Radiographic analysis of the proximal femoral anatomy in the Croatian population.

PURPOSE: The goal of total hip endoprosthesis is to achieve painless and functional hip for long term. Accurate reconstruction of hip anatomy largely depends on the implant design. In order to select an implant in correspondence with the native hip, the proximal femoral morphology has been in focus of many studies in the past years. The purpose of this study is to analyze proximal femoral geometry in the Croatian population by radiographic evaluation. METHODS: We conducted a retrospective study analyzing conventional radiographies of the hip, obtained within the last four years from the database of Clinic for Orthopaedic Surgery Lovran. The number of studied patients was 300,168 women and 132 men. The proximal femoral geometric parameters assessed were as follows: femoral head diameter, femoral neck length, neck-shaft angle, angle of femoral neck anteversion, and lateral femoral offset. The results obtained were compared between genders and with results of other studies. RESULTS: Proximal femoral anatomy differed in femoral head diameter and lateral femoral offset between males and females in our group of patients, while femoral neck length, femoral neck shaft angle, and femoral neck anteversion have shown similar values in both genders. Our study also showed specificity of the Croatian population in almost all parameters of proximal femoral anatomy, in comparison with other ethnic groups. CONCLUSION: Our results support the observation on high diversity in the morphology of the proximal femur and the specificity of the proximal femoral anatomy of the Croatian population.

Y sign: new landmark for anteromedial portal placement in knee arthroscopy.

PURPOSE: During arthroscopy training process, determination of anteromedial portal is more difficult in contrast with anterolateral portal and frequently results in suboptimal position, and longer operating times. The aim of our study was to identify an anatomical landmark which could facilitate anteromedial portal placement. METHODS: The relationship of the cutaneous veins at the anteromedial side of the knee was analysed regarding the optimally placed anteromedial portal and anatomical landmarks of the anteromedial part of the knee in 70 patients undergoing knee arthroscopy. The study was designed as case series. RESULTS: In 70% of the patients, the joining of the cutaneous veins was seen after transillumination resembling Y letter. In the remaining 30% of patients, a solitary vein with a curve which corresponds to the joining point was observed. The curve and the joining was located adjacent to optimally placed anteromedial portal measured 2 cm ± 0.3 from the medial patellar tendon border, and 1.1 cm ± 0.1 from the palpable edge of the medial tibial plateau. CONCLUSIONS: The "Y sign" can assist knee arthroscopy trainees in anteromedial portal placement, with the resulting avoidance of multiple puncturing of the skin with the needle, shorter operating room times to find the optimal portal placement, and potential reduction of damage to intraarticular structures.

Femoral neck fractures in children and the role of early hip decompression in final outcome.

BACKGROUND: Femoral neck fractures in children are very rare and account for about 1% of all paediatric fractures. The aim of this retrospective study was to analyse the clinical and radiographic outcome in paediatric femoral neck fracture and to review the role of early decompression of the hip in the final outcome. PATIENTS AND METHODS: The study was performed at the Department of Paediatric Orthopaedics and Traumatology, University Children's Hospital in Belgrade, Serbia from January 1996 to January 2010. The study included 28 patients, 12 female and 16 male, aged 4-14 years. Patients who were aged over 14 years or who had pathological femoral neck fractures or metabolic disturbances were excluded from the study. The type of neck fracture was determined according to the Delbet and Colonna classification. The patients were treated using different surgical procedures: closed reduction and cast immobilisation, closed reduction and percutaneous fixation with Kirschner wires (K-wires), closed reduction and fixation with cannulated screws and open reduction with Wagner plate stabilisation. The final outcome was evaluated using the clinical outcome (based on the Howorth-Ferguson scale), radiographic outcome and occurrence of complications. RESULTS: The median age of patients included in the study was 10.75 years and the average follow up was 9 years. According to the Delbet classification, there was one patient with type I, eight patients with type II, 16 patients with type III and three patients with type IV femoral neck fracture. Based on the Colonna classification, there were 23 displaced and five non-displaced femoral neck fractures. Decompression of the hip was performed in 21 patients. Avascular necrosis (AVN) developed as the main complication in 11 patients. The final outcome was excellent in 14 patients, good in four patients and poor in 14 patients. CONCLUSION: Our study unequivocally confirms the positive effect of urgent treatment on the incidence of AVN as well as on the outcome. We have established a 12-hour interval after injury as an optimal time limit for commencing treatment. Unambiguously positive effects of hip decompression on the incidence of AVN were also noted. We found similar efficiency for open and needle hip decompression.

Treatment of congenital leg length discrepancies in children using an Ilizarov external fixator: a comparative study.

The purpose of this study was to evaluate the influence of intramedullary (IM) alignment used in combination with an Ilizarov external fixation on the healing index (HI) and lengthening index (LI) in the treatment of congenital leg length discrepancies (LLD). This study included 35patients aged from 3.5 to 19 (average age 10.73) who underwent thl egalisation procedure using an Ilizarov external fixator. We compared the duration of the external fixator application, LLD, HI and LI between two groups of children: children in Group I underwent limb lengthening by the conventional llizarov technique using an Ilizarov external fixator alone, and children in Group II underwent a combination of Ilizarov technique and intramedullary alignment with two Kirschner wires, introduced through two mini-incisions. We found significant differences between the two groups of patients for duration of external fixator application and HI. Patients with congeni- tal LLD treated with combined method of treatment had benefit from intramedullary alignment due to its better outcome.

Periprosthetic infections after total hip and knee arthroplasty--a review.

Periprosthetic joint infections (PJI) in orthopedic surgery are considered to be very serious and dangerous complications of total joint arthroplasty. PJI becomes a long-lasting medical problem and a heavy burden on patient and his family. Patients with such a complication are a significant financial burden for the health care system. Recognizing this issue, investing in scientific research and simultaneously developing technologies in medicine are efforts taken to increase successfulness in preventing and treating PJI. Each year the number of total joint arthroplasties increases which entails a rise in the number of complications among which infections are the leading ones. Sometimes, in the worst case scenarios, infections can endanger patients' lives. New procedural algorithms and new diagnostic possibilities help us make accurate and early diagnoses of postoperative PJI with a great degree of certainty. These diagnostic methods include laboratory tests, imaging, histopathology and microbiological analyses. Treatment options depend on many factors which include the onset of symptoms, patients'general physical condition and type of pathogen. The approach to treating PJI is complex and it requires a multidisciplinary approach in order to ensure the most successful treatment possible. For adequate and successful treatment we need to take into account antibiotic therapy, one-stage or two-stage revision, Girdlestone operation, athrodesis and amputation. In this review we will try to sum up all relevant findings and suggest further steps in management of PJI.

High pressure injection injury of the foot: a role of negative pressure wound therapy.

High pressure injection injuries (HPII) of the foot are not common in every-day practice. We present a 50-year-old patient with a HPII of the left foot caused by water-gun in a self-inflicted accident working as a technical diver four meters under the sea surface. Surgical treatment included extensive debridement of necrotic tissue and fibrin deposits and removal of foreign material. A negative pressure wound therapy (NPWT) device was applied resulting in a good wound base for subsequent skin grafting leading to a good functional and cosmetic outcome.

Detection of coxarthrosis in femoral head radiographic images seems limited mainly to vertically oriented pattern features.

Out of 120 conventional hip joint X-rays, two indepenendent examiners have chosen 27 healthy and 62 coxarthrotic joints. Central parts of femoral head images were digitalized (300 points/inch) and pixel density values analysed. Two methods were applied separately to horizontal rows and to vertical columns: variance coefficient calculation and power coefficients of Fourier harmonics. The arithmetic mean and median of variance coefficient for 256 pixel columns were both significantly higher in data of osteoarthrotic femurs (Mann-Whitney U-test, p = 0.0046 and p = 0.0011, respectively), while no difference was found for horizontal rows. The arithmetic mean and median of variance coefficient for 128 pixels long columns were significantly lower in data of osteoarthrotic femurs (p < 0.001) with wider standard deviation (p = 0.0274), while standard deviation was significantly lower in rows of coxarthrotic heads (p < 0.001). Fourier analysis of 128 pixel vertical columns showed significantly higher values in coxarthrotic femoral heads (from 1st harmonic, wave length of 10.8 mm to 33rd harmonic, wave length of 0.328 mm, p < 0.05). Fourier analysis of 128 pixel horizontal rows did not differ much between coxarthrotic and normal femoral heads. Only valuds for the 60th and 61st harmonic (wavelength near 0.2 mm) showed significantly lower power in coxarthrotic images than in controls (p < 0.01). Results suggest that in the analyzed set of digitalized x-ray femoral head images, information regarding osteoarthrotic changes in the central part of femoral head is detectable mainly through mathematic postprocessing of vertically oriented patterns.

Subbrachial approach to humeral shaft fractures: new surgical technique and retrospective case series study.

BACKGROUND: There are few surgical approaches for treating humeral shaft fractures. Here we present our results using a subbrachial approach. METHODS: We conducted a retrospective case series involving patients who had surgery for a humeral shaft fracture between January 1994 and January 2008. We divided patients into 4 groups based on the surgical approach (anterior, anterolateral, posterior, subbrachial). In all patients, an AO 4.5 mm dynamic compression plate was used. RESULTS: During our study period, 280 patients aged 30-36 years underwent surgery for a humeral shaft fracture. The average duration of surgery was shortest using the subbrachial approach (40 min). The average loss of muscle strength was 40% for the anterolateral, 48% for the posterior, 42% for the anterior and 20% for the subbrachial approaches. The average loss of tension in the brachialis muscle after 4 months was 61% for the anterolateral, 48% for the anterior and 11% for the subbrachial approaches. Sixteen patients in the anterolateral and anterior groups and 6 patients in the posterior group experienced intraoperative lesions of the radial nerve. No postoperative complications were observed in the subbrachial group. CONCLUSION: The subbrachial approach is practical and effective. The average duration of the surgery is shortened by half, loss of the muscle strength is minimal, and patients can resume everyday activities within 4 months. No patients in the subbrachial group experienced injuries to the radial or musculocutaneous nerves.

Tibial stress fracture simulate osteomyelitic foci in the course of chronic recurrent multifocal osteomyelitis.

Chronic recurrent multifocal osteomyelitis (CRMO) is an extremely rare and most severe form of chronic nonbacterial osteomyelitis of unknown etiology. Here we present the first case of a six-year-old girl in which was observed that the stress fracture mimic osteomyelitic foci in the course of CRMO.

Total knee replacement surgery is followed by transitory endothelial dysfunction.

Acute coronary syndrome (ACS) presents today the leading group of post-operative cardiovascular complications, while endothelial dysfunction (ED) is one of the key elements in its development. The chronic ED represents thus the basis for the gradual development of atherosclerotic changes, while its sudden aggravation leads to ACS. The persistent ED occurs due to the effects of chronic cardiovascular risk factors, while according to the available studies it can also develop or aggravate under the impact of different acute events. We have directed this study to the investigation of the dynamic of endothelial function before and after a major orthopaedic surgical intervention. This randomised prospective study included 19 patients that underwent the intervention of total knee replacement and 20 healthy examinees of the adequate age and gender High-resolution ultrasound test based on the flow mediated dilatation of the brachial artery is what at we carried out at the beginning of the research, respectively 12, 24, 48 and 72 hours, as well as 7 days after the surgical intervention. The starting values of the FMD test were within the normal range in both groups, although the ability of dilatation upon stimulus was significantly lower in the investigated group. The FMD percentage change in the total sample was negatively connected with the body weight, not having shown additional connections with other cardiovascular risk factors. During the early post-operative period, a significant transitory lowering of the FMD percentage change was recorded, having reached the lowest value 24 hours after the surgery. During the seven-day prospective surveillance, no significant cardiovascular complications were recorded. Further research is necessary in order to confirm these results as well as the testing of the possible connection of the described post-operative transitory endothelial dysfunction with the development of cardiovascular complications and the adverse event.

Treatment of infected tibial nonunion with bone defect using central bone grafting technique.

Treatment of infected tibial nonunion with bone defect represents a challenge for every orthopaedic surgeon. Various methods of treatment have been described for nonunions with infection, bone loss or both. One of them is the central bone grafting technique, which is a safe and effective treatment for nonunions of the tibia. The technique involves placement of autogenous cancellous bone from the iliac crest on the anterior surface of the interosseous membrane with the aim of creating a tibiofibular synostosis. We present the results of uncontrolled, retrospective and continuous series of ten patients treated by a central bone grafting technique for infected tibial nonunion with bone loss. Mean follow-up period was 12 (10-15) years. Most injuries were a result of war injuries. Clinically and radiologically confirmed bony healing with total consolidation of the graft was achieved in all patients within a period of 10-12 months without further bone grafting. The newly-formed bone mass was able to fulfil the mechanical and functional demands of everyday life activities. Once again, the central bone grafting technique has shown to be a safe, reliable and effective method of treatment for infected tibial nonunion with bone defect.

Results of the surgical reconstruction of the anterior cruciate ligament.

Results of the surgical reconstruction of the anterior cruciate ligament (ACL), using as a graft fourfold hamstring tendons (gracilis and semitendinosus) and middle third of the patellar ligament, were compared. In all patients that were participating in this study clinical examination and magnetic resonance showed ACL rupture, and apart from the choice of the graft, surgical technique was identical. We evaluated 112 patients with implemented patellar ligament graft and fourfold hamstring tendons graft six months after the procedure. Both groups were similar according to age, sex, activity level, knee instability level and rehabilitation program. The results showed that there was no significant difference between groups regarding Lysholm Knee score, IKDC 2000 score, activity level, musculature hypotrophy, and knee joint stability 6 months after the surgery. Anterior knee pain incidence is significantly higher in the group with patellar ligament graft (44% vs. 21%). Both groups had a significant musculature hypotrophy of the upper leg of the knee joint that was surgically treated, six months after the procedure. Both grafts showed good subjective and objective results.

Hemiarthroplasty is an effective surgical method to manage unstable trochanteric fractures in elderly people.

Trochanteric femoral fractures are a major problem in the elderly because of higher bone fragility due to osteoporosis. Numerous chronic illnesses, which usually affect the elderly, aggravate and complicate their surgical treatment. Trochanteric femoral fractures results in high morbidity and mortality in elderly patients. The aim of our study is to evaluate the effectiveness of hemiarthroplasty in the treatment of unstable trochanteric femoral fractures in elderly patients. Between 2000 and 2005, 50 patients with unstable trochanteric femoral fractures (41 women) aged 75 to 92 years (mean 86 years) underwent cemented hemiarthroplasty. The surgical procedure was performed within first 48 hours after the fracture (out of which 14 in the first 12 hours, 27 in the first 24 hours and 9 in the first 48 hours), with minimal blood loss. Hemiarthroplasty was indicated in patients where stability was important to allow early mobilization. In forty patients (80%) early ambulation with full weight bearing was achieved during the short period of hospitalization (9-14 days). Given that the affected population is predominantly the elderly, who are less mobile and demanding and thus put less strain on the endoprosthesis, we believe that this kind of treatment is the treatment of choice for unstable trochanteric femoral fractures in these patients. This assumption is corroborated by the fact that we did not have any endoprosthesis luxation, apparent acetabular protrusion or instability during the mean follow up period of 15 months (range 12-18 months).

Spontaneous regression of intervertebral disc herniation--case reports.

Lumbar disc hernia (LDH) is a common cause of low back pain and radicular leg pain. It is well known that the majority of LDH patients recover spontaneously. Since the advent of MRI, a spontaneous regression of fragment size of disc hernia occurs, as well as mitigation of subjective difficulties and neurological disorders. Therefore, surgical treatment is not always method of choice in this disease. Two cases of conservatively treated large disc extrusion which result in significant reduction of difficulties, with simultaneous reduction in fragment size of hernia which is documented by MR.

New "L value" parameter simplifies and enhances hip ultrasound interpretation in the detection of developmental dysplasia of the hip.

PURPOSE: The purpose of this study was to simplify and enhance the ultrasound (US) analysis of the infant's hip by introducing a novel parameter named "L value" into the widely used Graf method. METHODS: We analysed 508 ultrasonographic images of the hips in infants aged three months. The images were first evaluated using the Graf measurements. On the same images, two additional measurements were performed in order to define the new parameter that was named L value. The threshold values of the new L value were identified based on the highest specificity as well as sensitivity for discrimination between the Graf groups. Those values were then used in order to reclassify the hips into three simplified groups. Inter-observer agreement was estimated by Cohen's kappa coefficient. RESULTS: The threshold values for the L value between Graf groups Ia and Ib was 0.46, between Ib and IIb was 0.68 and between IIb and IIc was 0.92. Correlation analysis between Graf's classification and the values of the L value was performed and was proved to be statistically significant, r = 0.49; p < 0.001. After simplifying the classification into three newly defined groups of patients depending on the degree of hip development, the correlation coefficient was much higher, r = 0.94, r (2) = 0.88 for p < 0.001. Inter-observer agreement for the L value was substantial. CONCLUSIONS: The new L value parameter in Graf's ultrasound hip evaluation enables a faster, simpler, more reliable and more unbiased classification for developmental dysplasia of the hip as the L value changes proportionally with the hip maturity.

Postoperative blood loss management in total knee arthroplasty: a comparison of four different methods.

PURPOSE: As the blood loss after the total knee arthroplasty (TKA) is not only a potentially serious medical problem but also an economical concern, the purpose of the study was to investigate the effectiveness of different combinations of knee positioning and the applied wound dressings on blood saving after TKA. METHODS: A randomized controlled trial including 147 TKA-operated patients was conducted. The subjects were assigned to one of the four groups; Group 1-controls, Group 2-flexion, Group 3-flexion and compression, Group 4-compression. The main outcome measures of the study were the blood loss volumes during the procedure and in the intensive care rooms and the decreases in haemoglobin, haemotocrit and red blood cells on the first and the second postoperative day. RESULTS: The MANOVA results showed no differences between the groups in any of the observed parameters. The post-hoc comparisons of the each group to the control group also revealed no influence of any of the proposed blood saving techniques on the actual blood loss. CONCLUSION: No significant differences among the four proposed blood saving methods were determined.

Transforaminal lumbar interbody fusion (TLIF) and unilateral transpedicular fixation.

TLIF (transforaminal lumbar interbody fusion) is a method of interbody fusion, which is alternative to other vertebral fusion wherein, with an approach through intervertebral foramen, through lateral segment of intervertebral space, complications occurring with other methods are reduced. Today, there are numerous versions of this method in terms of implants and transplants. At our Department patients with axial pain resistant to conservative treatment of minimum six months underwent TLIF method with unilateral transpendicular fixation with polyaxial screws, CAGE filled with autologous transplant obtained by lamina resection, and posteromedial contralateral fusion. 22 procedures were performed at 22 levels, 10 for relapsing hernia, and 12 for disc herniation combined with degenerative changes on the same level. Pain reduction was significant; according to VAS score, lumbar pain was reduced from preoperative 8.5 +/- 0.8 to 2.4 +/- 0.85 (-72.63%) a year after, and leg pain was reduced significantly from preoperative 8.45 +/- 0.91 to 2.072 +/- 0.81 (71%) 12 months after surgery. The Wilcoxon paired test demonstrated a significant difference between preoperative VAS score and the value measured 12 months after surgery (n = 22, Z = 4.1, p < 0.001) leg and back, respectively. In 15 (68.2%) patients fusion was evidenced on standard X-ray of lumbar spine, and in 4 patients, with aggravated clinical presentation, fusion in 2 patients and pseudoarthrosis in 2 patients were evidenced by CT. Total 17 patients (77.3%) showed signs of fusion. In our study we demonstrated that unilateral ipsilateral transpedicular fixation, with positioning of one CAGE filled with local autologous transplant represents a reliable and successful method of treatment of axial lumbar pain.

Salmonella typhimurium osteomyelitis of the femur in patient with Crohn's disease.

Osteomyelitis is an inflammation of the bone caused by infecting organisms. We present here the first case of osteomyelitis of the distal femur caused by Salmonella typhimurium in a patient with Crohn's disease. The infection was successfully treated with a combination of antibiotics and surgical treatment.

The influence of test repetition on bipodal visually controlled static and dynamic balance.

This study explores the influence of test repetition on bipodal visually controlled balance, both static and dynamic. Our goal was to get an insight into the pattern of changes in posture maintenance results during repeated balance tests. Fifteen young, healthy male recreational athletes were tested for static and for dynamic balance using KAT 2000 balance platform. The subjects first performed three trial tests of static and dynamic balance to get used to the platform followed by seven repetitions of static as well as dynamic test which were recorded. During the repeated tests we could not determine any significant improvements of static balance test resulting from number of test repetitions neither in static nor in dynamic balance (Friedman ANOVA: Static balance p = 0.497, Dynamic balance p = 0.393). Correlating static and dynamic balance results we found that only one third of the dynamic balance was related to static balance abilities (r2 = 0.36). Possible patterns in front-back and left-right directions were analyzed as well, however, none of these balance scores were found to be related to the number of repetitions. In conclusion, this study found no significant influence of limited number of repetitions (seven) on test results in static and dynamic posture. However, as large number of repetitions might still influence test results we discourage the use of KAT 2000 as a training tool in patients in which it will be used as an instrument to validate postoperative rehabilitation or investigation results.