Biomechanical comparison of six intramedullary nails, for the treatment of ex-tra-articular, proximal tibial fractures.

BACKGROUND: Intramedullary nailing is the "gold standard" treatment modality of diaphyseal fractures of the tibia. However, when the same method is used for extra-articular fractures of the proximal tibia, various problems may occur, like malalignment, loss of reduction, and non-union. The objective of the present biomechanical study was to compare the stability of six tibial nails when these are used for the treatment of unstable, extra-articular, proximal tibial fractures. METHODS: Thirty composite tibia models were divided into six groups, and a corresponding number of nails from six manufacturers (Citieffe, Braun Aesculap, Orthoselect, Orthofix, Stryker, and Depuy Synthes) was implanted in each group. The maximum number of proximal screws was used for each specimen, and a proximal gap osteotomy was performed. Each bone model was then submitted in dynamic, followed by static loading, and the passive construct stiffness was calculated, representing the specimen's rigidity. Furthermore, for each specimen, the force needed to cause a displacement of more than one millimeter at the fracture site was calculated. RESULTS: Stiffness values of a solid nail with two proximal screws and a cannulated nail with five screws were significantly higher compared to all other groups. On the other hand, a titanium cannulated nail with three screws showed the lowest rigidity. CONCLUSION: Solid nails provide more rigidity compared to cannulated ones, and the maximum number of proximal screws in all possible directions should be used in order to achieve maximum stability. HIPPOKRATIA 2019, 23(2): 58-63.

Midterm clinical and radiological outcomes of the surgical treatment of complex AO type C distal humeral fractures with two different double plate fixation techniques.

INTRODUCTION: The aim of this retrospective, case series was to report the clinical and radiological outcomes of plate fixation of AO Type C distal humeral fractures and to compare the two techniques, the double plate parallel fixation with the double plate orthogonal fixation. CASE SERIES: Twenty-six consecutive patients had their AO type C distal humeral fracture treated either with the orthogonal (group A: 15 patients; mean age 53.5 years, range 21-96) or the parallel (Group B: 11 patients; mean age 56.5 years, range 17-86) plate fixation. The patients were assessed clinically with the use of Mayo elbow performance index (MEPI), and the grading system of Jupiter as well as radiographically. Twenty four patients (14 from group A and ten from group B) were available for follow-up.  The mean follow-up for group A was 48.8 months and for group B, 33 months. According to MEPI, seven elbows were graded as excellent, five as good, one as fair, and one as poor in group A, whereas, in group B, six elbows were graded as excellent, and four as good. According to the Jupiter score, in group A the result was considered excellent in four cases, good in six, fair in three, and poor in one case, while three elbows were graded as excellent and seven as good in group B. Statistical analysis did not reveal any significant differences between the two groups in any of the parameters tested. CONCLUSIONS: Our results provide further evidence that double plate fixation is an adequate treatment option with satisfactory mid-term results for these fractures and indicate that both configurations are equally effective. HIPPOKRATIA 2017, 21(1): 38-42.

Arthroscopic removal of impinging cement after unicompartmental knee arthroplasty.

Complications following unicompartmental knee arthroplasty (UKA) include aseptic loosening, polyethylene wear, arthritis progression and periprothetic fractures. We report on a patient with a firmly fixed, sizeable cement extrusion into the posteromedial aspect of the knee after a UKA causing impingement and pain in full extension. Cement extrusion is an extremely rare but potentially disabling complication that may occur despite care to remove all cement following implantation of the prosthesis. Removing a cement fragment, especially when this is firmly fixed to difficult-to-visualise and access parts of the prosthesis, is challenging. We believe the patient we report is the first one where a firmly fixed, sizeable cement extrusion was removed arthroscopically from the posterior aspect of the knee. This was achieved via an anterolateral portal with trans-notch view, combined with a posteromedial portal used both for viewing and instrument insertion. Arthroscopic removal of the impinging cement with the technique described above is a safe and effective option for the treatment of this difficult albeit rare problem.

Imaging of an unusually located aggressive osteoblastoma of the pelvis: a case report.

INTRODUCTION: We present a case of an aggressive osteoblastoma involving the posterior acetabular column and the ischium, which is very rare location for the tumor. CASE PRESENTATION: A 21-year-old man presented with a persistent pain on the left buttock which extended on the rear surface of the thigh and the front surface of the left hip. A plain radiograph, a CT and MRI examinations were performed. The tumor was radically excised and histologically it proved to be an aggressive osteoblastoma. CONCLUSIONS: Although aggressive osteoblastoma is a rare entity it should be considered in the differential diagnosis of bone tumors. Our purpose is to reveal the radiographic presentation of this rare tumor.

Knee joint effusion following ipsilateral hip surgery.

PURPOSE: To correlate patellar reflex inhibition with sympathetic knee joint effusion. METHODS: 65 women and 40 men aged 45 to 75 (mean, 65) years underwent hip surgery. The surgery entailed dynamic hip screw fixation using the lateral approach with reflection of the vastus lateralis for pertrochantric fractures (n = 49), and hip hemiarthroplasty or total hip replacement using the Watson-Jones approach (n = 38) or hip hemiarthroplasty using the posterior approach (n = 18) for subcapital femoral fractures (n = 28) or osteoarthritis (n = 28). Knee joint effusion, patellar reflex, and thigh circumference were assessed in both legs before and after surgery (at day 0.5, 2, 7, 14, 30, and 45). Time-sequence plots were used for chronological analysis, and correlation between patellar reflex inhibition and knee joint effusion was tested. RESULTS: In the time-sequence plot, the peak frequency of patellar reflex inhibition (on day 0.5) preceded that of the knee joint effusion and the thigh circumference increase (on day 2). Patellar reflex inhibition correlated positively with the knee joint effusion (r = 0.843, p = 0.035). These 2 factors correlated significantly for all 3 surgical approaches (p < 0.0005). All 3 approaches were associated with patellar reflex inhibition on day 0.5 (p = 0.033) and knee joint effusion on day 2 (p = 0.051). CONCLUSION: Surgical trauma of the thigh may cause patellar reflex inhibition and subsequently knee joint effusion.

Total elbow arthroplasty for the treatment of insufficient distal humeral fractures. A retrospective clinical study and review of the literature.

Treatment of complex distal humeral fractures in older patients with osteopenic bone remains a major surgical challenge. We report the results of 11 patients over 75 years of age who underwent semiconstrained sloppy-hinge total elbow arthroplasty (TEA) due to comminuted intraarticular fractures of the distal humerus. There were 9 women and 2 men with a mean age of 79.6 years. The mean duration of follow up was 2.8 years. According to AO classification, there were 8 type C3 and 3 type C2 fractures. The mean time from injury to operation was 4.3 days and the mean length of hospital stay was 9.8 days. The elbow flexion/extension and forearm pronation/supination arc of motion averaged 107(0) and 121(0) respectively. The mean Mayo Elbow Performance Score (MEPS) was 90 points, equivalent to excellent result. One patient sustained a periprosthetic humeral fracture and signs of non-progressive radiolucency were found in 8 out of the 11 elbows. Our search in the English and International literature revealed 9 other clinical studies describing the results of TEA in 167 patients with 168 distal humeral fractures. The mean age of patients varied from 69 to 84.6 years and the mean follow up from 17.8 months to 7 years. The mean MEPS among the studies was between 85 and 95 points. Wound infection was diagnosed in 9 cases (5.4%) but component removal and subsequent reimplantation was only applied in 3 elbows (1.8%). Partial ulnar nerve lesions were reported in 11 patients (6.5%) and reflex sympathetic dystrophy was developed in 5 patients (3%). In 3 elbows (1.8%) a periprosthetic fracture after a fall was recorded. Radiolucent lines between the cement mantle and bone interface were described in 24 cases (14.3%) but the majority of them (17 cases) were stable and asymptomatic. In conclusion, TEA constitutes a viable treatment option for the complex distal humeral fractures in elderly and medically compromised patients. Careful patient selection and regular follow up evaluation are mandatory for achieving an optimal result and eliminating the risks of mismanagement and early implant failure.

The role of erythropoietin in the acute phase of trauma management: evidence today.

Trauma patients often present in a state of haemorrhagic shock. Blood products remain the gold standard of resuscitation, but allogeneic blood transfusions (ABTs) are associated with several risks. The stimulating effect of recombinant-erythropoietin (EPO-A) on erythropoiesis has raised interest in its administration as an alternative. The existing evidence on the early use of EPO-A in the acute phase of trauma patients management consists of only 14 publications. The level of evidence of these studies and the number of treated patients was not found to be adequate to support its generalised use, despite their favourable results. Its safety profile, the preliminary proofs of its efficacy, and the additional cyto-protective properties of EPO-A strongly encourage further controlled studies assessing its use in the acute setting of initial trauma management.

Multifocal Proteus mirabilis osteomyelitis requiring bilateral amputation in an HIV-positive patient.

We present a rare case of multifocal Proteus mirabilis osteomyelitis in an HIV-positive patient. Despite the patient's good immune status as assessed by her CD4 cell count and the aggressive treatment, she eventually underwent bilateral above-knee amputations to eradicate the infection. Multifocal Proteus mirabilis osteomyelitis can have an unpredictable clinical course with a severe outcome in HIV-positive patients.

Does aprotinin reduce blood loss in total hip arthroplasty?

This prospective randomized study examined the effects of aprotinin during total hip arthroplasty (THA). Fifty patients who were enrolled in the study received aprotinin or normal saline. Mean intraoperative blood loss was reduced from 1496 mL in the control group to 1073 mL in the aprotinin group. The mean transfusion unit was 1.56 in the aprotinin group and 3.8 in the control group.