Unstable Fractures of the Greater Tubercle of the Humerus. A Case Report.

The paper presents the results of stabilization of an unstable, comminuted fracture of the greater tubercle with absorbable sutures after fixation of a comminuted fracture of the proximal humerus with a reconstructive nail. This unusual procedure was performed upon ascertaining an anatomical reconstruction of the humeral head fragments and mechanical efficiency of the intramedullary nail fixation.Stabilization was performed with absorbable sutures through an extended surgical approach that allowed anchoring the unstable fragments of the greater tubercle to the shaft. The resulting anatomical positioning was additionally reinforced with screws locking the nail in its proximal end. After the procedure, a Dessault orthosis was used for 3 weeks, with intensive rehabilitation afterwards. A final assessment was made one year after the injury. It was based on the patients subjective feelings, the quality of bone union and fragment repositioning, estimated range of motion and limb function with Constant-Murley and QuickDash scores.An excellent treatment result was obtained. The anatomical position and shoulder function was fully restored. The patient reported no pain and no limb dysfunction.Based on these results we concluded that an open reduction and suturing of the unstable bone fragments of the greater tubercle with absorbable sutures allows anatomical repositioning and sufficient stabilization after intramedullary nailing. It may serve as an alternative to the conversion from intramedullary nailing to plate fixation in cases similar to ours.

Stabilization of Comminuted Fractures of the Proximal Humerus with Intramedullary Nails and Angularly Stable Locking Plates-Functional Results before and during the SARS-COVID-19 Pandemics.

Background and Objectives: Intramedullary nailing (IMN) and angularly stable plating (ASP) are the most popular techniques for the stabilization of comminuted fractures of the proximal humerus, without either one being obviously superior. The aim of the study was to validate the functional outcomes of both stabilization techniques in the COVID-19 pandemic by comparing them with data obtained just before the pandemic, because the limitations of the COVID-19 pandemic are affecting several aspects of social and medical life-being afraid of the transmission of the infection, patients reduce their exposure to healthcare to absolutely essential emergencies. Moreover, working conditions in the operating theater have also become more restrictive. Materials and Methods: Investigations were performed on 112 adult patients with Neer's three- and four-fragment fractures stabilized with IMN (64) and ASP (48). Treatment effects were validated six months after surgery based on radiographs for evidence of bone union, humeral neck-shaft angle (NSA) and implant placement. Limb function was assessed with the QuickDash and Constant-Murley scores. Data obtained from patients treated in the COVID-19 pandemic were compared with those obtained before the pandemic. Results: The healing of all fractures was satisfactory, but complications developed in six cases. Three patients required secondary interventions due to inadequate repositioning: one after IMN and two after ASP. Additionally, one ASP was complicated by the secondary destabilization of a primarily properly stabilized major tubercle, and in two cases by conflict of the protruding implant with the acromion. ASP was noted to provide better functional results during the COVID-19 pandemic according to the Constant-Murley score (p = 0.0048; Student's t-test). No significant differences were observed in the pre-COVID-19 pandemic. Conclusions: Our results suggest that ASP is more beneficial for the stabilization of comminuted fractures of the proximal humerus during the COVID-19 pandemic.

Identification of human-dependent routes of pathogen's transmission in a tertiary care hospital.

OBJECTIVES: The purpose of the study was to validate the risk of patients' exposure to pathogenic flora carried on hands of students, visitors, and patients themselves, analyzing its density and genera and to compare them with the microflora of healthcare workers (HCWs). PATIENTS AND METHODS: Between May and June 2018, five groups of participants were included. Each group consisted of eight individuals. Palmar skin imprints were obtained from dominant hands of doctors, nurses, students, visitors, and patients in orthopedics ward. Imprints were incubated at 37°C under aerobic conditions, and colony-forming units (CFU) on each plate were counted after 24, 48, and 72 h. Microorganisms were identified. RESULTS: Hands of doctors were colonized more often by Gram - positive non-spore-forming rods bacteria than hands of nurses (p<0.05). A higher number of Staphylococcus epidermidis CFUs was observed on doctors' than on nurses' hands (p<0.05), whereas Staphylococcus hominis was isolated from doctor's and patients' imprints, but was not from nurses' and students' imprints (p<0.05). Micrococcus luteus colonized patients' hands more often than students' (p<0.05), visitors' hands than doctors' (p<0.05), students' than nurses' (p<0.05), visitors' than nurses' (p<0.05) and patients' hands (p<0.05). Staphylococcus aureus (S. aureus) was isolated only from one doctor and one nurse (203 and 10 CFUs/25 cm2 ). Imprints taken from the hands of patients, students and visitors were S. aureus-free. No methicillin-resistant S. aureus (MRSA), vancomycin-resistant enterococci, nor expanded spectrum betalactamase-positive or carbapenemase-positive rods were isolated. The number of Gram-negative rods was the highest on visitors' hands, significantly differing from the number on patient's, doctor's, nurse's, and student's hands. Spore-forming rods from genus of Bacillus were isolated from representatives of all tested groups. Bacillus cereus occurred more commonly on visitors' hands than doctors' hands (p<0.05). CONCLUSION: Patients, students, and visitors may play the causal role in the spread of pathogenic bacteria, particularly spore-forming rods. Our study results confirm the effectiveness of educational activities, that is the hospital's hand hygiene program among HCWs, patients, and visitors. Hand hygiene procedures should be reviewed to put much more effort into reducing the impact of all studied groups on the transmission of infectious diseases.

Deformation of the Titanium Plate Stabilizing the Lateral Ankle Fracture Due to Its Overloading in Case of the Young, Obese Patient: Case Report Including the Biomechanical Analysis.

The number of overweight and obese patients in developed countries is gradually increasing. It was reported that 1287 (64%) out of 2007 adults operated on in 2017 had a body mass index (BMI) greater than 25 kg/m2, and 26.4% even greater than 30, while the BMI of the most obese patient was as high as 57.6 kg/m2. Such distressing statistics raised an issue related to the inadequate durability of implants used for the fixation of bone fractures. Implants for the lower-extremity fractures may not be durable enough to fit the requirements of overweight and obese patients. This case report presents the history of a 23-year-old obese male with a BMI of 38.7, who bent the angularly stabile titanium plate stabilizing his broken lateral ankle and torn distal tibiofibular syndesmosis. Biomechanical analysis showed that the maximal static bending moment registered during one-leg standing was equal to 1.55 Nm. This value was circa one-third of the maximally admissible bending moment for this particular plate (5.34 Nm) that could be transmitted without its plastic deformation. Since dynamic forces exceed static ones several (3-12) times during typical activities, such as walking, climbing the stairs, running, and jumping, unpredictable forces may occur and increase the risk of loosening, bending, and even breaking implants. None of these situations should have occurred for the typical patient's body mass of 75 kg, or even for the analyzed mass of the young patient (120 kg) who tried to avoid excessive loading during his daily routine. Subsequent implant bending and destabilization of the fracture shows that for the significantly high and still growing number of obese patients, a very strict physical regime should be recommended to prevent overabundant dynamic loads. On the other hand, the geometry of implants dedicated to these patients should be reconsidered.

Narrative Review of the Mechanism of Hip Prosthesis Dislocation and Methods to Reduce the Risk of Dislocation.

Total hip arthroplasty (THA) is one of the most effective surgical procedures. It improves quality of life, increases range of motion, and reduces pain in patients with hip joint degeneration. THA allows patients to return to everyday social and professional activities. Therefore, today it is the best approach to treatment of several chronic conditions affecting the hip joint, including advanced degenerative diseases, avascular necrosis, and some traumatic events. The aim of this study was to present the mechanism of hip prosthesis dislocation, associated risk factors, and the factors reducing the risk of dislocation, as well as its consequences and methods of risk minimization. Hip dislocation is a common complication following THA. It is responsible for up to 2% to 3% failures of primary replacements, increasing even to 10% in extreme cases of patients highly predisposed to this condition. In most cases, technical errors during implant placement are responsible for the incidence. The measures taken to prevent complications include activities aimed at correct implant insertion and the selection of the most appropriate type of implant for the patient, depending on individual needs. We summarized the current knowledge of implant dislocation to help surgeons understand the changes in biomechanics of the hip after its replacement and the impact of each particular element that participates in it. This knowledge can enable a surgeon choose the most favorable surgical method and the most appropriate implant to reduce the risk of implant dislocation.

A Review on Biomaterials for Orthopaedic Surgery and Traumatology: From Past to Present.

The principal features essential for the success of an orthopaedic implant are its shape, dimensional accuracy, and adequate mechanical properties. Unlike other manufactured products, chemical stability and toxicity are of increased importance due to the need for biocompatibility over an implants life which could span several years. Thus, the combination of mechanical and biological properties determines the clinical usefulness of biomaterials in orthopaedic and musculoskeletal trauma surgery. Materials commonly used for these applications include stainless steel, cobalt-chromium and titanium alloys, ceramics, polyethylene, and poly(methyl methacrylate) (PMMA) bone cement. This study reviews the properties of commonly used materials and the advantages and disadvantages of each, with special emphasis on the sensitivity, toxicity, irritancy, and possible mutagenic and teratogenic capabilities. In addition, the production and final finishing processes of implants are discussed. Finally, potential directions for future implant development are discussed, with an emphasis on developing advanced personalised implants, according to a patient's stature and physical requirements.

Evolution of the Hyaluronic Acid in Viscosupplementation - from Linear Particles to Hybrid Complexes.

The discovery of unique properties of the hyaluronic acid and learning about the role of this aid in pathophysiology of extracellular matrices resulted in using this substance in pharmacological support in cases of tissue dysfunction due to numerous disease units. Therefore, the products containing this substance are now widely used in medicine including dermatology and aesthetic medicine, ophthalmology, facial-mandibular surgery and orthopedics, being among the most effective products used in the treatment of numerous cases of function impairment and deformation of tissues and organs. There are applied in both post-traumatic and post-inflammatory conditions as well as in symptoms due to chronic conditions. Their therapeutic effects result from joint surface moisturizing, reduction of the coefficient of friction (COF) and good bio-tolerance and biocompatibility confirmed by a low percentage of side effects and biocompatibility. The introduction of hyaluronic acid hybrid complexes with high and low molecular mass (H/L-HA) has increased the clinical usefulness of hyaluronic acid products thanks to their increased viscoelasticity, increased anti-inflammatory and chondroprotective properties and thermodynamic stabilization of the product guaranteeing its half-life. Thanks to the above mentioned pro-perties it becomes more effective in the non-surgical treatment of osteoarthritis.

Microstructural Analysis of Fractured Orthopedic Implants.

In this paper, fracture behavior of four types of implants with different geometries (pure titanium locking plate, pure titanium femoral implant, Ti-6Al-4V titanium alloy pelvic implant, X2CrNiMo18 14-3 steel femoral implant) was studied in detail. Each implant fractured in the human body. The scanning electron microscopy (SEM) was used to determine the potential cause of implants fracture. It was found that the implants fracture mainly occurred in consequence of mechanical overloads resulting from repetitive, prohibited excessive limb loads or singular, un-intendent, secondary injures. Among many possible loading types, the implants were subjected to an excessive fatigue loads with additional interactions caused by screws that were mounted in their threaded holes. The results of this work enable to conclude that the design of orthopedic implants is not fully sufficient to transduce mechanical loads acting over them due to an increasing weight of treated patients and much higher their physical activity.

Comminuted fractures of the proximal humerus - principles of the diagnosis, treatment and rehabilitation.

Comminuted fractures of the proximal humerus impair shoulder function, resulting in more or less severe disability. They rank among the most frequent fractures in adults, with incidence increasing with age and the degree of bone loss (osteoporosis). Among all currently used methods of stabilization of proximal humeral fractures, the best outcomes are afforded by angularly-stable plate fixation and interlocking or reconstructive intramedullary nailing. Both methods produce comparable results enabling bone union and restoration of limb functionality. Nevertheless, in elderly patients with advanced bone loss, in whom anatomical reduction of bone fragments is difficult or impossible, stabilization questionable and patient cooperation in the postoperative rehabilitation impossible to enforce, arthroplasty should be considered. Non-displaced or minimally displaced fractures may be treated conservatively by immobilizing the limb in an orthosis for three weeks. Nevertheless, the recommendations for operative interventions are being broadened, as stabilization eliminates the need to immobilize the limb, thus not affecting the patient's professional and social activities, enabling immediate rehabilitation, reducing the risk of joint stiffness and shortening recovery time.

Advances in Imaging of Hip Osteoarthritis.

Osteoarthritis is the most common musculoskeletal disease worldwide, generating enormous social and medical costs. In recent years, research shedding new light on the etiology and pathogenesis of osteoarthritis has been closely related to innovations in diagnostic imaging. Precise visualization of all joint structures affected by osteoarthritis is critical for early detection and assessment of the prognosis and response to treatment. The purpose of this paper is to present recent advances in the imaging of hip osteoarthritis.

Intentional Overscrewing of Humeral Head in Comminuted Fracture of Proximal Humerus and its Impact on Shoulder Function . A Case Study.

An 86-year-old female was operated on due to a comminuted fracture of the right proximal humerus whose configu-ration necessitated over-screwing of the humeral head to improve stability, with the screws directed divergently: anteriorly and poste-riorly, to minimize their conflict with the acetabulum. 3.5 years later she sustained a corresponding fracture of the left shoulder which was stabilized without over-screwing. On both occasions, the fractures were stabilized with titanium interlocking plates (ChM, Poland) and the limbs were immobilized in a shoulder brace for three weeks followed by in-tensive rehabilitation. The patient attended a follow-up visit at 12 months (i.e. 52 months post the right shoulder fracture) which included an assess-ment of radiographs, pain and limb function as well as tests of the range of movement of the shoulder and girdle. Assessments were repeated at 12 and 18 months afterwards. Patient denied limb pain and dysfunction. Abduction was reduced by 20°, which was compensated for by the scapulothoracic joint. Shoulder (girdle) abduction reached 50° (150°) for the right and 70° (170°) for the left extremity. Flexion was reduced by 20°, but extension and rotations were comparable. At 12 months post fracture, no improvement of limb mobility was noted despite continued intensive physiotherapy. X-rays showed satisfactory bone union. The patient scored 87 for the right and 89 for the left shoulder according to the Con-stant score and 6.8 points for each limb according to the QuickDash score. Overscrewing of the humeral head is not the most beneficial method for improving stability of comminuted proximal humeral fractures; however, it may be used when alternative and more suitable methods are unavailable. Moreover, directing screws divergently anteriorly and posteriorly to minimize their conflict with the scapular acetabulum does not interfere with joint function outcomes.

Failures of Operative Treatment of Comminuted Fractures of Proximal Humerusin in Own Material.

BACKGROUND: Fractures of the proximal humerus make up 4 to 10% of all fractures. Their incidence increaseswith age, usually affecting individuals over 40 years old, reflecting the mineral status of the bone, Material and methods. Out of a group of 131 patients operated on due to comminuted proximal humeral fractures, 25 cases presenting inappropriate postoperative results were selected for further analysis. RESULTS: Failures were found in 16 cases, but affected the final outcome in seven cases only (lack of anatomical repositioning of bone fragments, including one that was stabilized at the fifth postfracture week, in whom a severe contracture of the supraspinatus muscle dislocated the major tubercle, or conflict of the implant with the acromion), and were negligible in the other nine. In two, properly stabilized major tubercles were dislocated due to their bearing the body weight immediately after the procedure. Another two developed necrosis of the humeral head, and in one the fracture was revealed to be pathological, requiring further oncological treatment. In four cases, ostensible false stabilizations were recorded as a consequence of inappropriate patient positioning for x-rays. CONCLUSIONS: 1. Our observations indicate that anatomical repositioning of bone fragments, especially those containing articular surface and muscle attachments, and their firm stabilization as well as proper implant positioning are crucial for the final result. 2. In some cases objective and unpredictable factors influencing the type and time of intervention affect the final results. 3. In those cases the decision to operate seems to be controversial. 4. The possibility of a pathological fracture should also be remembered, as such fractures require an appropriate oncological treatment.

Intentional "Over-Screwing" of Humeral Head to Improve Stability of Comminuted Fractures.

A high rate of humeral head "overscrewing" du-ring stabilization of comminuted fractures of the pro-ximal humerus, reaching 14-19% and, according to some reports, even more than 20% of all stabiliza-tions, as reported by various surgeons around the world, suggests that this complication does not simply reflect the lack of surgical skills or in-attention during the procedure.

Regulation of Bone Homeostasis by Osteocytes.

New data concerning the function of osteocytes as the central regulators of bone homeostasis are briefly outlined. It is established that osteocytes are the main target cells for parathormone. They are a rich source of sclerostin, the main inhibitor of osteoblast activity, and of the RANKL cytokine, the most important regulator of osteoclastogenesis. Under shear stress causing microinjury, osteocytes enter programmed cell death (apoptosis) and osteocyte apoptosis is a signal for nearby healthy osteocytes to activate osteoclasts to resorb bone.

Fracture Healing and its Disturbances. A Literature Review.

The healing of a bone fracture is a biological process depending on the activation of mesenchymal progenitors, their accumulation in the fracture gap, proliferation and differentiation into the osteoblastic cell lineage. Its aim is to form a callus in the fracture gap which is later remodelled into mature bone, restoring the mechanical properties lost in consequence of the fracture. Disturbances in fracture repair occur relatively often, causing therapeutic problems and increasing costs of treatment. They are caused by the lack of or damage to progenitor cells, disturbances in molecular regulation of their activation, homing, proliferation and differentiation into the osteoblastic cell lineage, or lack of appropriate environment for their optimal metabolism for fracture repair. This paper discusses the roles of individual factors crucial for the reparative process as well as the mechanisms responsible for their disturbances.

Outcomes of treatment of periprosthetic femoral fractures after total hip replacement - experience of department of orthopedics and traumatology, medical university of Warsaw.

BACKGROUND: As more and more hip replacement procedures are being performed, the incidence of periprosthetic femoral fractures is also growing. The aim of the study was to assess the outcomes of periprosthetic fracture treatment with the use of the functional Harris Hip Score (HHS). It compares the outcomes of periprosthetic fracture treatment and prefracture treatment results obtained during follow-up outpatient consultations. MATERIAL AND METHODS: The study involved 65 patients divided into the following four groups, depending on the type of the primary procedure: patients with periprosthetic femoral fractures after hip hemiarthroplasty; patients after cemented total hip replacement; patients after cementless arthroplasty; and patients after revision hip arthroplasty. The types of fractures were classified according to the Vancouver scale. RESULTS: The HHS questionnaires showed a deterioration of treatment outcomes in all patients from the four groups as compared with the outcomes obtained prior to the fracture. The most pronounced decrease in functional outcomes was observed in the group of patients after hemiarthroplasty and revision hip replacement. CONCLUSIONS: 1. The outcomes of periprosthetic fracture treatment, assessed with the HHS, are worse than the results obtained prior to the fracture. 2. Good results of periprosthetic fracture treatment were obtained only in patients with Vancouver Type B1 fractures. 3. The presence of co-morbidities in elderly patients contributes to a poorer final result of periprosthetic fracture treatment.

Current guidelines for management of severe hand injuries.

BACKGROUND: Severe, multitissue hand injuries constitute a serious problem of the modern world. Despite investing significant funds in their management these injuries often exclude young people from professional life. It is often due to improper management conducted by untrained personnel lacking appropriate instruments. The goal of this work is to review the literature on the problem and attempt to organize this information. MATERIAL/METHODS: A review of available literature on mutilating hand trauma, amputations in the hand region, replantation and scales used for assessment of the severity of injury and hand function, both in Poland and internationally. RESULTS: Hand injuries may be managed through three approaches: concomitant definitive, delayed and secondary. The best results are achieved through the first approach. However sometimes, due to the character of injury or lack of trained personnel, the team is forced to apply temporary dressing and, subsequently, initiate complex further management. HISS scale is a useful tool allowing for precise determination of the severity of injury and, used together with DASH questionnaire, prediction of long-term treatment outcome. CONCLUSIONS: Necessary changes need to be implemented in the healthcare system in order to achieve better results of treatment of severe hand injuries. Proper guidelines for everyday practice should be also introduced. Changes should encompass precise determination of competences of individual centers as well as the mode and indications for patient transport between them. Training of doctors should be modified in such way to ensure that at least one person in each center would be capable of performing proper immediate management of such injuries, making further treatment possible. At the same time, financing, as a strong motivator, should promote appropriate management.

Long-term preservation of Bone Morphogenetic Activity in stored demineralized murine incisors.

Demineralized bone or dentine implanted intramuscularly induce endochondral bone formation. This phenomenon, termed "bone induction" is triggered by non-collagenous signal molecules, named "Bone Morphogenetic Proteins" (BMPs), released from bone or dentine. Demineralization of bone/dentine prior their implantation facilitates the release of BMPs from the extracellular matrix allowing to reach a BMP threshold level needed to initiate the process of differentiation of mesenchymal cells towards an osteogenic/chondrogenic lineage. Unprocessed, mineralized tissues usually fail to induce cartilage/bone. Isolated BMPs are commercially available, and in clinical practice are an alternative for demineralized tissues, however, in many cases demineralized bone has advantages over soluble BMPs, as it combines both bone inducing principles and mechanical properties, a feature important for bridging bone fracture and filling bone defects. Demineralized bones are an inexpensive source of bone forming agents for bone-fracture healing or filling bone defects. In this report we demonstrated that storage of lyophilized demineralized murine incisors for 30 months does not deteriorate its osteoinductive potency and colonizing induced bone by bone marrow. Lyophylized incisors, stored for 0-30 months at refrigator were implanted intramuscularly and recovered, together with surrounding tissues at various time intervals ranging 10-450 days. Bone closely associated with implant was observed in about 87% of cases, regardless the storage duration. It is concluded that storage of demineralized and lyophilized incisor matrices for at least 30 months does not change their osteoinductive potency.

Minimally invasive osteosynthesis of ankle fractures.

BACKGROUND: In this publication, we present a technique for internal ankle fracture fixation through minimally invasive surgical access. MATERIAL/METHOD: Observations were carried out in a group of 17 patients (9 men and 8 women) treated due to closed injuries. Fractures were reduced under fluoroscopic guidance and stabilized percutaneously with 2 or 3 Kirschner wires (lateral malleole), 1-2 malleolar screws (medial malleole) and cortical screws (syndesmosis). If displaced or involving articular surfaces, posterior tibia was reduced and stabilized with cortical screws. RESULTS: We compared the results from our group with those obtained in a group of 17 patients (13 men and 4 women) operated on using traditional technique. In all cases, satisfactory stabilizations with forthcoming healing process were achieved, but in 2 cases widening of approach to medial malleole was required to remove interposing soft tissues. The operation time of procedures performed via minimal approach was shorter (50.1±23.4 min vs. 77.8±12.0 min; p=0.002), as well as duration of hospital stay (7.8±3.6 days vs. 10.5±5.5 days, NS), but required longer exposition to fluoroscopy (271.2±137.8 vs. 96.1±103.7 sec.; p=0.0002). CONCLUSIONS: Minimally invasive technique is an alternative to traditional method. It allows for proper stabilization with minimal soft tissue traumatization, and thus could be recommended for patients with coexisting massive injuries affecting soft tissues and for those who, do not agree to open reductions for cosmetic reasons. It allows for reduction of operation time and hospital stay. Nevertheless, it involves higher exposition to fluoroscopy and, in some cases, widening of surgical approach.