Upper extremity vascular injuries: Etiology, management and outcome.

BACKGROUND: Vascular injuries of the upper extremities are considered relatively rare injuries affecting mostly the young population. They often are complex injuries accompanied by other musculoskeletal trauma or trauma in other anatomic locations. Their management is challenging since they can lead to disabilities with major socioeconomic effects. AIM: To analyze data about the mechanism of injury, the management algorithm and functional outcomes of vascular injuries of the upper extremity. METHODS: One hundred and fifteen patients (96 males and 19 females) with arterial injuries of the upper extremity treated in a tertiary trauma center from January 2003 to December 2022 was conducted. Mean patients' age was 33.7 years and the mean follow up time was 7.4 years. Patients with Mangled Extremity Severity Score ≥ 7 and Injury Severity Score ≥ 20, previous upper limb surgery or major trauma and any neuromuscular or psychiatric disease were excluded, from the study. RESULTS: A penetrating trauma was the most common cause of injury. The radial artery was the artery injured in most of the cases (37.4%) followed by the ulnar (29.5%), the brachial (12.1%) and the axillary (6%). A simultaneous injury of both of the forearm's arteries was in 15.6% of the cases. In 93% of the cases there were other concomitant musculoskeletal injuries of the extremity. Tendon lacerations were the most common, followed by nerve injuries. The postoperative functional scores (full Disabilities of the Arm, Shoulder, and Hand and VAS) had very satisfactory values. CONCLUSION: Although vascular injuries of the upper extremity are rare, they may occur in the context of major combined musculoskeletal trauma. Although a multidisciplinary approach is essential to optimize outcome, the ability of trained hand surgeons to repair all injuries in combined vascular and musculoskeletal upper extremity trauma, excluding isolated vascular injuries, ensures shorter operative times and better functional outcomes.

MiR-217 Regulates SIRT1 Expression and Promotes Inflammatory and Apoptotic Responses in Osteoarthritis.

Previous studies have reported miR-217 uregulation in age-related pathologies. We investigated the impact of miR-217-5p on sirtuin 1 (SIRT1) regulation in human osteoarthritic (OA) chondrocytes. MiR-217 target enrichment analyses were performed using three public databases, Gene Ontology and Kyoto Encyclopedia of Genes and Genomes. MiR-217-5p expression levels were quantified in normal and OA chondrocytes. SIRT1 expression levels, nuclear factor kappa-B p65 subunit (NF-κBp65) and p53 acetylation levels, and expression levels of OA-related pro-inflammatory markers [tumor necrosis factor α (TNFα), interleukin 1ß (IL-1ß), IL-6], pro-apoptotic markers [Bax, pro-caspase 3, cleaved caspase 3] and matrix regulators [matrix metalloproteinase (MMP)-1, MMP-13, MMP-9, Collagen 2 (COL2A1), Aggrecan (ACAN)] were evaluated in miR-217 mimic-treated and/or miR-217 inhibitor-treated OA chondrocytes, with/without subsequent treatment with siRNA against SIRT1 (siSIRT1). MiR-217-5p was upregulated in OA chondrocytes, while target prediction/enrichment analyses revealed SIRT1 as miR-217 target-gene. Deacetylation of NF-κBp65 and p53 in miR-217 inhibitor-treated OA chondrocytes was reversed by siSIRT1 treatment. MiR-217 inhibitor-treated OA chondrocytes showed increased COL2A1, ACAN and decreased IL-1ß, IL-6, TNFα, Bax, cleaved caspase 3 and MMPs expression levels, which were reversed following miR-217 inhibitor/siSIRT1 treatment. Our findings highlight the impact of miR-217-5p on SIRT1 downregulation contributing to OA pathogenesis.

Update in combined musculoskeletal and vascular injuries of the extremities.

Combined musculoskeletal and vascular injuries of the extremities are conditions in which a multidisciplinary approach is a sine qua non to ensure life initially and limb viability secondarily. Vascular injuries as part of musculoskeletal trauma are usually the result of the release of a high energy load in the wound site so that the prognosis is determined by the degree of soft-tissue damage, duration of limb ischemia, patient's medical status and presence of associated injuries. The management of these injuries is challenging and requires a specific algorithm of action, because they are usually characterized by increased morbidity, amputation rate, infection, neurological and functional deficits, and they could be life threatening. Although vascular injuries are rare and occur either isolated or in the context of major combined musculoskeletal trauma, the high index of suspicion, imaging control, and timely referral of the patient to organized trauma centers ensure the best functional outcome of the extremity in such challenging cases. Even after a successful initial treatment of a combined trauma pattern, long-term follow-up is crucial to prevent and detect early possible complications. The purpose of this manuscript is to provide an update on diagnosis and treatment of combined musculoskeletal and vascular injuries of the extremities, from an orthopedic point of view.

Medico-legal risks associated to hand and wrist trauma.

BACKGROUND: Acute hand and wrist injuries are common and may lead to long-term disability if not managed adequately. Claims for negligence have been increasing in medical practice over the past few decades, with hand and wrist injuries and their treatment representing a significant percentage of orthopedic surgery lawsuits. There is no available literature regarding medical malpractice claims in hand and wrist injuries and surgery in Greece. AIM: To identify claims related to hand and wrist trauma and surgery and to define the reasons of successful litigations. METHODS: We performed a retrospective study of all legal claims of negligence for hand and upper extremity surgery that went to a trial, attributed to all surgical specialties, in Greece for a 20-year period. Data was further analyzed to identify claims related to hand and wrist trauma and surgery. RESULTS: There were six malpractice claims related to hand and wrist trauma that ended in a trial. A missed diagnosis, which resulted in failure of initial management of the injury, was the main reason for a claim. Three of the six cases resulted in complete or partial loss of a finger. Two cases are still open, requiring an expert witness's report, two cases were closed in favor of the defendant, and two cases were closed in favor of the plaintiff with a mean compensation of €2000 (€1000-€3000). CONCLUSION: Missed diagnosis was the main reason for a malpractice claim. Better understanding of factors leading to successful claims will help surgeons improve their practice to minimize legal implications and litigation.

Current Concepts in Compressive Neuropathies of the Upper Extremity.

The carpal and cubital tunnel syndromes are the most common compression neuropathies of the upper extremity. Although the diagnosis and management of these neuropathies have evolved over the past few decades, the ideal primary surgical treatment has not yet been established and management of recurrence remains a challenge. Revision surgery with simple repeated nerve decompression even accompanied by neurolysis does not always result in satisfactory clinical outcomes. Coverage with soft tissue or wrapping of the nerve with biologic or synthetic protective barriers can be used as an ancillary technique in the revision surgery to enhance nerve healing, preventing perineural scarring and adhesions. Future randomized larger trials combined with better understanding of nerve biology may be necessary to optimize primary and revision surgical treatment for carpal and cubital tunnel syndrome.

Use of Fortified Bread for Addressing Vitamin D Deficiency.

Vitamin D deficiency due to inadequate sun exposure and/or inadequate intake from food is very common worldwide, consisting a major public health problem. As prolonged exposure to ultraviolet radiation involves risks, food fortification of staple foods emerges as a favorable solution for addressing vitamin D deficiency. Bread is a suitable candidate for fortification as it is consumed often and is the main carbohydrate source in European countries.The purpose of this study was the evaluation of the bioavailability of vitamin D from a fortified Greek-type bread that was developed as a means for addressing vitamin D deficiency, by comparing the absorption curve of vitamin D in fortified bread in relation to that of plain vitamin supplementation. Two groups of clinically healthy volunteers consumed 25,000 international units (IU) of vitamin D3 (cholecalciferol) either in fortified bread (Group A) or in a plain supplement form (Group B). The baseline plasma concentrations of cholecalciferol were 8.1 ± 6.0 ng/mL and 6.8 ± 3.4 ng/mL in Groups A and B, respectively. After 12, 24, and 48 h, the concentrations of cholecalciferol in Group A were 16.7 ± 4.8, 15.3 ± 8.3 and 11.9 ± 6.0 ng/mL, respectively, and in Group B, 15.2 ± 3.3, 11.6 ± 2.4, and 9.6 ± 3.6 ng/mL, respectively. In both groups, the concentrations of cholecalciferol at 12 and 24 h were significantly higher than the baseline concentrations (p < 0.01). There were no statistically significant differences between the concentrations of cholecalciferol between Groups A and B, at each time point.Cholecalciferol is bioavailable from Greek-type fortified bread and bread could be used for addressing vitamin D deficiency.

Anatomy Learning from Prosected Cadaveric Specimens Versus Plastic Models: A Comparative Study of Upper Limb Anatomy.

Human cadaveric prosections are a traditional, effective, and highly appreciated modality of anatomy learning. Plastic models are an alternative teaching modality, though few studies examine their effectiveness in learning of upper limb musculoskeletal anatomy. The purpose of this study is to investigate which modality is associated with a better outcome, as assessed by students' performance on examinations. Overall, 60 undergraduate medical students without previous knowledge of anatomy participated in the study. Students were assigned into two groups. Group 1 attended lectures and studied from cadaveric prosections (n = 30) and Group 2 attended lectures and used plastic models in the laboratory (n = 30). A knowledge assessment, including examination with tag questions (spot test) and written multiple-choice questions, was held after the end of the study. Students' perceptions were also investigated via an anonymous questionnaire. No significant difference in students' performance was observed between the group using prosections and the group using plastic models (32.2 ± 14.7 vs 35.0 ± 14.8, respectively; P = 0.477). Similarly, no statistically significant difference was found regarding students' satisfaction from using each learning modality (P = 0.441). Plastic models may be a valuable supplementary modality in learning upper limb musculoskeletal anatomy, despite their limitations. Easy to use and with no need for maintaining facilities, they are highly appreciated by students and can be useful when preparing for the use of cadaveric specimens.

Scaphoid nonunions in adolescents: Treatment with vascularized bone grafts.

INTRODUCTION: Scaphoid nonunions (SN) are rare in adolescents. The use of vascularized bone grafts (VBG) from the distal radius as an alternative to conventional grafting for the treatment of established SN in adolescents is described. PATIENTS AND METHODS: The technique was applied in 13 patients with symptomatic SN resulting from fractures. All patients were male with average age of 16.5 years (15-17.5). The average period from injury to surgery was 8.3 months (4-13). Patients underwent vascularized bone grafting and internal fixation with K-wires. In 6 patients with proximal pole nonunion a VBG from the dorsal distal radius was used, and in 7 with a waist nonunion a VBG from the palmar distal radius was used. The valuation was clinical (grip strength, range of motion, VAS pain score, DASH) and radiographic. The time to return to activity was also recorded. RESULTS: The mean follow-up was 9.8 years (range, 4-16). The union rate was 100% (11/11 cases). Union was achieved in a mean period of 7.2 weeks (range, 6-10), without growth disturbance or other complications from the epiphyseal plate of the distal radius. The range of motion and grip strength was 89% and 92% of the contralateral respectively. The mean postoperative DASH score was 8 and the VAS score was 1. All patients returned to daily activities and sports in a mean period of 4.5 months. CONCLUSIONS: The use of VBG from the distal radius provided a permanent solution in the rare case of SN in adolescents, without donor site morbidity or epiphyseal plate disturbance. The deformity and carpal height were corrected resulting in painless motion and grip strength.

Thumb duplication: molecular analysis of different clinical types.

PURPOSE: Molecular analysis of different types of thumb duplication and identification of new suspected gene mutations. MATERIALS AND METHODS: In a series of patients operated for polydactyly, DNA was extracted from blood samples collected preoperatively. Among these, the samples of two patients with thumb duplication (Wassel types III and IV) were initially selected for molecular analysis. The method of Clinical Exome Solution was used for the study of the phenotype-involved genes. Next-generation sequencing (NGS) was performed on a NextSeq-500 Platform (Illumina), and Sophia DDM® SaaS algorithms were used for the bioinformatics analysis of the data. RESULTS: In total, 8-including 4 new-mutations were detected in CEP290 (1 mutation), RPGRIP1 (2 mutations), TMEM216 (2 mutations), FBN1 (1 mutation), CEP164 (1 mutation), and MEGF8 (1 mutation) genes. NGS revealed 3 mutated genes in the patient with Wassel III thumb duplication and 5 mutated genes in the patient with Wassel IV duplication. The molecular analysis revealed that the patients had 2 mutated genes in common, but they only shared one common mutation. CONCLUSION: The new detected mutations are most probably associated with thumb duplication, as they belong to genes with already described mutations causing ciliopathies, often including polydactyly in their phenotype. Recognition of these mutations will be helpful to prenatal diagnosis, operative treatment strategy prediction, and possible future experimental applications in gene therapy.

MR angiogram confirms sustained blood flow in 1,2 ICSR artery of vascularized bone grafting in scaphoid nonunion treatment.

PURPOSE: To evaluate the functioning of 1,2 intercompartmental supraretinacular artery (ICSRA) in vascularized bone grafting (VBG) of scaphoid nonunions with avascular necrosis of proximal pole. MATERIALS AND METHODS: Fourteen patients with scaphoid nonunion were treated operatively with 1,2 ICSRA VBG. Viability of the pedicle artery was evaluated by MR angiography with intravenous contrast agent. RESULTS: In 13 out of 14 patients, the 1,2 ICSR artery was found to be patent and functional. Revascularization of scaphoid proximal pole was revealed in all cases, and nonunion healing was confirmed as well. CONCLUSION: 1,2 ICSRA VBG in scaphoid nonunion is an effective surgical technique. It combines the advantages of bone grafting and vascular supply via the transferred pedicle artery which seems to be functional postoperatively if a meticulous operative technique is used.

Magnetic resonance morphometry of the adult normal lumbar intervertebral space.

PURPOSE: This study aims to: (a) quantify and evaluate normal relationships between neighboring spinal units using MR imaging indices, (b) propose an easy-to-apply-and-reproduce method of estimating the correct amount of distraction when surgically restoring a collapsed intervertebral disc, based on individualized measurements. METHODS: This is a retrospective cross-sectional MR imaging study of 119 adult subjects, aged 18-54, asymptomatic for low back pain. Each of the examinees should demonstrate two or more consecutive intervertebral discs classified as Pfirrmann grade I or II to be included. We measured and studied the relationships of disc height index, Dabbs index, Farfan index, disc convexity index and mean and posterior disc height per spinal level using multiple regression analysis. All measurements were tested for intra- and interobserver agreement by two raters. RESULTS: DHI, Dabbs, Farfan, and mean disc height had a statistically significant correlation with the spinal level and age. Our results were highly reproducible, with excellent inter- and intraobserver agreement and reliability between two raters (ICC = 0.992 and 0.994, respectively). Furthermore, we expressed each intervertebral space as a percentage of its adjacent space, introducing the coefficient α factor for every intervertebral space. CONCLUSIONS: Our results suggest that a normal values' database to refer during preoperative planning of correction of a degenerated intervertebral disc is feasible. Our study offers new anatomical and radiological insight in terms of spinal measurements and their potential correlation with current surgical techniques. A new approach for calculating disc space as an expression of its adjacent disc has been introduced with various potential applications.

Anatomy learning from prosected cadaveric specimens versus three-dimensional software: A comparative study of upper limb anatomy.

INTRODUCTION: Modern, three-dimensional (3D) anatomy software is a promising teaching method, though few studies examine its effectiveness on upper limb and musculoskeletal anatomy learning. The purpose of this study is to investigate which method is associated with a better outcome, as assessed by students' performance on examinations, when comparing learning with prosections to the use of 3D software. MATERIALS AND METHODS: Two groups of undergraduate, first-year medical students without previous knowledge of anatomy were compared. Overall, 72 students attended lectures and cadaveric prosections in the laboratory (n=40), or lectures and the BioDigital Human software (n=32). Four hours of lectures and four hours of laboratory work, combining brief demonstration and independent study in small teams, were completed by each group. An anonymous examination, including tag questions from both cadaveric and 3D images, and multiple-choice questions, was held after the end of the educational process. Students' perceptions were also investigated via an anonymous questionnaire, which comprised 15 questions. Chi-square and student's t-test were used for comparisons. RESULTS: Students using the 3D software showed better performance in examinations, compared to students using prosection (mean: 55.88±19.60 vs. 48±16.11; p=0.05, Cohen's d=0.5). No statistically significant difference was found regarding students' satisfaction from using each learning method (p=0.39). CONCLUSIONS: Although prosection is the most common method of teaching anatomy, recent technologies, such as 3D software, are also considered useful teaching tools. However, further research has to be done before they can be safely used as a part of a multimodal curriculum, since results from this study are limited to the upper limb musculoskeletal anatomy.

Quality of life and psychological consequences in elderly patients after a hip fracture: a review.

Fractures due to fragility of the bone around the hip joint have become a major public health issue, presenting with an increasing incidence due to the growth of the elderly population. The purpose of this review was to evaluate the impact of hip fractures on the quality of life (QoL), health status (HS), functioning, and psychological parameters, and factors influencing the outcome and the appropriate interventions for improvement of elderly patients. A systematic electronic search of the relevant literature was carried out using the CINAHL, Cochrane, EMBASE, Medline (OvidSP), and PubMed databases spanning the time period from their establishment up to January 2017. Forty-nine randomized controlled trials or prospective cohort studies reporting the QoL and psychological outcomes were assessed by using standardized questionnaires. Patients with a hip fracture who were older than 65 years, were included in the analysis. In the majority of elderly patients, the hip fracture seriously affected physical and mental functioning and exerted a severe impact on their HS and health-related QoL (HRQoL). Moreover, most of the patients did not return to prefracture levels of performance regarding both the parameters. The levels of mental, physical, and nutritional status, prior to the fracture, comorbidity, and female gender, in addition to the postoperative pain, complications, and the length of hospital stay, were the factors associated with the outcome. Psychosocial factors and symptoms of depression could increase pain severity and emotional distress. For the displaced femoral neck fractures, the treatment with total hip arthroplasty or hemiarthroplasty, when compared to the treatment with internal fixation, provided a better functional outcome. Supportive rehabilitation programs, complemented by psychotherapy and nutritional supplementation prior to and after surgery, provided beneficial effects on the HS and the psychosocial dimension of the more debilitated patients' lives. Lack of consensus concerning the most appropriate HRQoL questionnaires to screen and identify those patients with more difficulties in the psychosocial functions, demonstrates the necessity for further research to assess the newer outcome measurement tools, which might improve our understanding for better care of patients with hip fractures.

Great trochanter bursitis vs sciatica, a diagnostic-anatomic trap: differential diagnosis and brief review of the literature.

PURPOSE: The purpose of this study is to point out the difficulty of differentiating great trochanter bursitis (GTB) from sciatica and estimating the prevalence of GTΒ, in patients poorly diagnosed with sciatica in their first visit to the general practitioner and referred to a spine infirmary. METHODS: The diagnosis of GTΒ was made based on history and physical examination, and was confirmed by ultrasonography and/or response to an anesthetic plus corticosteroid injection to the trochanteric bursa. Demographic and clinical characteristics of the study group were evaluated. The statistical analysis was held with the SPSS pc package (version 24.0). RESULTS: In a total of 657 referrals for sciatica, 72 patients (10.95%) were incorrectly diagnosed as suffering from sciatica, whereas, in fact, they were suffering from GTΒ. In addition, 18 patients (2.74%) were diagnosed as suffering from persistent sciatica with coexisting GTΒ. More women than men had GTΒ (79-11). Mean age for patients with sciatica diagnosis but suffering from GTΒ was 60 years. Mean age for patients with both sciatica and GTΒ was 61 years. CONCLUSIONS: The GTB is a common clinical entity in middle-aged women, which can escape from the physician in cases of incomplete medical history and clinical examination, leading to unnecessary imaging tests and treatment approaches, burdening both the patient and the health system. Early diagnosis of GTB may dramatically reduce cost, prevent unwanted and inappropriate imaging exams and treatment, and make the patient free of symptoms immediately. These slides can be retrieved under Electronic Supplementary Material.

Efficacy of Local Administration of Tranexamic Acid for Blood Salvage in Patients Undergoing Intertrochanteric Fracture Surgery.

OBJECTIVES: The primary aim of this study was to assess whether local administration of tranexamic acid (TXA) reduced the need for a blood transfusion in elderly patients treated with an intramedullary (IM) nail for an intertrochanteric fracture. DESIGN: Randomized prospective trial. SETTING: Academic level 1 trauma center. PATIENTS: Two hundred patients (200 fractures) over 65 years with an intertrochanteric fracture treated by IM nail between April 1, 2012, and March 31, 2014. INTERVENTION: Subfascial administration of 3 g of TXA around the fracture site at the end of the surgical procedure, versus a control group without TXA. Follow-up ranged from 12 to 24 months. MAIN OUTCOME MEASURES: Group differences in number of transfused packed red blood cell (PRBC) units, and hematocrit, hemoglobin, and platelet count. RESULTS: There was a 43% reduction in transfusion requirements in the TXA group (P < 0.01). Twenty-seven units of PRBC were transfused in 22/100 patients in the TXA group, whereas 48 PRBC units were transfused in 29/100 patients in control group. There was no difference between the 2 groups in terms of late complications and overall mortality rate. CONCLUSIONS: Subfascial administration of TXA around the fracture site in elderly patients undergoing IM nailing for intertrochanteric fractures is safe and cost-effective. A significant reduction in blood loss and transfused blood units, and health care cost can be achieved. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Fast sequences MR imaging at the investigation of painful skeletal sites in patients with hip osteonecrosis.

BACKGROUND: Multiple osteonecrotic foci can be clinically silent when located in metaphyses and becomes painful when it affects juxta-articular areas. The purpose of this study was to assess the value of fast MR imaging to depict the underlying pathology in cases with skeletal pain other than the already diagnosed hip osteonecrosis. METHODS/DESIGN: Between 2008 and 2013, 49 patients with already diagnosed hip osteonecrosis reported symptoms of deep skeletal pain in an anatomical site different from the affected hip joint. All patients after thorough history & clinical examination underwent evaluation with x-rays and a single fat suppressed sequence with MR Imaging applying either T2-w TSE or STIR-TSE at the painful site. False positive and false negative findings were recorded for the conventional x-rays and compared to MRI. DISCUSSION: Forty four (89.8%) patients were positive for osteonecrotic lesions in this study and 76 symptomatic osteonecrosis lesions were revealed at 14 distinct anatomic sites. The agreement between the x-ray findings and the MR imaging regarding osteonecrosis was 46.9%. Plain x-rays showed 43.4% sensitivity, 100% specificity, 100% positive predictive value and 10.4% negative predictive value. Fast MR imaging with fat suppressed sequences is necessary and adequate as a single method for the investigation of painful skeletal sites in patients with already diagnosed hip osteonecrosis. It allows early diagnosis of the potentially debilitating multiple juxta-articular lesions and consequently their prompt management.

Pediatric terrible triad elbow fracture dislocations: report of 2 cases.

An elbow dislocation associated with radial head and coronoid process fractures, the terrible triad injury, has an unpredictable outcome in adults and is rare in children. We present 2 such injuries in children, 1 combined with an olecranon fracture, and both with good early clinical outcomes. However, in 1 of the 2 cases, avascular necrosis of the proximal radius was evident on radiographs.

Delayed fracture of a zirconium head after total hip arthroplasty.

We present a case of fracture of a zirconium head after a cemented total hip arthroplasty. The fracture occurred 81 months after the index operation without any history of trauma. The patient was thin, not participating in sports, and the zirconium head had 0-mm neck length. Preoperative radiographs demonstrated aseptic loosening of both components and significant polyethylene wear. Fracture pattern was unusual as the major fragment was half of the head. A revision was performed to a cementless arthroplasty. The authors have obtained the patient's informed written consent for print and electronic publication of the case report.