical approaches: 27 patients underwent the anterior modified Hueter approach, while the other group of 28 patients were operated using the posterior approach. Study outcomes were Modified Harris Hip Score (MHHS), satisfaction score, pain when lying on the affected side, and requiring an injection. Hip offset, femur lateralization and leg lengthening were measured before and after surgery. RESULTS: Forty-five patients were available for complete follow-up at a mean of 62 months (range: 48-74). The incidence of GTP was higher in the posterior approach [PA: 6/21 (29%) vs DAA 4/24 (17%)) (p=0.3). Patients operated through a PA experienced more pain [5/21 (24%) of patients; VAS=mean 5.3] when lying on their operated side, compared to DAA patients [2/24 (8%) of patients; VAS=mean 2) (p=0.2)]. However, MHHS, patient satisfaction with surgery, radiological assessment for hip offset, femur lateralization or leg lengthening, and injections required were similar for both approaches. Overall, satisfaction and functional outcome with surgery was significantly lower in GTP patients, regardless of the approach. CONCLUSIONS: GTP impacts patient satisfaction and functional outcome in total hip arthroplasty patients. PA patients reported more trochanteric pain than DAA patients, which affected their clinical outcome. LEVEL OF EVIDENCE: III.

Direct anterior versus posterior approach for total hip arthroplasty: a multicentre, prospective, randomized clinical trial.

BACKGROUND: The ideal approach for a total hip arthroplasty (THA) would be kind to soft tissues, have the lowest complication rates and be easily reproducible. Although there have been several attempts to find the best approach for THA in the last decade, a definitive answer has not been found. We performed a prospective study to compare the direct anterior and posterior approaches for THA in terms of hospital length of stay, functional outcome, pain, implant position, complications and surgical time. METHODS: A prospective, randomized, multicentre clinical study was conducted between February 2011 and July 2013, with an average follow-up of 55 months. Patients undergoing the direct anterior or posterior approach for THA were enrolled. Hospital length of stay, surgical time and complications were documented. The Harris Hip Score and visual analogue scale were used to monitor functional outcome and pain until 5 years postoperatively. Radiologic analysis was used to assess implant position. RESULTS: Fifty-five patients (28 undergoing the direct anterior approach, 27 undergoing the posterior approach) were enrolled in this study. Length of stay, functional outcome, pain, implant position and complications were similar for the 2 approaches. There was a trend toward a better functional outcome for patients who underwent the direct anterior approach in the first 3 months postoperatively, with a peak at 4 weeks (Harris Hip Score 76.7 v. 68.7; p = 0.08). Average surgical time for the direct anterior approach was significantly longer (69.9 v. 45.7 min; p = 0.002). CONCLUSION: The direct anterior approach for THA appears to be a safe and effective option. However, there is no significant difference in hospital length of stay or postoperative recovery between the 2 approaches. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov, no. NCT03673514.

CONTEXTE: L'approche idéale pour l'arthroplastie totale de la hanche (ATH) serait douce pour les tissus mous, aurait le taux de complications le plus bas et serait facilement reproductible. Dans les 10 dernières années, on a tenté à de nombreuses reprises de déterminer quelle est la meilleure approche, sans obtenir de réponse concluante. Nous avons mené une étude prospective visant à comparer la durée du séjour à l'hôpital, les résultats fonctionnels, la douleur, la position de l'implant, les complications et le temps de chirurgie associés aux approches antérieure directe et postérieure pour l'ATH. MÉTHODES: Un essai clinique randomisé prospectif multicentrique a été mené auprès de patients ayant subi une ATH par voie antérieure directe ou postérieure entre février 2011 et juillet 2013; le suivi moyen était de 55 mois. La durée du séjour à l'hôpital, le temps de chirurgie et les complications ont été notés. Le score de Harris pour la hanche et l'échelle analogique visuelle ont servi au suivi des résultats fonctionnels et de la douleur dans les 5 ans suivant l'opération. Des clichés radiologiques ont été analysés pour évaluer la position de l'implant. RÉSULTATS: Au total, 55 patients ont été recrutés (28 ayant subi une ATH par voie antérieure directe, et 27, une ATH par voie postérieure). La durée du séjour, les résultats fonctionnels, la douleur, la position de l'implant et les complications étaient sensiblement les mêmes, quelle que soit l'approche utilisée. Dans les 3 premiers mois suivant l'opération, les patients ayant subi une ATH par voie antérieure directe avaient tendance à présenter de meilleurs résultats fonctionnels que les autres, en particulier à la quatrième semaine postopératoire (score de Harris pour la hanche : 76,7 c. 68,7; p = 0,08). Le temps de chirurgie moyen pour l'approche antérieure directe était significativement plus long (69,9 c. 45,7 min; p = 0,002). CONCLUSION: La voie antérieure directe semble être une approche efficace et sûre. Aucune différence significative n'a toutefois été observée entre les 2 approches quant à la durée du séjour à l'hôpital ou au rétablissement postopératoire. ENREGISTREMENT DE L'ESSAI: ClinicalTrials.gov, no NCT03673514.

Outcomes of combined hip procedure with dual mobility cup versus osteosynthesis for acetabular fractures in elderly patients: a retrospective observational cohort study of fifty one patients.

PURPOSES: Acetabular fractures are more and more common in the elderly. Open reduction and internal fixation (ORIF) may lead to poor outcomes and high revision rates. Primary total hip arthroplasty (THA) combined with internal fixation, also known as the combined hip procedure (CHP), associated with dual mobility cup (DM-CHP) could be an efficient procedure in selected elderly patients. The aim of this study is to compare functional and radiological outcomes between ORIF and DM-CHP. METHODS: Between 2007 and 2018, 51 patients older than 65 years were surgically treated for acetabular fractures. Twenty-six patients were treated by DM-CHP and 25 by ORIF. Each group was divided into two subgroups regarding a single or combined approach. Hospital stay, surgical time, intraoperative blood loss, and complications were documented. The Harris Hip Score (HHS) was used for measuring the functional outcome. Radiological analysis was used to assess the centre of rotation in the DM-CHP group. RESULTS: Median surgery time and intra-operative blood loss were higher in DM-CHP than those in ORIF. Early medical complication rate was higher for a combined approach as compared with a single posterior approach in DM-CHP (p = 0.003). Dislocation rate was 7.7% in DM-CHP. Revision rate was higher in ORIF (20% versus 7.7%). HHS was similar in both groups. CONCLUSIONS: DM-CHP leads to similar functional outcomes and less revision than ORIF. This study strengthens the practice of using only the posterior approach for primary THA in the elderly. Dual mobility is a valid therapeutic option for acetabular fractures in elderly patients.

Acute leg compartment syndrome after CT-guided core needle biopsy of a giant cell tumor of the proximal fibula.

Imaging-guided percutaneous core needle biopsy (CNB) is the preferred diagnostic method for bone and soft tissue tumors. In less than 1% of cases, complications are clinically significant and include mainly haema-toma and bleeding. We present a case of acute compartment syndrome (ACS) following CNB of the proximal fibula. A 26-year-old female patient was referred to our sarcoma center with a suspicion of giant cell tumor (GCT) of the proximal fibula. The CT-guided CNB under local anesthesia had caused transient severe pain irradiating to the foot, rapidly subsiding after correction of the needle trajectory. The patient was discharged on the same day without residual symptoms. She presented at the emergency department 48 hours later with severe leg pain and swelling. Compartment pressure was elevated. Urgent fasciotomies were performed, revealing muscle edema, without significant haematoma. Postoperatively, paresthesia improved progressively and the patient regained a normal neurologic status within 4 months. Pathologic analysis confirmed the diagnosis of GCT, which was resected after neoadjuvant denosumab therapy. At the 2-year follow up visit, the patient still presented pain at exertion, but had no objective neurological sequela. ACS is not a well-known complication of CNB in the diagnosis of bone tumors. This rare complication might be diagnosed too late, or even missed, due to pre-existing pain, which can sometimes be severe in GCT, and to the usually short post-procedure surveillance in an outpatient procedure.

[Surgical treatment of proximal femur metastases]. / Traitement chirurgical des métastases du fémur proximal.

Aging of the population results in an increase of the incidence of cancer and bone metastases. The proximal femur is one of the most frequent locations of bone metastases. A pathological fracture has a major impact on the quality of life and potentially on survival. In case of impending fracture, prophylactic fixation is therefore strongly recommended. The management of metastases of the proximal femur depends on multiple parameters, life expectancy and fracture risk being the most important ones. If survival is estimated to be less than 6 weeks, surgery is generally not indicated. Beyond 6 weeks, surgical indication essentially depends on location of the metastases on the proximal femur and the presence of a fracture.

L'augmentation de l'espérance de vie s'accompagne d'une croissance de l'incidence des cancers et des métastases osseuses. Le fémur proximal est un des sites les plus fréquents de métastases osseuses. Une fracture pathologique dans cette localisation a un impact majeur sur la qualité de vie et potentiellement sur la survie du patient. Un traitement chirurgical prophylactique est ainsi recommandé en cas de risque de fracture imminente. La prise en charge des métastases fémorales proximales se décide en fonction de multiples paramètres, dont la survie théorique et le risque de fracture sont les plus importants. Si la survie est estimée à moins de 6 semaines, une chirurgie n'est en général pas indiquée. Au-delà, l'indication chirurgicale dépend essentiellement de la localisation des lésions et de la présence d'une fracture associée.

[The irreducible ankle dislocation: beware of the Bosworth injury]. / Irreponible Luxation des oberen Sprunggelenks: die Bosworth-Verletzung.

A luxation fracture of the ankle characterized by a dislocation of the fibula posterior to the tibial tubercle is defined as a Bosworth injury. The Bosworth fracture is a frequently overlooked complex injury of the ankle joint. Associated injuries such as a pilon fracture and posterior malleolus fracture have rarely been reported. In the case of a closed irreducible ankle fracture dislocation, Bosworth injuries should be considered as a potential cause. This article reports the course, treatment and clinical outcome 12 months after trauma of a Bosworth fracture with associated impaction of the posteromedial pilon and fracture of the posterior malleolus. To date, there are only few reports of comparable injuries in the German language literature.

Intra-prosthetic dislocation of dual mobility hip prosthesis: an original and unusual complication.

A 78-year-old female presented with dislocation of a dual mobility hip prosthesis. On standard radiographs after closed reduction, the hip prosthesis appeared to be properly reduced, but clinically the hip was unstable. A Computed Tomography showed a round foreign body, that was in fact a dislocation of the intra-prosthetic implant. This was confirmed intra-operatively during revision surgery. Intra-prosthetic dislocation is a specific complication of dual mobility system. Classically, it's a late complication, linked to the wear of retention area of the polyethylene insert. In this case report we describe an unusual reason of intra-prosthetic dislocation caused by a reduction maneuver of a dislocated dual mobility total hip prosthesis, which to our knowledge has never been documented with Computed Tomography imagery and intra operative pictures. The aim of this article is to analyse the advantages and complications of this implant and to establish recommendations. Dealing with an intra-prosthetic dislocation of a dual mobility hip prosthesis, we recommend attempting a reduction under general anesthesia to avoid mechanical complications. In case of persistent instability after reduction, we recommend performing a Computed Tomography scan.

Infection after fracture fixation.

Infection after fracture fixation is a feared complication in orthopaedic surgery leading to poor bone healing and loss of function.Early detection is essential and interdisciplinary care is mandatory.Eradication of infection is only possible through combined surgical and antibiotic treatment.Intraoperative tissue samples must be taken and are effective for guidance of the antibiotic regimen.Infection after fracture fixation is different from prosthetic joint infection (PJI) and needs a specific strategy.In this review, we define infection after fracture fixation, and outline the clinical, radiological and laboratory signs of these infections, as well as a treatment algorithm for optimal patient care. Cite this article: EFORT Open Rev 2019;4:468-475. DOI: 10.1302/2058-5241.4.180093.

Perioperative Contamination of Orthopaedic Polyethylene Implants, Targeting Devices and Arthroscopes. Experts' Decision Tree and Literature Review.

Introduction Sterility errors during orthopaedic procedures can be stressful for the surgeon or scrub nurse and lead to devastating infectious complications and liability issues. This paper aims to review orthopaedic surgeon practices and propose possible attitudes to adopt. Methods Out of 1023 questionnaires sent, 170 orthopaedic surgeons answered a Volunteer Feedback Template (multiple-choice test) by SurveyMonkey® (San Mateo, CA, USA) anonymously. The survey questioned surgeon's response to a sterility mistake during a standard total knee joint replacement, trauma surgery and arthroscopic procedure. Those "sterility mistake" situations occurred when there was contamination of 1) a sterile polyethylene (PE) 2) a sterile targeting device, and 3) an arthroscope. Results When the definitive PE is contaminated, and if a new definitive PE will only be available 2 hours later, 52% of surgeons would wait for the new definitive PE (p<0.001). In the same situation, if a new PE will only be available in 4 hours, the results showed a significant difference favoring two other options: "putting a definitive PE one size smaller or bigger with balance adjustment" (31%); and "leaving the provisional PE in the joint, closing the wound and re-operating the patient in the coming days when the definitive PE arrives" (29%) (p<0.001). When the new PE is only available 24 hours later results were 34% and 31%, respectively (p<0.001). In the case of a surgical procedure for a classic intertrochanteric fracture, if the carbon fiber targeting device is contaminated, most surgeons (50%) chose to put the nail without the targeting device and finish the surgery (p<0.001). When the arthroscope is desterilized, 39% of participants would wait until the arthroscope has been sterilized again (approximately 2 hours), while 24% would use another procedure (p<0.001). Sixty-two percent of surgeons would adapt their strategy. No clear trend could be identified in terms of antibiotic treatment following a sterility error. Conclusions There are no established guidelines on how to deal with sterility breaches during surgery and on the antibiotic strategy following the prolonged surgical time resulting from the delay for a new implant. The most common course of action chosen by participating surgeons is detailed in our expert decision tree - if another sterile component is not available within 2 hours - : insertion of another PE size, rescheduling the operation, adapting the surgical technique (for trauma procedures), or soaking the arthroscope in disinfectant solution. As instances of contamination cannot be avoided, it is recommended to have a minimum of two copies of sterile PE implants, arthroscopes or targeting devices readily available before surgery begins-.

Association of Bosworth, Pilon, and Open Talus Fractures: A Very Unusual Ankle Trauma.

INTRODUCTION: A Bosworth fracture-dislocation is a rare lesion resulting in a fixed dislocation of the distal fibula behind the posterior tibial tubercle. Only few cases have been reported showing an associated consequent fracture, namely, a pilon or a medial malleolus fracture. CASE REPORT: We present a case report of a patient with an unusual combination of a Bosworth injury with a pilon fracture and an open multifragmentary talus fracture and our approach for open reduction and internal fixation. At one year postoperative, the patient developed an invalidating tibiotalar and subtalar arthrosis that eventually required an ankle-hindfoot arthrodesis. A Bosworth injury is an infrequent entity and is even rarer when associated with other fractures. Careful preoperative planning is necessary, as the combination of these fractures is a surgical challenge. Special care must be taken to preserve the neurovascular bundle. DISCUSSION: The present case highlights a Bosworth injury involving a severity that has never been described before and suggests adding an eighth stage to the classification presented by Perry et al.

Total Hip Arthroplasty for Bilateral Femoral Neck Stress Fracture: A Case Report and Review of the Literature.

Femoral neck stress fractures (FNSFs) can be treated conservatively or surgically, depending on initial displacement and patient condition. Surgical treatment options include internal fixation, with or without valgus osteotomy or hip arthroplasty, either hemi or total. The latter is mainly considered when initial treatment fails. A review of the literature shows that total hip arthroplasty (THA) is only considered as primary treatment in displaced fractures (type 3) in low-demand patients. We present a case of successive bilateral FNSF in a young active patient, where a THA was performed on one side, after failed internal fixation, and where it was chosen as primary treatment on the other side after failed conservative treatment.

Simultaneous Ipsilateral Quadriceps and Triceps Tendon Rupture in a Patient with End-Stage Renal Failure.

INTRODUCTION: Quadriceps tendon ruptures (QTR) frequently occur in patients with end-stage renal failure, while triceps brachii tendon ruptures (TTR) are less common. This is the first properly documented report of a simultaneous ipsilateral traumatic rupture of both of these tendons. CASE REPORT: A 50-year-old patient, on hemodialysis for end-stage renal failure, fell on his right side. He presented with sudden right knee and elbow pain, with functional impairment of both joints. X-rays showed avulsion-like osseous lesions on the olecranon and patella with a low-riding patella. Ultrasound confirmed complete quadriceps and triceps avulsion ruptures. Both lesions were treated surgically. Fixation was performed with anchors using the Krackow suture technique for both tendons. Postoperative clinical and radiological results were satisfactory, and follow-up was uneventful. The patient regained his preinjury functional level with a complete range of motion of both his knee and elbow. DISCUSSION: Isolated QTR and TTR are frequent lesions in chronic renal failure patients treated with hemodialysis. Simultaneous ipsilateral rupture of both tendons however is extremely rare and should therefore not be overlooked. Surgical treatment is recommended for complete ruptures.