Increased stability of short femoral stem through customized distribution of coefficient of friction in porous coating.

Stress shielding and aseptic loosening are complications of short stem total hip arthroplasty, which may lead to hardware failure. Stems with increased porosity toward the distal end were discovered to be effective in reducing stress shielding, however, there is a lack of research on optimized porous distribution in stem's coating. This study aimed to optimize the distribution of the coefficient of friction of a metaphyseal femoral stem, aiming for reducing stress shielding in the proximal area. A finite element analysis model of an implanted, titanium alloy short-tapered wedge stem featuring a porous coating made of titanium was designed to simulate a static structural analysis of the femoral stem's behavior under axial loading in Analysis System Mechanical Software. For computational feasibility, 500 combinations of coefficients of friction were randomly sampled. Increased strains in proximal femur were found in 8.4% of the models, which had decreased coefficients of friction in middle medial areas of porous coating and increased in lateral proximal and lateral and medial distal areas. This study reported the importance of the interface between bone and middle medial and distal lateral areas of the porous coating in influencing the biomechanical behavior of the proximal femur, and potentially reducing stress shielding.

Intrapelvic Cup Migration Following Revision Total Hip Arthroplasty: A Case Report and Review of the Literature.

Intrapelvic acetabular cup migration is a rare but serious complication that can occur following either primary or revision total hip arthroplasty. Medial acetabular wall weakening is considered the main predisposing factor for acetabular protrusion. A thorough preoperative plan is essential to advocate proper pelvic anatomy reconstruction, including osteosynthesis of the pelvis, if necessary, preservation of muscle and bone stock, and selection of the right prosthetic components without damaging adjacent anatomical structures. We present a rare case of an 84-year-old woman with a hip dislocation and complete intrapelvic migration of the acetabular component, nine years after her second revision surgery of a hip prosthesis placed 60 years ago due to congenital hip dysplasia. The protruded acetabulum was not removed since preoperative CT and digital subtraction angiography (DSA) revealed no vascular compromise. A non-cemented, tantalum acetabular cup, reinforced by a short flange titanium acetabular cage, was placed with a cemented, polyethylene-bearing surface, which was revised to a cemented, constrained acetabular insert three months postoperatively due to dislocation after mobilization on the bed. We conducted a literature review to elucidate the causes, proper diagnostic tools, and preoperative planning of this rare occurrence while trying to evaluate a potential treatment protocol.

Fracture of femoral neck in modular total hip arthroplasty: a systematic review of the literature.

BACKGROUND: Modular femoral stems have the advantage of anatomic hip reconstruction by restoring the femoral offset thus minimising the bearing surface wear, implant loosening and dislocation. AIM: This study aims to investigate the existing literature on modular neck fractures, to identify predisposing factors and guide the decision-making process in the management of these difficult cases. METHODS: A systematic literature review was conducted until July 2022. PRISMA guidelines were followed, eligibility criteria were set, and methodology assessment of included studies was conducted based on MINORS criteria, size and primary outcome. Data were extracted and analysed thoroughly. RESULTS: 5657 studies were initially screened; the full texts of 124 records were assessed and finally, 32 reports were included. There were 7 clinical studies and 25 case reports. A total of 4825 patients (5204 hips) with a mean age 62.38 years and a mean BMI 29.06 kg/m2 were analysed in the 7 clinical studies. The reported overall weighted revision rate was 0.86%, while the weighted mean modular neck fracture rate was 0.26%. The usual history was sudden experience of hip pain and instability. The average time interval to neck fracture was 4.57 (range 3-4.7) years and a long modular neck was identified in 91.17% of them. Data from case reports showed a mean age and average BMI of 55.85 and 31.63 kg/m2. 82.35% of the patients were male. Necks were fractured after an average time interval of 64.5 ± 8.8 months. CONCLUSIONS: The incidence of modular neck fracture is significant. The profile of a male, obese patient with a long modular neck increased risk of neck fracture. Microstructural investigation of the retrieved implants demonstrated a higher incidence of fracture line in the base of the neck junction and at its anterolateral distal part. Surgeons should be aware of this complication while using or revising such protheses.

Clinical and Radiological Outcomes of Closed-Loop, Double Button, Coracoclavicular Fixation for Extralateral (Neer Type IIC) Fractures of the Distal Clavicle.

BACKGROUND: The distal end of the clavicle accounts for 10-28% of all clavicle fractures of which 52.8% are considered displaced and require internal fixation due to their high percentage of non-union. Numerous surgical techniques have been described for the well-known Neer types IIA, IIB, and V. Still, the literature is scarce for the rare "extralateral" (type IIC) fracture where the fracture line is located lateral to the completely torn coracoclavicular (CC) ligaments; such small fractures are sometimes not amenable for standard locking plate fixation. METHODS: We present a series of seven patients treated surgically with closed-looped double button CC stabilization via an open approach. There were four males and three females with a mean age of 31 years (range: 19-46 years). The mechanism of injury was a motor vehicle accident in four cases and a fall from height in three cases. The average time from injury to surgery was 2.7 ± 1.3 days and the average follow-up period was 25.7 months (range: 16-48 months). A custom-made, closed-looped, double button device was made using the ProCinch Adjustable Cortical Fixation for anterior cruciate ligament (ACL) (Stryker, Kalamazoo, Michigan) and another standard or slotted button. The fracture was reduced anatomically and the device was tightened and secured with five to six knots. In two cases, additional interfragmentary sutures were used for extra stability. Postoperatively, the arm was immobilized in a simple sling for four weeks; passive assisted elevation up to 90 degrees was allowed from the second postoperative week, followed by active elevation after the sixth postoperative week. Radiological outcomes (bony union, loss of reduction, implant mispositioning, or subsidence of buttons) were assessed using serial plain radiographs. The Constant score (CS) and the Acromioclavicular Joint Instability Score (AJIS) were used for the final clinical evaluation, at least one year postoperatively. RESULTS: Bony union was achieved in all patients at a mean time of 2.7 months (range: 2.5-3.6 months). No cases of delayed union, loss of reduction, button migration, or subsidence were noted. The mean CS was 96.6 ± 3.4 and the mean AJIS score was 94.1 ± 4.7 in a mean follow-up period of 25.7 months (range: 16-48 months). One patient developed a hypertrophic scar and another had mild skin irritation by the suture knots; no other complications were noted except for one patient who developed an early superficial skin infection managed with antibiotics and debridement under local anesthesia. Four patients who participated in sports before injury were able to regain almost full activity seven to nine months after the operation. All were satisfied with the final result. Two patients showed ossification of the CC ligaments with no significant clinical implications. CONCLUSIONS: Although we retrospectively reviewed a small series of patients, we were able to demonstrate a complete rate of fracture union and excellent clinical outcomes with no major complications. Type IIC distal clavicle fractures are rare and require special attention in terms of reduction and optimal fixation. Open CC fixation with closed-looped double buttons is a relatively easy and reproducible technique. We advocate the readjustment of Neer's classification, including "extralateral" fractures as a IIC subtype.

What is the optimal surgical treatment for Neer type IIB (IIC) distal clavicle fractures? A systematic review and meta-analysis.

BACKGROUND: The purpose of the present study was to systematically review the current treatment strategies for the treatment of Neer type IIB distal clavicle fractures in terms of functional outcome and complication rates and to examine the most appropriate surgical method by comparing all the available surgical techniques and implants. METHODS: We performed a systematic review of the existing literature (2000-2021) in accordance with the PRISMA statement. We searched PubMed, Scopus, Web of Science, Research Gate and Google Scholar using the general terms 'distal AND clavicle AND fracture' to capture as many reports as possible. The MINORS tool was used to assess the risk of bias of the nonrandomized studies. We categorized the reported surgical techniques into four main types: open or arthroscopic coracoclavicular (CC) stabilization, locking plate fixation with or without CC augmentation, hook plate fixation and acromioclavicular joint (ACJ) transfixation. We reported findings for two main outcomes: clinical results and complication rates categorized into major and minor. RESULTS: Our database search yielded a total of 630 records; 34 studies were appropriate for qualitative analysis. There were 790 patients, with a mean age of 40.1 years, a female percentage of 37% and a mean follow-up period of 29.3 months. In total, 132 patients received a hook plate, 252 received a locking plate, 368 received CC stabilization and 41 received transacromial transfixation. All studies were retrospective and had fair MINORS scores. Locking plate, CC stabilization and ACJ transfixation showed similar clinical results but were much better than hook plate fixation; CC augmentation did not significantly improve the outcome of locking plate fixation. The rate of major complications was similar among groups; hook plate and AC joint transfixation had the worst rates of minor complications. Open CC techniques were slightly better than arthroscopic techniques. CONCLUSIONS: The present systematic review for the optimal fixation method for Neer type IIB fractures of the distal clavicle showed similar major complication rates among techniques; the hook plate technique demonstrated inferior clinical results to other techniques. Open CC stabilization and locking plate fixation without CC augmentation seem to be the best available treatment options.

Early, Bilateral Re-Rupture of Quadriceps Tendon After Previous Bone-Anchor Repair for Simultaneous, Low-Energy, Bilateral Quadriceps Rupture: A Case Report and Literature Review.

BACKGROUND Bilateral simultaneous quadriceps tendon rupture is a relatively rare injury, more commonly seen in patients older than 50 years and is usually associated with underlying metabolic or inflammatory diseases. CASE REPORT We report the case of an otherwise healthy, 42-year-old man who sustained a bilateral, quadriceps tendon rupture while he was trying to pound a branch of an olive tree into the ground. On clinical examination, a defect in both proximal patella poles was found on palpation, with complete discontinuity of the extensor apparatus. A meticulous surgical repair was performed using 3 bone anchors with an uneventful postoperative rehabilitation. A biopsy specimen taken at surgery showed evidence of chronic inflammation. He had a second episode while walking fast on the beach 3.5 months postoperatively, and presented again with bilateral quadriceps rupture. He was successfully managed with bilateral allograft reconstructions, showing a very good outcome at 18 months of follow-up. Our systematic literature review covering a 20-year period (2000-2020) revealed 10 articles on bilateral quadriceps ruptures in 14 healthy patients without comorbidities. All these injuries occurred in males, with a mean age of 56.8 years, during walking, descending stairs, or participating in recreational sports; the functional outcome was good to excellent in most cases, without any reported re-ruptures. To the best of our knowledge, no similar case has been reported in the literature. CONCLUSIONS Bilateral quadriceps tendons rupture is a rare injury, especially in young patients without associated comorbidities. The risk of recurrence is low, but when it occurs, more complex techniques of reconstruction are needed.

A Case of Bilateral Galeazzi Fracture-Dislocations.

Bilateral Galeazzi fracture-dislocations are extremely rare injuries and only a few case reports have been described so far in the literature. Herein, we report the case of a 31-year-old bicyclist who sustained bilateral Galeazzi fracture-dislocations after a collision with a car. Both radial shaft fractures were simple (AO type 22-A2.3), at the same level (Type I: <7.5 cm from the joint line), and without severe comminution having their apex located dorsally. Internal fixation was accomplished in both fractures with an 8-hole, 3.5-mm locking plate; the stability of the distal radioulnar joint (DRUJ) was assessed with several intraoperative tests and found to be stable so that no additional stabilization was necessary. Postoperatively, the forearms were immobilized in a long forearm cast for four weeks. At the last follow-up evaluation, six years postoperatively, the patient was pain-free, had a full range of motion with a total Mayo wrist score of 95 in both wrists. Bilateral Galeazzi fracture-dislocations are rare injuries requiring proper radial fracture management and thorough assessment of DRUJ stability.

A Unique Technique for Precise Targeting in Treatment of Rare Bifocal Intraosseous Ganglion Cysts of the Talus: A Case Report and Review of the Literature.

BACKGROUND This article presents a rare case of 2 separate intraosseous ganglion cysts of the talus in a 51-year-old man, treated with a unique technique of precise lesion targeting to avoid extensive bone loss and minimize articular chondral injury of the talus. CASE REPORT Two separate intraosseous ganglion cysts of the talus were diagnosed in a 51-year-old man with chronic ankle pain. A single straight-line incision with an entry point through the talonavicular joint was created to spare the precarious blood supply of the talus network. The 2 distinct subchondral lesions were approached under fluoroscopic control for curettage and autologous bone grafting using the anterior cruciate ligament tibial guide in a pair-of-compasses fashion. In almost 5 years of follow-up the patient has been asymptomatic. Magnetic resonance imaging has revealed no signs of degenerative changes in the ankle or the talonavicular joint, and the intraosseous edema has almost disappeared. CONCLUSIONS To the best of our knowledge, this case is the first report of 2 distinct intraosseous ganglion cysts of the talus. We recommend the precise targeting technique used in our case for treating intraosseous talar lesions with intact articular cartilage.

Transosseous Suture Fixation of True 4-part Valgus Impacted Fractures of the Proximal Humerus: Clinical and Radiological Outcome in 49 Patients.

BACKGROUND: The valgus-impacted (VI) 4-part fractures are a subset of fractures of the proximal humerus with a unique anatomic configuration characterized by a relatively lower incidence of avascular necrosis after operative intervention. OBJECTIVES: The present study reports the midterm clinical and radiological results of a large series of consecutive patients with 4-part VI fractures treated with a minimal invasive technique of internal fixation. METHODS: Over a ten-year period (2004-2014), we treated 56 patients with a true 4-part valgus impacted fracture of the proximal part of the humerus. Four patients were lost to follow-up and three died, leaving 49 patients (33 female, 16 males, average age 60,1 years) available for the study. Fracture fixation was achieved through the lateral transdeltoid approach with transosseous suturing of the tuberosities to each other, to the metaphysis and to the articular part of the humeral head avoiding gross disimpaction of the humeral head from the valgus position. Functional outcome assessment was performed using the parameters of the Constant-Murley score within a mean follow up period of 43,8 months (range, 24 to 115 months). RESULTS: All fractures were united within the first 3 months except one that showed late displacement and finally nonunion. The median Constant score was 81,7 points and the functional score in comparison with the unaffected shoulder was 86.2%. There were three patients with total Avascular Necrosis (AVN) of the head revised to hemiarthroplasty. The nonunion case was revised to reverse shoulder arthroplasty 12 months after surgery. In five cases, absorption of the greater tuberosity was noted in the last radiographic control without any serious consequences to the shoulder function. CONCLUSION: Advantages of this minimally invasive technique can be summarized as shorter operative time, no use of hardware, minimal soft tissue damage, low incidence of avascular necrosis, stable osteosynthesis with "tension band effect" and adequate rotator cuff repair allowing for early joint motion.

Irreducible Anterior Shoulder Dislocation with Interposition of the Long Head of the Biceps and Greater Tuberosity Fracture: A Case Report and Review of the Literature.

BACKGROUND: Failure of closed manipulative reduction of an acute anterior shoulder dislocation is seldom reported in the literature and is usually due to structural blocks such as soft tissue entrapment (biceps, subscapularis, labrum), bony fragments (glenoid, greater tuberosity) and severe head impaction (Hill-Sachs lesion). CASE REPORT: We present a case of an irreducible anterior shoulder dislocation in a 57-year-old male patient after a road-traffic accident. He had severe impaction of the head underneath glenoid rim and associated fracture of the greater tuberosity. Closed reduction performed in the emergency room under sedation and later at the theatre under general anaesthesia was unsuccessful. Open reduction using the dectopectoral approach revealed that the reason for obstruction was the posterolateral entrapment of the biceps tendon between the humeral head and the tuberosity fragment. Reduction was achieved after subscapularis tenotomy and opening of the joint; the tuberosity fragment was fixed with transosseous sutures and the long head of the biceps tendon was tenodesized. The patient had an uneventful postoperative recovery and at his last follow up, 12 months postoperatively, he had a stable joint, full range of motion and a Constant score of 90. CONCLUSION: A comprehensive literature review revealed 22 similar reports affecting a total of 30 patients. Interposition of the LHBT alone or in combination with greater tuberosity fracture was the most common obstacle to reduction, followed by subscapularis tendon interposition and other less common reasons. Early surgical intervention with open reduction and confrontation of associated injuries is mandatory for a successful outcome.

Translation, cultural adaptation, validity and reliability of the Greek version of the modified Constant Score.

AIM: The purpose of this study was to produce a modified Greek translation of the CS and to test this version in terms of reliability and validity. MATERIALS AND METHODS: Translation of the modified Constant score testing protocol was done according to established international guidelines. Sixty-three patients with shoulder pain caused by degenerative or inflammatory disorders completed the Greek version of CS along with the Greek versions of SF-12 and Quick Dash Scores and the ASES Rating Scale and were included into the validation process. To assess test-retest reliability, 58 individuals completed the subjective part of the test again after 24-36 hours, while abstaining from all forms of treatment; internal consistency was measured using Cronbach's alpha (α); reliability was assessed with test-retest procedure and the use of Interclass Correlation Coefficient (ICC), whereas the validity of the reference questionnaire was evaluated using Pearson's correlation coefficient in relation to control questionnaires. RESULTS: There were no major problems during the forward-backward translation of the CS into Greek. The internal consistency was high (Cronbach's alpha 0.92) while the test-retest reliability for the overall questionnaire was also high (intra-class coefficient 0.95). Construct validity was confirmed with high values of Pearson's correlation between CS and Q-DASH (0.84), SF-12 (0.80) and ASES score (0.86) in respect. CONCLUSION: A translation and cultural adaptation of CS into Greek was successfully contacted. The Greek version of the modified Constant Score can be a useful modality in the evaluation of shoulder disorders among Greek patients and doctors.

Clinical Outcomes and Complications of Cortical Button Distal Biceps Repair: A Systematic Review of the Literature.

Objectives. The purpose of the present study was to investigate the clinical outcomes and complications of the cortical button distal biceps fixation method. Material and Methods. All methods followed the PRISMA guidelines. Included studies had to describe clinical outcomes and complications after acute distal biceps repair with cortical button fixation. Eligibility criteria also included English language, more than 5 cases with minimum follow-up of 6 months, and preferably usage of at least one relevant clinical score (MEPS, ASES, and/or DASH) for final outcome. A loss of at least 30° in motion-flexion, extension, pronation, or supination-and a loss of at least 30% of strength were considered an unsatisfactory result. Results. The review identified 7 articles including 105 patients (mean age 43.6 years) with 106 acute distal biceps ruptures. Mean follow-up was 26.3 months. Functional outcome of ROM regarding flexion/extension and pronation/supination was satisfactory in 94 (89.5%) and 86 (82%) patients in respect. Averaged flexion and supination strength had been reported in 6/7 studies (97 patients) and were satisfactory in 82.4% of them. The most common complication was transient nerve palsy (14.2%). The overall reoperation rate was 4.8% (5/105 cases). Conclusion. Cortical button fixation for acute distal biceps repair is a reproducible operation with good clinical results. Most of the complications can be avoided with appropriate surgical technique.

Least Possible Fixation Techniques of 4-Part Valgus Impacted Fractures of the Proximal Humerus: A Systematic Review.

UNLABELLED: The valgus-impacted (VI) 4-part fractures are a subset of fractures of the proximal humerus with a unique anatomic configuration characterized by a relatively lower incidence of avascular necrosis after operative intervention. We systematically reviewed clinical studies assessing the benefits and harms of least possible fixation techniques (LPFT) for this unique fracture type. Such information would be potentially helpful in developing an evidence-based approach in the management of these complex injuries. We performed analytic searches of PubMed, Embase, Web of Science, Google Scholar and the Cochrane Library, restricting it to the years 1991-2014. Included studies had to describe outcomes and complications after primary osteosynthesis with any type of LPFT apart from plate-screws and intramedullary nailing. Eligibility criteria were also included English language, more than 5 cases, minimum follow up of one year and report of clinical outcome using at least one relevant score (Constant, Neer or ASES). Based on 292 database hits we identified 12 eligible studies including 190 four-part valgus impacted fractures in 188 patients. All eligible studies were case series composed of min 8 to max 45 patients per study. The gender distribution was 60% (112) female and 40% (76) male. The average age of the patients at the time of injury was 54.5 years. In 8/12 studies an open reduction was used for fracture fixation using different surgical techniques including KW, cerclage wires, cannulated screws and osteosutures. Closed reduction and percutaneous fixation was used in 4 studies. Mean follow-up time ranged from 24 to 69 months. A good functional outcome (constant score >80) was reported in 9/12 studies. The most common complication was avascular necrosis of the humeral head with an overall incidence of 11% (range, 0-26.3%). Total avascular necrosis (AVN) was found in 15/188 patients (7.9%) and was more common in percutaneous techniques and partial AVN in 6/188 (3.1%) being more common in open techniques. The overall re-operation rate was very low (3.7%). Insufficient study designs cannot provide definite treatment recommendations and quantitative data synthesis of outcome. In general, LPFT for 4-part VI fractures leads to satisfactory outcomes with low incidence of complications. A considerable risk of biases can be attributed to fracture classification, proper radiological control, mean age of patients, mixed types of fixation methods, nonage adjusted clinical scoring and small follow up periods. These factors are discussed in detail. LEVEL OF EVIDENCE: systematic review of literature (level IV) as most of the studies were level IV.

Long Term Survivorship of a Severely Notched Femoral Stem after Replacing the Fractured Ceramic head with a Cobalt-Chromium Head.

BACKGROUND: Although ceramic head fracture occurs infrequently today, in the event of a fracture, the resulting revision surgery can prove very challenging, since the ceramic particles lodge into the surrounding soft tissue and can cause rapid implant failure. CASE PRESENTATION: A case of long term survivorship of a severed notched femoral stem after replacing the fractured femoral head with a cobalt-chromium one is reported in a 40-year old woman with hip dysplasia who underwent an uncomplicated total hip arthroplasty. The incident of ceramic femoral head fracture occurred 14 months postoperatively without reporting any significant trauma. Intraoperative findings at revision were a multifragmented femoral head and a damaged polyethylene insert along with diffuse metallosis and excessive wear of the cone of the stem. Both the stem and the acetabular component were stable. After removal of ceramic fragments, metallotic tissue excision and careful lavage of the joint, the inlay was replaced by a similar one and a cobalt-chromium femoral head was placed to the existing notched taper of the firmly incorporated stem. At the 13th year follow up examination, the patient had no pain, used no walking aids, and had normal activity with no signs of wearing or loosening in the plain x-rays. CONCLUSION: Despite current recommendations of using ceramic femoral heads in cases of fracture or to revise the severely damaged stems we were able to provide a long term survivorship up to 13 years postoperatively of a cobalt-chromium femoral head applied to a severe damaged stem.

Giant Cell Tumor of the Patella Tendon Sheath Presenting as a Painful Locked Knee.

BACKGROUND: The giant cell tumor of the tendon sheath (GCT-TS) is a benign proliferative synovial tumor manifesting as an intra-articular solitary nodule. When it involves the infrapatellar fat pad it can present acutely as a painful locked knee. CASE REPORT: A 26-year-old white male presented with a 2-week history of painful locking in his right knee. Clinical examination revealed lack of extension by approximately 20°. To help establish the diagnosis, an MRI scan of the right knee was performed, showing a large (5×4×2 cm), oval, well-circumscribed mass with a low-intensity homogenous signal. The size of the mass prohibited the removal by arthroscopy and we therefore proceeded with an open arthrotomy. Histological examination showed a tendosynovial giant cell tumor of the patella tendon sheath. At the latest follow-up, 2 years postoperatively, there was no local tumor recurrence. CONCLUSIONS: These rare tumorous lesions should be included in the differential diagnosis of painful locking knee, especially in the absence of definite traumatic history.