Young men undergoing anterior cruciate ligament reconstruction with patellar tendon autograft and anteromedial drilling outperform at 5- to 10-year follow-up in terms of graft stability and activity levels compared to those undergoing reconstruction with hamstring autograft and transtibial drilling.

OBJECTIVE: To compare 5- to 10-year outcomes of anterior cruciate ligament (ACL) reconstruction in young men performed with bone-patellar tendon bone (BPTB) autograft and anteromedial portal to reconstruction with hamstring autograft and transtibial technique. It was hypothesised that in young adult men, at 5- to 10-year follow-up, superior restoration of knee laxity and activity levels would be demonstrated using BPTB autograft and anteromedial portal technique. METHODS: Ninety-four men who had ACL reconstruction with BPTB autograft and anteromedial portal were eligible for comparison to 106 men who had reconstruction with hamstring autograft and transtibial technique. Inclusion criteria were: (1) age 18-35 years, (2) ACL tear caused by sports trauma only, (3) no concomitant ligament reconstruction and (4) 5- to 10-year follow-up. Outcome measures compared between the two groups included Lachman and pivot shift tests, KT side-to-side difference, Tegner and Marx scores, International Knee Documentation Committee (IKDC)-subjective score, Knee Osteoarthritis Outcome Scale (KOOS), Short Form (SF)-36, and single hop test for distance. P value â€‹< â€‹0.05 indicated statistical significance. RESULTS: Forty-five patients with BPTB and 55 patients with hamstring ACL reconstruction were available for in-person assessment at 5-10 years after surgery. Outcomes in the BPTB group compared to the hamstring group showed KT difference 1.4 â€‹± â€‹1.9 mm vs. 2.8 â€‹± â€‹2.3 mm (p â€‹< â€‹0.01), pivot shift grade 2-3 in 4% vs. 34% (p â€‹< â€‹0.01), return to preinjury Tegner level in 51% vs. 36% (p â€‹= 0.1) and to preinjury Marx score in 29% vs. 11% (p â€‹= 0.02), and IKDC-subjective 88 â€‹± â€‹10 vs. 82 â€‹± â€‹13 vs (p â€‹< â€‹0.01), respectively. Statistically significant inter-relationships were found between KT side-to-side difference and the Tegner, Marx and IKDC-subjective scores at follow-up (r â€‹= â€‹-0.314, p â€‹< â€‹0.01; r â€‹= â€‹-0.263, p â€‹< â€‹0.01; r â€‹= â€‹-0.218, p â€‹= â€‹0.03, respectively). CONCLUSION: Young men undergoing ACL reconstruction with patellar tendon autograft and anteromedial drilling outperform at 5- to 10-year follow-up in terms of graft stability and activity levels compared to young men undergoing reconstruction with hamstring autograft and transtibial drilling. LEVEL OF EVIDENCE: III (Retrospective cross-sectional comparative study).

A pilot study exploring the use of hyaluronic acid in treating insertional achilles tendinopathy.

PURPOSE: This study explores the use of ultrasound-guided Hyaluronic Acid (HA) injections for Insertional Achilles Tendinopathy (IAT). METHODS: A cohort of 15 ankles diagnosed with IAT received three weekly ultrasound-guided HA injections. The Victorian Institute of Sport Assessment - Achilles (VISA-A) questionnaire scored the severity of symptoms and functional impairment before treatment, and at one and six months post-treatment. RESULTS: Significant improvement was observed in VISA-A scores post-treatment, rising from an average baseline of 34.8 ± 15.2 (11-63) to 53.6 ± 20.9 (15-77) after one month, and then to 50.7 ± 18.6 (20-75) after six months. No adverse reactions were noted, underscoring the safety of the intervention. CONCLUSION: The pilot study presents HA injections as a potentially effective treatment for IAT, while interpretation of these findings must take into account the variability in results, indicating a range of patient responses. It encourages further research to confirm these findings and to explore HA's full potential in managing IAT, despite the limitations of a small sample size and lack of control group.

Better Short-term Outcomes after Total Hip Arthroplasty Compared to Hemiarthroplasty in Active Older Patients with Displaced Intracapsular Femoral Neck Fracture.

BACKGROUND: Hip fractures are a public health problem that disproportionately affects the elderly. Displaced femoral neck fractures were treated historically with hemiarthroplasty, but the use of total hip arthroplasty (THA) is increasing showing superior long-term results. OBJECTIVES: To assess whether THA has superior short-term results compared to bipolar hemiarthroplasty for displaced femoral neck fractures. METHODS: Two groups of active older patients underwent either cementless bipolar hemiarthroplasty or THA for displaced femoral neck fracture. All patients were operated on using the direct lateral approach to the hip joint. Patients were assessed using the Harris Hip Score at hospital discharge and at 6 weeks follow-up. RESULTS: We included 40 patients ages 65-85 years; 18 underwent bipolar hemiarthroplasty and 22 THA. The number of women in each group was similar, as was mean age: 73.1 ± 4.2 years in the hemiarthroplasty group and 71.0 ± 3.7 in THA. Harris Hip Score on hospital discharge was similar in both groups. Walking ability at discharge was better in the THA cohort and they were discharged sooner: 5.2 ± 1.3 vs. 6.4 ± 1.7 days following hemiarthroplasty (P = 0.021). At 6 weeks follow-up, the mean Harris Hip Score was higher in the THA group (78.6 ± 11 vs. 61.5 ± 17 for hemiarthroplasty, P < 0.001). Patients in the THA group walked longer distances, needed less support while walking, and reported less pain. CONCLUSIONS: Better short-term results at hospital discharge and at 6 weeks follow-up after THA contributed to earlier patient independence and shorter hospital stays.

The anterior superior iliac spine is a reliable novel landmark for preemptive periacetabular analgesia in hip arthroscopy.

Appropriate post-operative (post-op) pain control has been shown to reduce length of stay and facilitate day case surgery. Periacetabular injection of bupivacaine is effective in pain reduction after hip arthroscopy. This study aims to evaluate the anterior superior iliac spine (ASIS) as an anatomical landmark to facilitate needle insertion prior to fluoroscopy. The meeting point derived from a vertical line one fingerbreadth distal to the ASIS and a longitudinal line from the greater trochanter (GT) was used as a landmark in 30 consecutive hip arthroscopy patients for periacetabular analgesia. The distance between the tip of the needle and the acetabular roof was measured via fluoroscopy. Needle location was corrected if needed, followed by periacetabular bupivacaine injection (at anterior, lateral and posterior joint aspects). Post-op pain was measured using the Visual Analog Scale (VAS) 4-6 h post-op and at discharge. The ASIS and GT were identified and used for periacetabular analgesia landmarks in all cases. Results revealed that 93.3% of needle entries fell within 10 mm of the lateral acetabular rim and only one case had fallen distal to it. The post-op mean VAS score was 1.03 (range 0-6, standard error - 0.30, median = 0). At hospital discharge, 90% (27/30 of patients) reported VAS score ≤ 5. Twenty-six of the 30 patients were discharged on the same day as the operation (remaining four patients stayed due to accommodation/traveling issues). The ASIS and GT can be used as an anatomical landmark for periacetabular analgesia in hip arthroscopy with reproducible needle location, significant analgesic effect and minimal radiation.

Unveiling the Economic Toll of Surgical Learning Curve in Elderly Hip Fractures.

Can the financial impact of implant choice during the learning curve of inexperienced surgeons in hip fracture surgery be quantified? Hip fractures in the elderly are a significant medical concern, often requiring surgical interventions performed by orthopedic surgery residents. As healthcare costs rise, exploring cost reduction opportunities within the healthcare system becomes crucial. In this prospective analysis, we examined the financial implications of implant choices encountered by residents during their learning curve in hip fracture surgery. Our study included 278 surgically treated pertrochanteric fractures using the same locking cephalomedullary nail. Data on patients, surgeons (including their experience and seniority), and all implants charged by the hospital were collected. This encompassed documentation of any nail-related equipment that was opened on the operating table and whether it was subsequently used by the end of the procedure. By calculating the number and cost of these implants, we assessed the financial burden associated with suboptimal choices made during the learning curve. Our findings revealed that in 16.18% of surgeries, instances of suboptimal implant utilization occurred, highlighting the complexities of the learning process. Importantly, the rate of these challenges was not influenced by surgeon seniority or patient characteristics. The mean additional cost per surgery was determined to be USD 65.69 ± 157.63 for surgeries with suboptimal implant utilization, compared to USD 56.55 ± 139.13 for surgeries without such challenges. Although there was a trend towards higher implant-related costs in resident-led surgeries, the difference did not reach statistical significance. These findings underscore the feasibility of enabling residents to autonomously perform intramedullary nailing surgeries, even without specialist supervision, while incurring minimal additional expenses during the learning curve. By acknowledging the financial implications associated with the learning curve in the management of hip fractures, we can strive to optimize healthcare costs, thus addressing an important aspect of this issue.

Direct Anterior vs. Direct Lateral Approach Total Hip Arthroplasty for Displaced Femoral Neck Fracture.

BACKGROUND: This study compared outcomes of the direct anterior approach (DAA) and direct lateral approach (DLA) for treating displaced femoral neck fractures in active elderly patients. METHODS: This retrospective study included active elderly patients who sustained a displaced femoral neck fracture and underwent a cementless total hip arthroplasty either with a supine DAA or a decubitus DLA. Patients were assessed using the Harris hip score at discharge and at a 6-week follow-up. RESULTS: A total of 41 women and 18 men were included in the study. Of those, 22 underwent DLA and 37 received DAA, all performed by the same team. In both groups, 69% were women, mean age was 70 years, and mean BMI was 25.2. Mean hemoglobin loss was 2.3 g/dl between admission and the first post-operative day in both groups. Similar numbers in each cohort were discharged home rather than to a rehabilitation center. The patients who underwent the DAA experienced a 2-day reduction in their hospital stay compared to the DLA group (4.2 ± 1.9 vs. 6.8 ± 3.7, respectively; p < 0.001). The Harris hip score in the DAA group was significantly higher at the 6-week follow-up than in the DLA group (87.23 ± 7.75 vs. 81.23 ± 7.67, respectively; p < 0.031). CONCLUSIONS: The patients who underwent THA with the DAA demonstrated better short term outcomes compared to the alternative approach for displaced femoral neck fractures in active elderly patients. DAA helped patients regain independence faster and might decrease hospitalization and rehabilitation costs. Based on these results, we recommend using the DAA for active elderly patients with a displaced femoral neck fracture.

A modified minimally invasive osteotomy for hallux valgus enables reduction of malpositioned sesamoid bones.

BACKGROUND: The current minimally invasive distal metatarsal osteotomy for hallux valgus (HV) is V-shaped, which prevents the correction of the rotational metatarsal head deformity and reduction of the sesamoid bones. We sought to determine the optimal method for sesamoid bone reduction during HV surgery. METHODS: We reviewed the medical records of 53 patients who underwent HV surgery between 2017 and 2019 using one of three techniques: open chevron osteotomy (n = 19), minimally invasive V-shaped osteotomy (n = 18), and a modified straight minimally invasive osteotomy (n = 16). The sesamoid position was graded using the Hardy and Clapham method on weight-bearing radiographs. RESULTS: When compared to open chevron and V-shaped osteotomies, the modified osteotomy resulted in significantly lower postoperative sesamoid position scores (3.74 ± 1.48, 4.61 ± 1.09, and 1.44 ± 0.81, respectively, P < 0.001). Furthermore, the mean change in postoperative sesamoid position score was greater (P < 0.001). CONCLUSION: The modified minimally invasive osteotomy was superior to the other two techniques in correcting HV deformity in all planes, including sesamoid reduction.

Ipsilateral Quadriceps Tendon-Bone ACL Revision Reconstruction to Address Failed Primary Bone-Patellar Tendon-Bone ACL Reconstruction with Persistent Patellar Bone Defect.

Bone-patellar tendon-bone (BPTB) autograft is a popular graft choice for anterior cruciate ligament reconstruction (ACLR) in active young adults. In case of BPTB ACLR failure, the 3 most popular autograft choices for a revision surgery include contralateral BPTB, contralateral or ipsilateral hamstrings autograft, and contralateral or ipsilateral quadriceps tendon autograft. Quadriceps tendon autograft has been gaining increasing popularity in recent years in this respect, but using quadriceps tendon-bone autograft in the setup of a previous use of ipsilateral BPTB autograft deserves special technical considerations, with emphasis on preserving patellar bone integrity. We describe a technique for performing revision ACLR after failed primary BPTB ACLR by using ipsilateral quadriceps tendon-bone autograft in the setup of persistent distal patellar bone defect. Using this autograft benefits the advantages of highly resilient graft tissue in addition to fast bone-to-bone healing on the femoral side, and it can be an excellent choice in revision reconstruction for surgeons who prefer tendon-bone autograft for highly active young adults and specifically when the patients underwent bilateral primary autologous BPTB ACLRs.

Proximal Femur Fractures in the Elderly-A Novel Modality to Predict Mortality: The Neutrophil-to-Lymphocyte Ratio.

Background: The assessment and identification of elderly patients with proximal femur fractures (PFF) who are at high risk of postoperative mortality may influence the treatment decision-making process. The purpose of this study was to determine whether the neutrophil-to-lymphocyte ratio (NLR) could be used to predict postoperative mortality in the elderly population. Methods: A four-year retrospective cohort study of electronic medical records was conducted at a single tertiary care hospital between 2015 and 2018. Data from 1551 patients aged 65 years and older who underwent surgical treatment for PFF were collected and analyzed. The data included complete blood counts at admission, demographic information, underlying illnesses, type of surgery, and postoperative mortality and complications during the first year of follow-up. A survival analysis model was utilized. Results: The mean age was 90.76 ± 1.88 years, 1066 (68.7%) women. Forty-four (2.8%) patients experienced postoperative infection. A higher NLR0 was independently associated with higher all-cause mortality rates in patients who underwent surgical treatment for PFF (p = 0.041). Moreover, the mean NLR0 value was higher when the death occurred earlier after surgery (p < 0.001). Conclusions: When combined with other clinical and laboratory findings, NLR0 levels may serve as a potentially valuable, inexpensive, and reliable prognostic biomarker to improve risk stratification for elderly patients who are candidates for PFF surgery. Furthermore, with additional research, we could potentially develop a treatment algorithm to identify patients at high risk of postoperative mortality.

Promising results in a 3-year follow-up for adults undergoing a one-stage surgery for residual talipes equinovarus as part of a humanitarian mission in Vietnam.

BACKGROUND: Rigid talipes equinovarus (TEV) is a complex foot deformity in which the foot is fixed in a plantarflexed, inverted, and adducted position. This pathology has the potential to severely limit basic life activities, which can be devastating for patients in developing countries. The objective of this study was to present the outcomes of patients with mature bones presenting with severe rigid TEV deformity who were operated on during a humanitarian mission to Vietnam using a single lateral approach and a simple and inexpensive fixation technique. METHODS: This is a retrospective analysis of prospectively collected data. We analyzed the outcomes of patients who underwent surgery for a severe rigid TEV that prevented them from walking minimal distances unaided. All feet were fixed in a non-plantigrade position. The surgeries were conducted as part of two International Extremity Project (IEP) missions in Can Tho, Vietnam (2013 and 2018). Pre- and post-operative AOFAS scores were compared using the paired sample t-test. RESULTS: We operated on 14 feet of 12 patients, 6 (50%) of whom were males, aged 34.42 ± 11.7 (range 12 to 58). Four patients were followed for three months, two patients were followed for 12 months, and eight patients were followed for three years. On the final follow-up visit of each patient, all 14 operated feet were plantigrade with good alignment, and patients reported an improvement in daily activity. After 3 years of follow-up, the mean AOFAS score of eight patients with available data improved by 42.88 ± 3.91 points (95% CI 39.61 to 46.14, P < 0.01). Our patients also reported an improvement in mobility. At the final follow-up examination, no recurrence of the deformity was observed in any of the patients. CONCLUSIONS: Using low-technical surgical modalities, we were able to achieve plantigrade and walkable feet in patients with mature bones who had fixed rigid equinovarus. LEVEL OF EVIDENCE: Level IV- Case Series.

Thousand shades of gray - The role of imaging display in diagnosis of occult scaphoid fractures - A pilot study.

Introduction: Most hospitals and clinics utilize commercial grade displays for viewing wrist radiographs. There is no evidence regarding the role of the imaging display used to evaluate the radiographs. The aim of this study was to compare the rates of scaphoid fracture diagnosis by commercial grade and medical grade displays. Methods: Wrist radiographs of patients that had clinical signs of scaphoid fracture without findings on plain radiography (suspected scaphoid fractures) were retrospectively collected from ER department and interpreted for radiographic signs of fracture by four orthopedics seniors commercial grade and medical grade displays. The difference in fracture diagnosis rates were studied. Inter- and intra-observer variability were also studied. Results: Study population comprised of 175 high quality wrist radiographs were interpreted. Mean 48.25 (27%) scaphoid fractures were observed on commercial grade display compared to 66 (38.2%) on medical grade display (p = 0.076). The total inter-observer agreement could be defined as a moderate agreement (κ = 0.527, Accuracy = 0.77). Total agreement between all observers were observed in 86 (49.1%) cases compared to 89 (50.9%) cases when reviewing X-rays on commercial and medical displays, respectively. Discussion: The scaphoid fracture detection rate on medical grade display was not statistically higher compared to non-medical grade displays, but we did find a tendency toward medical grade display. We found that in a substantial number of cases, our observers recognize signs of fracture that were initially evaluated as "suspected fracture" by the ER physicians. As a pilot study, we found evidence that support the need for a prospective study designed to compare the observations to a gold standard modality, such as MRI. We believe utilizing medical grade displays can increase the rate of diagnosis in cases of clinically suspected scaphoid fractures and better manage the clinical scenario of a suspected scaphoid fracture.

Osteoporosis Treatment After Osteoporotic Fractures: Data From a Single Medical Center.

OBJECTIVE: Most patients do not receive osteoporosis treatment after osteoporotic fracture. This study reviewed osteoporosis treatment after osteoporotic fractures in a center without a Fracture Liaison Service. METHODS: We identified all patients with hip, vertebral, humeral or radial fractures, evaluated in Meir Medical Center, in 2017. The exclusion criteria were not a Clalit Health Services member, high-energy fracture or 30-day postoperative mortality. The primary endpoint was osteoporosis drugs issued within 12 months of fracture. Secondary endpoints included bone densitometry and 1-year mortality. RESULTS: Five-hundred-eighty-two patients (average age 78.6 ± 11.1 years, 75.8% women) were included. There were 321 (55.5%) hip, 84 (14.1%) humeral, 33 (5.6%) vertebral, and 144 (24.7%) radial fractures. Osteoporosis drugs were issued to 26.5% of the patients; those with humeral fractures received the least (21.4%) and vertebral, the most (30.3%; P = .51). Bone densitometry was performed in 23.2% of patients. One-year mortality after hip fracture was 12.1%, followed by humeral (3.6%; P < .05). Logistic regression showed that previous treatment (odds ratio [OR] = 7.4; 95% confidence interval [CI] 3.6-15.2), bone densitometry (OR = 4.4; 95% CI 2.6-7.4) and endocrinology visit (OR = 2.6; 95% CI, 1.4-4.6) were the most important factors associated with treatment. CONCLUSION: Fewer than one third of patients received pharmacotherapy within 1 year after fracture. Because pharmacotherapy reduces future fractures and mortality, we recommend that medical staff who care for patients with fracture adopt practical and effective strategies to increase treatment rates among patients with osteoporotic fractures.

Factors Associated with Timing of Syndactyly Release in the United States.

Background: Syndactyly is one of the commonly encountered congenital hand anomalies. However, there are no strict guidelines regarding the timing of surgical release. The aim of this study was to investigate the age and factors associated with syndactyly release in the United States. Methods: A retrospective analysis of the California and Florida State Ambulatory Surgery and Services Databases for patients aged 18 years or younger who underwent syndactyly release surgery between 2005 and 2011 was performed. Demographic data that included the age at release, gender, race and primary payor (insurance) was collected. A sub-analysis was performed to compare the demographic characteristics between those patients undergoing syndactyly release before 5 years of age ('Early Release') and at (of after) 5 years ('Late Release'). Results: A total of 2,280 children (68% male, 43% Caucasian) were identified. The mean age of syndactyly release was 3.6 years, and 72.9% of patients underwent release before the age of 5 years. A significantly larger proportion of females (p = 0.002), and Hispanics and African Americans (p = 0.024), underwent late release compared to early release. Additionally, a significantly higher percentage of patients undergoing late release utilised private insurance (p = 0.005). However, the actual differences in gender, race and primary payor were small. Conclusion: The majority of syndactyly releases were performed before school age, which is the primary goal in the management of syndactyly. While gender and racial disparities in the surgical treatment of syndactyly may exist, the differences in the present study were relatively small. Level of Evidence: Level III (Therapeutic).

Treating Hallux Valgus Associated Metatarsus Adductus by Minimally Invasive Surgery: A Simple Solution for a Difficult Problem.

This study aims to assess a novel minimally invasive surgical technique that addresses hallux valgus accompanied by metatarsus adductus. We retrospectively analysed the results of 20 patients (21 feet) that underwent a newly developed percutaneous osteotomy procedure of the lesser metatarsal bones in order to correct hallux valgus deformities accompanied by metatarsus adductus. We used x-ray studies in order to evaluate changes in the hallux valgus angle, the first intermetatarsal angle, and the metatarsal angle (using the modified Sgarlato method). We also compared the pre- and postoperative American Orthopaedic Foot and Ankle Society scores when available. The paired sample t test was used to compare variables. At a 1-y follow-up the mean hallux valgus angle, inter-metatarsal angle and the metatarsal angle have been reduced by 31.62 (-3 to 9), 3.86 (11-52) and 14.69 (4-36) respectively (p < .001 for all). The mean American Orthopaedic Foot and Ankle Society score (n = 15 feet available) has been improved by a mean of 44.53 (22-72, p < .001). In addition, the patient satisfaction rates were high. Patients suffered from mild to moderate midfoot pain during the first few weeks following surgery, which resolved when union occurred. No cases of lesser metatarsal nonunion have been documented. The presented minimally invasive method can be used effectively to correct hallux valgus that is associated with metatarsus adductus. Proximal minimally invasive metatarsal osteotomy can effectively correct hallux valgus accompanied by metatarsus adductus.

Red cell distribution width-A mortality predictor in older adults with proximal femoral fracture.

BACKGROUND: Identifying elderly patients with proximal femoral fractures (PFF) who are at risk of postoperative mortality may influence the treatment decision-making process. The purpose of this study was to examine whether red blood cell distribution width (RDW) can serve as a predictor of postoperative mortality in these patients. METHODS: A retrospective cohort study of electronic medical records at a single tertiary care hospital over a 3-year period between 2015 and 2018. We reviewed the records of 1574 patients aged > 65 years who underwent surgical treatment for PFF and who's preoperative RDW levels were available. Data collected consisted of patient demographics, underlying illnesses at the time of admission, type of procedure performed as well as postoperative mortality and complications over the course of a 1-year follow-up period. The cohort was then divided into two groups based on their RDW levels at the time of admission: low (<14.5%) and high (>14.5%). RESULTS: The mean age was 90.77±1.87 years; 68.7% were women. Majority of patients (69.1%) underwent closed reduction internal fixation; 414 (26.4%) underwent hemiarthroplasty, and 71 (4.5%) had total hip arthroplasty. At admission, 576 patients (36.6%) had high RDW levels and 998 (63.4%) had low RDW levels. There were no statistically significant differences between the groups with regard to age, gender, type of surgery, or duration. Patients with high RDW had more co-morbidities (p<0.001) and more abnormal laboratory test results when compared to patients with low RDW. Overall mortality rate within 1-year post-surgery was 17.5% (276 patients). All-cause mortality was greater for patients with high baseline RDW, at 3 months (p = 0.001), 6 months (p<0.0001), and 1-year post-surgery (p<0.0001). Forty-four (2.8%) patients had surgical site infection (SSI) without any significant association to baseline RDW levels. CONCLUSIONS: Preoperative RDW levels, when combined with clinical and laboratory findings, may help to improve the risk stratification of older patients who are candidates for PFF. With further research, a treatment algorithm could be developed to potentially identify patients at high risk of preoperative mortality, allowing for more conservative management.

Mortality following surgery for geriatric hip fractures: is it the timing or the co-morbidities?

BACKGROUND: Hip fractures are prevalent in the elderly population and present serious health, social and economic problems, with an impact on morbidity and mortality. Today, it is common practice to surgically repair these fractures as early as possible, preferably within 48 hours of hospital admission. However, there is conflicting evidence in the literature about the effect of the timing of surgery on postoperative mortality. OBJECTIVES: To assess the association between surgery delay and other demographic and clinical variables with an increased mortality rate after surgical treatment of hip fractures in the elderly. METHODS: A retrospective study was conducted on patients aged ⩾65 years with a primary diagnosis of hip fracture. All patients underwent surgery in our Medical Center from 2015 to 2017. A multivariate model of logistic regression, Cox regression model and Kaplan-Meier survival analysis were used to evaluate the relationship between various variables and mortality rates at 3- and 12-month follow-ups. RESULTS: A total of 877 patients were included, 30% were men and 70% women; the mean age was 83.3 years. Multivariate analysis showed that mortality was significantly higher among patients who underwent late surgery, after adjusting for gender, age, co-morbidity, age of surgeon, duration of surgery and duration of hospitalisation (p = 0.030). Surgical delay was significantly associated with higher mortality rates both at 3 month (p = 0.041) and at 12 months after surgery (p = 0.013). The presence of ischemic heart disease, congestive heart failure, paroxysmal atrial fibrillation and chronic renal failure, as well as male gender and older age, were also significantly associated with higher early and late mortality. CONCLUSIONS: In elderly patients, hip fracture surgery should be performed within 48 hours of admission. Male and older patients, as well as patients with the aforementioned co-morbidities, are at higher risk of mortality at 3 and 12 months after surgery.

The effect of postoperative weight-bearing status on mortality rate following proximal femoral fractures surgery.

INTRODUCTION: Proximal femur fractures are associated with an increased mortality rate in the elderly. Early weight-bearing presents as a modifiable factor that may reduce negative postoperative outcomes and complications. As such, we aimed to compare non-weight-bearing, partial-weight-bearing and full weight-bearing cohorts, in terms of risk factors and postoperative outcomes and complications. METHODS: We retrospectively reviewed our database to identify the three cohorts based on the postoperative weight-bearing status the day of surgery from 2003 to 20014. We collected data on numerous risk factors, including age, cerebrovascular accident (CVA), pulmonary embolism (PE), surgical fixation method and diagnosis type. We also collected data on postoperative outcomes, including the number of days of hospitalization, pain levels, and mortality rate. We performed a univariate and multivariate analysis; P < 0.05 was the significant threshold. RESULTS: There were 186 patients in the non-weight-bearing group, 127 patients in the partial-weight-bearing group and 1791 patients in the full weight-bearing group. We found a significant difference in the type of diagnosis between cohorts (P < 0.001 in univariate, P < 0.001 in multivariate), but not in fixation type (P < 0.001 in univariate, but P = 0.76 in multivariate). The full weight-bearing group was diagnosed most with pertrochanteric fracture, 48.0%, and used Richard's nailing predominantly. Finally, we found that age was not a significant determinant of mortality rate but only weight-bearing cohort (P = 0.13 vs. P < 0.001, respectively). CONCLUSION: We recommend early weight-bearing, which may act to decrease the mortality rate compared to non-weight-bearing and partial weight-bearing. In addition, appropriate expectations and standardizations should be set since age and type of diagnosis act as significant predictors of weight-bearing status.

A practical method for real-time detection of pedicle wall breaching during funneling.

BACKGROUND: A reliable, real-time method for the detection of pedicle wall breaching during funnelling in spine deformity surgery could be accessible to any surgeon assisted with neuromonitoring. METHODS: Fifty-six consecutive patients (1066 pedicles), who were submitted to spinal deformity surgery from December 2013 to July 2015 were included in the study group. A control group of 13 consecutive patients (226 pedicles) with spinal deformity surgery were operated on from January to December 2013 and were excluded from finder stimulation. In the study cohort, continuous stimulation during funnelling was delivered via a finder and subsequently a compound muscle action potential (CMAP) threshold was determined. Following funnelling, manual inspection of the pedicular internal walls was performed. The CMAP thresholds were compared with the results of palpation to determine the sensitivity and specificity of the technique for detecting pedicular breaching. To cover common ranges of damage, the medial and lateral breaches were compared and the concave-apical breaches compared to the non-apical or convex-apical breaches. In addition, a pedicle screw test was estimated for all patients. RESULTS: ROC analysis showed 9 mA cut-off to have a sensitivity of 88.0% and a specificity of 89.5% for predicting pedicular breaching, with an area under the curve of 0.92 (95% confidence interval 0.90-0.94; P < 0.001). Using 9 mA threshold as an alert criterion, funnelling at the concave-apical pedicles showed significantly more true and false positive alerts and fewer true negative alerts when compared with the non-apical and convex-apical pedicles (P < 0.001). Medial breaches had significantly lower stimulation thresholds than lateral breaches (P < 0.001). Thresholds of screw-testing were significantly higher for study than for control-patients (P = 0.002). CONCLUSIONS: Finder stimulation has a considerably higher sensitivity and specificity for prediction of pedicular breaching, most prominent for medial breaches. Screw-testing displayed significantly better results in patients undergoing the finder stimulation technique, as compared with the control group. The main advantages of our method are its high safety level and low cost, which may be critical in less affluent countries. LEVEL OF EVIDENCE: III.

Amputation versus Primary Nonoperative Management of Chronic Osteomyelitis Involving a Pedal Digit in Diabetic Patients.

BACKGROUND: The preferred primary treatment of toe osteomyelitis in diabetic patients is controversial. We compared the outcome of primary nonoperative antibiotic treatment versus digital amputation in patients with diabetes-related chronic digital osteomyelitis. METHODS: We conducted a retrospective medical record review of patients treated for digital osteomyelitis at a single center. Patients were divided into two groups according to initial treatment: 1) nonoperative treatment with intravenous antibiotics and 2) amputation of the involved toe or ray. Duration of hospitalization, number of rehospitalizations, and rate of below- or above-the-knee major amputations were evaluated. RESULTS: The nonoperative group comprised 39 patients and the operative group included 21 patients. The mean ± SD total duration of hospitalization was 24.05 ± 15.43 and 20.67 ± 15.97 days, respectively (P = .43). The mean ± SD number of rehospitalizations after infection recurrence was 2.62 ± 1.63 and 1.67 ± 1.24, respectively (P = .02). During follow-up, the involved digit was eventually amputated in 13 of the 39 nonoperatively treated patients (33.3%). The rate of major amputation (above- or below-knee amputation was four of 39 (10.3%) and three of 21 (14.3%), respectively (P = .69). CONCLUSIONS: Despite a higher rate of rehospitalizations and a high failure rate, in patients with mild and limited digital foot osteomyelitis in the absence of sepsis it may be reasonable to offer a primary nonoperative treatment for digital osteomyelitis of the foot.

All-Autograft Multiligament Knee Reconstruction of the Posterior Cruciate Ligament, Anterior Cruciate Ligament, and Posterolateral Corner (KD-IIIL).

Multiligament knee reconstruction constitutes a challenging entity. While allograft use gained popularity in this scenario because it can reduce surgery time and the risk of donor-site morbidities, in some places high-quality allografts are not readily available. In addition, allografts are subjected to some disadvantages compared with autografts, including slower biological incorporation and risk of disease transmission. Choosing and using wisely autografts to address these cases becomes valuable for these reasons. In this manuscript a technique is described for performing all-autograft multiligament knee reconstruction of the posterior cruciate ligament, anterior cruciate ligament and posterolateral corner.