Bilateral Acute Achilles Tendon Rupture Can Be Effectively Treated Non-operatively.

Acute rupture of the Achilles tendon (AT) is a common but debilitating injury that requires immediate diagnosis and effective management. Spontaneous bilateral AT rupture is rare; however, it can lead to severe disability for a significant period. This case report presents a 76-year-old patient who suffered a bilateral AT rupture while engaging in a non-strenuous activity. Upon confirmation of the diagnosis by physical examination and radiologic evaluation, conservative treatment was decided due to the presence of numerous comorbidities. A personalized rehabilitation protocol was implemented, allowing weight-bearing activities using Achilles boots at six weeks. Healing of both ATs was confirmed by an MRI at three months. Our case shows that non-operative treatment of these injuries can result in exceptionally favorable outcomes and should not be disregarded. However, thorough patient compliance and surveillance are prerequisites.

Development of Prediction Model for 1-year Mortality after Hip Fracture Surgery.

Purpose: Hip fractures are associated with increased mortality. The identification of risk factors of mortality could improve patient care. The aim of the study was to identify risk factors of mortality after surgery for a hip fracture and construct a mortality model. Materials and Methods: A cohort study was conducted on patients with hip fractures at two institutions. Five hundred and ninety-seven patients with hip fractures that were treated in the tertiary hospital, and another 147 patients that were treated in a secondary hospital. The perioperative data were collected from medical charts and interviews. Functional Assessment Measure score, Short Form-12 and mortality were recorded at 12 months. Patients and surgery variables that were associated with increased mortality were used to develop a mortality model. Results: Mortality for the whole cohort was 19.4% at one year. From the variables tested only age >80 years, American Society of Anesthesiologists category, time to surgery (>48 hours), Charlson comorbidity index, sex, use of anti-coagulants, and body mass index <25 kg/m2 were associated with increased mortality and used to construct the mortality model. The area under the curve for the prediction model was 0.814. Functional outcome at one year was similar to preoperative status, even though their level of physical function dropped after the hip surgery and slowly recovered. Conclusion: The mortality prediction model that was developed in this study calculates the risk of death at one year for patients with hip fractures, is simple, and could detect high risk patients that need special management.

Appraisal of the clinical practice guidelines on thromboprophylaxis in orthopaedic procedures; Do we AGREE (II)?

OBJECTIVE: Optimal thromboprophylaxis in orthopaedic procedures is crucial in an attempt to lower the risk of venous thromboembolism, including deep vein thrombosis and pulmonary embolism. We aim to: 1) identify clinical practice guidelines (CPGs) and recommendations (CPRs) on thromboprophylaxis in adult patients undergoing orthopaedic procedures, and 2) assess the methodological quality and reporting clarity of these guidelines. METHODS: The study was conducted following the 2020 PRISMA guidelines for a systematic review and has been registered on the international prospective register of systematic reviews (PROSPERO) under the registration number (CRD42023406988). An electronic search was conducted using Medline, Embase, Cochrane, Web of Science, Google Scholar and medRxiv. The search terms used were ""adults", "orthopedic surgery", "orthopedic surgeries", "orthopedic surgical procedure", "orthopedic surgical procedures" "english language", "venous thromboembolism", in all possible combinations (January 2013 to March 2023). The eligible studies were evaluated by four blind raters, employing the Appraisal of Guidelines for Research & Evaluation II (AGREE-II) analysis tool. RESULTS: The literature research resulted in 931 studies. Finally, a total of 16 sets of guidelines were included in the current analysis. There were 8 national and 8 international CPGs. Eight CPGs made specific recommendations for orthopaedic surgery and referred mostly to joints; one guideline focused on pelvi-acetabular trauma, while the rest were more inclusive and non-specific. Four guidelines, one from the American Society of Hematology (ASH), two from the United Kingdom (UK) and one from India were found to have the highest methodological quality and reporting clarity according to the AGREE-II tool. Inter-rater agreement was very good with a mean Cohens Kappa 0.962 (95 % CI, 0.895-0.986) in the current analysis. So, the reliability of the measurements can be interpreted as good to excellent. CONCLUSION: Optimal thromboprophylaxis in orthopaedic procedures is crucial. The available guidelines were found to be mostly of high methodological quality and inter-rater agreement was very good, according to our study.

Coexisting Benign Tumors in a Finger Are Rare but Not Impossible.

Giant cell tumors of the tendon sheath (GCTTS) and enchondroma are identified as the most prevalent benign soft tissue and bone tumors of the hand. While their individual presence is a common finding, their concurrent appearance in the same anatomic region is exceptionally rare, making simultaneous diagnosis more burdensome. We present a noteworthy case of GCTTS and enchondroma in the index finger of a young patient, along with the therapeutic strategy for correct diagnosis and effective treatment of such an occurrence.

Solitary Radio-Opaque Lesion of Wrist (Tumoral Calcinosis) Disappears Spontaneously After Causing Acute Carpal Tunnel Syndrome: A Case Report.

CASE: We describe the case of a 53-year-old male patient with a history of acute carpal tunnel syndrome (CTS) provoked by a radio-opaque mass on the palmar side of the wrist. Although the mass disappeared in new radiographs 6 weeks later without any intervention apart from the carpal tunnel release, excisional biopsy was conducted on the residue, revealing tumoral calcinosis. CONCLUSION: Both acute CTS and spontaneous resolution are clinical manifestations of this rare condition on suspicion of which biopsy can be avoided by following a "wait and see" strategy.

Treatment of periprosthetic femoral fractures following total hip arthroplasty: results of an online survey of the European Hip Society.

BACKGROUND: Periprosthetic femoral fractures (PPF) are a devastating complication after total hip arthroplasty (THA). Both trauma and adult reconstruction surgeons or combined teams treat these fractures following management algorithms. The aim of this study is to investigate the current treatment of PPF by members of the European Hip Society (EHS). METHODS: An online survey of the members of the European Hip Society (EHS) was conducted. 20 cases of periprosthetic fracture were presented and surgeons were asked to answer questions regarding classification, treatment and postoperative treatment protocol. RESULTS: A total of 132 (130 male; 2 female) EHS members responded. Mean years in surgical practice was 18.8 (min. 1 year; max. 50 years). The preferred surgical method was combined open reduction and internal fixation (ORIF) (30.3%) for AG fractures, ORIF with cables (30.4%) for AL fractures, combined ORIF (cable and plate) for B1 fractures (49.2%), stem revision with cables for B2 fractures (73.1%), stem revision with cables for B3 (55.9%) fractures and combined ORIF (cable and plate: 55.5%) for C fractures. Surprisingly, 10.8% suggested various stem revision techniques for B1 and 17.4% for C fractures. Strong variations were observed regarding postoperative weight-bearing protocol. CONCLUSIONS: A strong consensus was found for the choice of conservative or surgical treatment of the different PPF types according to the Vancouver Classification. Various stem revision techniques were the preferred surgical techniques for Vancouver B2 (91.2%) and B3 (88.6%) fractures. However, for postoperative weight-bearing, when the ORIF technique was used, a significant variation of protocols was found.

Revision total hip arthroplasty for aseptic loosening compared with primary total hip arthroplasty for osteoarthritis: long-term clinical, functional and quality of life outcome data.

PURPOSE: The aim of this study was the comparative assessment of long-term clinical (subjective and objective), functional and quality of life outcome data between primary and revision THA. METHODS: 122 patients (130 hips) who underwent cementless revision THA of both components (TMT cup, Wagner SL stem, Zimmer Biomet) for aseptic loosening only (Group A) were compared to a matched group of 100 patients (100 hips) who underwent cementless primary THA for osteoarthritis (Synergy stem, R3 cup, Smith & Nephew) (Group B). Outcomes were evaluated with survival analysis curves, Harris Hip Score (HHS), WOMAC, Oxford Hip Score (OHS), Short-Form Health Survey (SF-12) and EQ-5D-5L scales. Mobility was assessed with walking speed, Timed Up And Go Test (TUG), Parker Mobility Score, Lower Extremity Functional Scale (LEFS) and UCLA scores. RESULTS: At a mean follow-up of 11.1 (8-17) years a cumulative success rate of 96% (95% CI, 96-99%) in Group A and 98% (95% CI, 97-99%) in Group B with operation for any reason as an endpoint was recorded. Statistically significant differences between groups were developed for WOMAC (Mann-Whitney U-test, p = 0.014), OHS (Mann-Whitney U-test, p = 0.020) and physical component of SF-12 scores (Mann-Whitney U-test, p = 0.029) only. Group A had less improvement in function as compared with group B. In Group A, in multiple regression analysis, patients' cognition (p = 0.001), BMI (p = 0.007) and pain (p = 0.022) were found to be independent factors influencing functional recovery (WOMAC). Similarly, pain (p = 0.03) was found to influence quality of life (EQ-5D-5). CONCLUSIONS: In the long term, revision THA shows satisfactory but inferior clinical, functional, and quality of life outcomes when compared to primary THA. Residual pain, BMI and cognitive impairment independently affect functional outcomes.

Double Plating in Type C Distal Humerus Fractures: Current Treatment Options and Factors that Affect the Outcome.

Purpose: This is a retrospective cohort study of type C distal humeral fractures (AO classification system) aimed at evaluating the effectiveness of current operative treatment options. Materials and methods: Thirty-seven patients with type C distal humeral fractures, treated operatively from January 2002 to September 2016, were retrospectively studied. Thirty-two were eligible for inclusion. Patients were treated by open reduction using the posterior approach, olecranon osteotomy and parallel-plate two-column internal fixation. Patients were evaluated for fracture healing, functional outcomes and complications (infection, ulnar neuropathy, heterotopic ossification and need for implant removal). Restoration of the normal anatomy was defined by measuring carrying angle, posterior angulation and intercondylar distance of distal humerus. Results: The mean follow-up time was 8.7 years [range 2-15.5 years, standard deviation (SD) = 3.96]. Mean time to fracture union was 8 weeks for 29 patients (90.6%) (range, 6-10 weeks). In nine cases, there was malunion of varied importance (28.1%). There was one case with postoperative ulnar neuropathy and one case with deep infection. The mean Disabilities of the Arm, Shoulder and Hand (DASH) score and mean Mayo Elbow Performance Score (MEPS) were 20 (range 0-49) and 83.3 (range 25-100), respectively. Conclusion: In complex distal humerus fractures, the posterior approach with olecranon osteotomy and parallel plating of two columns, after anatomic reconstruction of the articular segment, is a prerequisite for successful elbow function. How to cite this article: Athanaselis ED, Komnos G, Deligeorgis D, et al. Double Plating in Type C Distal Humerus Fractures: Current Treatment Options and Factors that Affect the Outcome. Strategies Trauma Limb Reconstr 2022;17(1):7-13.

Personal protection equipment for orthopaedic and trauma surgery during the COVID-19 pandemic: The results of an EFORT survey initiative.

Orthopaedic and trauma surgeons performing surgery in the COVID-19 pandemic environment faced problems with availability, use, rationing, modification, compliance and recycling of personal protection equipment (PPE). Orthopaedic and trauma surgeons were not well informed concerning the use of PPE for aerosol-generating orthopaedic and trauma procedures. Scientific bodies, health authorities and management have provided insufficient guidelines for the use of PPE in aerosol-generating orthopaedic and trauma procedures. The availability of specific PPE for orthopaedic and trauma operating theatres is low. Hospital management and surgeons failed to address the quality of operating theatre ventilation or to conform to recommendations and guidelines. Operating theatre PPE negatively affected surgical performance by means of impaired vision, impaired communication, discomfort and fatigue. Existing PPE is not adequately designed for orthopaedic and trauma surgery, and therefore, novel or modified and improved devices are needed.

Early failure of an uncemented femoral stem, as compared to two other stems with similar design, following primary total hip arthroplasty performed with direct anterior approach.

INTRODUCTION: An increased risk of early femoral component loosening has been reported using the direct anterior approach (DAA) compared with other common surgical approaches. However, long-term data are scarce. The purpose of this study is: (1) to determine the incidence of early femoral loosening in a high volume, single surgeon's practice utilising the DAA approach; and (2) to examine the effect of stem design and type of coating on aseptic loosening in the early and mid-term postoperative period. METHODS: A retrospective review of 1650 consecutive patients (1800 hips) who underwent total hip arthroplasty (THA) using the DAA between August 2011 and December 2017 was conducted at our institution. 3 types of uncemented femoral stems (Quadra-S, Avenir, TwinSys), with similar design, but different coating, were implanted. Patients were evaluated clinically and radiologically at 4 weeks, 3 months, 1 year, and annually thereafter. RESULTS: After a mean follow-up of 46.4 months, the total incidence of revision for aseptic loosening was 0.44% (n = 8). All loose stems were Quadra-S, failing to achieve osseointegration, for an overall incidence of 0.96% (p = 0.002). None of the other stems were loose. Radiolucent lines around the proximal stem portion were visible in 75 Quadra-S stems (4.1%) on radiographs taken at 1 year postoperatively and continued to deteriorate at the latest follow-up. CONCLUSIONS: In this specific cohort of patients, the increased rate of femoral stem aseptic loosening was implant-related and was attributed only to a specific type of femoral stem (Quadra-S). No relation to other factors was proven suggesting that the surface characteristics of this femoral stem and the lack of bioactive coating are responsible for the observed early femoral failures. These findings should be confirmed by additional registry work and larger population sample sizes are needed to evaluate the prosthesis performance after implantation through the DAA.

Clinical, functional and radiographic outcomes after revision total hip arthroplasty with tapered fluted modular or non-modular stems: a systematic review.

PURPOSE: The aim of the study was to systematically evaluate clinical outcomes of tapered fluted stems, either monoblock or modular, in revision total hip arthroplasty. METHODS: PubMed, EMBASE and Web of Science and Cochrane databases were systematically searched by 2 researchers. Clinical studies reporting primarily on survival and re-revision rates, and secondarily on subsidence, dislocation, intraoperative fractures, periprosthetic fractures and infection were included. 2 investigators assessed the quality of the studies. RESULTS: 46 studies were included in this review, reporting on 4601 stem revisions. The pooled re-revision rate was 5.1% and long-term survival ranged from 75% to 98.5%. No differences were observed between monoblock and modular stems regarding re-revision rate, dislocation rate, periprosthetic fracture rate or infection rates. Monoblock stems exhibited more subsidence and modular stems displayed more intraoperative fractures. CONCLUSIONS: Satisfactory results can be obtained with the use of tapered fluted end-bearing stems. Monoblock stems offer the same clinical results as modular stems.

The effect of zoledronic acid and high-dose vitamin D on function after hip fractures. A prospective cohort study.

PURPOSE: Hip fractures are associated with functional decline and increased mortality. The aim of this study was to investigate the effect of zoledronic acid and high-dose vitamin D on function and mortality after hip fractures. PATIENTS AND METHODS: Forty-five patients received zoledronic acid and high dose of vitamin D during hospitalization after fracture management. These patients were compared with a control group of 46 patients. Pre- and postoperative prospectively collected data including ASA score, Charlson comorbidity score, presence of dementia, Vitamin D, and the Barthel index were available. Final follow-up was performed after one year. Primary outcome was patients' function at final follow-up as measured with Barthel index score. Secondary outcomes included mortality, assessment of pain, and complications. RESULTS: Barthel index score at final follow-up was decreased in both groups. There was no significant difference in Barthel index between the two groups (15.5 ± 5.0 vs 15.8 ± 5.8, p = 0.850). However, the Barthel index in the control group decreased beyond the smallest detectable change (3 points). Mortality was statistically different between groups (8.8% vs 28.2%, p = 0.047). Complications and pain at final follow-up were not different between groups. Multivariate analysis revealed that preoperative Barthel index and Charlson comorbidity score independently affected function at final follow-up. Logistic regression analysis disclosed that not receiving active treatment and complications were associated with increased mortality. CONCLUSIONS: Medical treatment after surgical management of hip fractures results in reduced mortality and lessens the functional decline associated with these fractures.

Management strategies for prosthetic joint infection: long-term infection control rates, overall survival rates, functional and quality of life outcomes.

DAIR (debridement, antibiotics, and implant retention), one-stage and two-stage revision surgery are the most common management strategies for prosthetic joint infection (PJI) management. Our knowledge concerning their efficacy is based on short to medium-term low-quality studies.Most studies report infection recurrence rates or infection-free time intervals. However, long-term survival rates of the infection-free joints, functional and quality of life outcome data are of paramount importance.DAIR, one-stage and two-stage revision strategies are not unique surgical techniques, presenting several variables. Infection control rates for the above strategies vary from 75% to 90%, but comparisons are difficult because different indications and patient selection criteria are used in each strategy.Recent outcome data show that DAIR and one-stage revision in selected patients (based on host, bacteriological, soft tissue and type of infection criteria) may present improved functional and quality of life outcomes and reduced costs for health systems as compared to those of two-stage revision.It is expected that health system administrators and providers will apply pressure on surgeons and departments towards the wider use of DAIR and one-stage revision strategies. It is the orthopaedic surgeon's responsibility to conduct quality studies in order to fully clarify the indications and outcomes of the different revision strategies. Cite this article: EFORT Open Rev 2021;6:727-734. DOI: 10.1302/2058-5241.6.210008.

A Single-Center Surgical Experience With the Reverse Sural Artery Flap as a Reliable Solution for Lower Leg Soft Tissue Defects, With Minimum Two-Year Follow-Up.

AIM: Small soft tissue defects of the distal tibia and hindfoot resulting from traumatic, operative, or neoplastic conditions and chronic ulcers can be successfully dealt with the use of the reverse sural artery flap (RSAF). This study aims to describe a single center's results and familiarity with this technique over a 15-year period of time. MATERIAL AND METHODS: We retrospectively reviewed the clinical files of patients who were consecutively treated with RSAF and regularly followed up between January 1, 2004 and December 31, 2018, with a minimum postoperative follow-up period of two years. Patient demographics and comorbidities, location of the defect, performing surgeon, mean operation time, flap pedicle width, mean size of the defect, days of hospitalization following the operation, healing flap rate, and complications were recorded. RESULTS: The sample consisted of 30 adult patients (25 men, 5 women), with a mean age of 51.07 years (16-80 years, SD 18.61). The mean operation time was 99.03 min (range 83-131, SD 10.57), and the mean size of the defect was 11.11 cm2 (range 6.1-19.4, SD 3.22). Successful flap rate (complete healing and coverage of the defect, with or without additional minor intervention) was 83.3% (25/30). Among successfully healed flaps, six patients with partial necrosis of the dermis were treated by an additional split-thickness skin graft. Five flaps failed to heal. Deep infection was present in two patients, leading to flap failure and reoperation. Serious venous congestion resulting in flap ischemia occurred in three cases. Circumferential keloid formation (not affecting successful outcome) was present in seven cases. Flap thickness approximated to normal within six months. All donor sites healed well (either by a split-thickness cutaneous flap or by immediate wound closure). Light paresthesia on the lateral border of the leg and foot disappeared within six months. CONCLUSIONS: A single-center experience with the RSAF has yielded satisfactory clinical outcomes, and the long-term tackle with the difficult reconstruction conditions around the ankle, has led to valuable advice on surgical technique and postoperative protocol, based on an anatomical basis.

Isolated Salter-Harris Type II Fracture of the Distal Ulna.

Isolated distal ulna epiphyseal plate injuries are very rare and are often associated with early epiphyseal plate arrest. A 13-year-old boy sustained an isolated minimally displaced Salter-Harris type II fracture of the left distal ulna following a fall from a bicycle. The fracture was reduced, and a long arm plaster cast was applied for four weeks. At the six-month follow-up, the patient presented with a painless, full range of movement of the left wrist, but on radiological examination, a mild shortening of the ulna was detected. We plan to regularly evaluate this patient until distal epiphyseal plate closure and surgically intervene if necessary. To our knowledge, this is the third Salter-Harris type II distal ulnar fracture ever reported, and the second treated nonoperatively. It was shown to be associated with a mild growth disturbance. Although Salter-Harris type II injuries are considered benign, surgeons should closely evaluate this rare type II isolated distal ulnar fracture and inform parents regarding possible future complications, which range from clinically insignificant cosmetic deformity to severe instability of the distal radioulnar joint, depending on the degree of shortening.

Patients Undergoing Surgery for Hip Fractures Suffer from Severe Oxidative Stress as Compared to Patients with Hip Osteoarthritis Undergoing Total Hip Arthroplasty.

Hip fractures are associated with the highest degree of morbidity and mortality of all fractures in elderly patients and pose a major risk for subsequent fractures. Patients with hip fractures also present accelerated bone turnover despite early stable fracture fixation and early mobilization. We aimed to evaluate oxidative stress in two groups of patients (25 patients each, matched for age, side, and BMI) who underwent internal fixation of hip fractures and total hip arthroplasty for hip osteoarthritis. Blood samples were taken from all patients during admission, the day of surgery, the 4th postoperative day, and the 15th postoperative day. Reduced (GSH) and oxidized (GSSG) glutathione, GSH/GSSG, catalase (CAT), thiobarbituric acid reactive substances (TBARS), protein carbonyls (PC), and total antioxidant capacity (TAC) as a widely used battery of redox biomarkers were recorded from blood samples. Patients with hip fractures who undergo fixation surgery, compared to those with hip osteoarthritis, suffer significant oxidative stress with an active but insufficient first line of oxidative defense, an intensive first line reaction, a very active second line of oxidative defense, and a low plasma antioxidant capacity. Surgery worsened already present lipid- and protein-related tissue damage. The severe oxidative stress observed may explain high morbidity and mortality rates and high bone turnover status, as well as the high incidence of refractures. Furthermore, the question of whether antioxidant therapy measures should be introduced in the management of hip fracture patients is raised.

Should We Routinely Exclude Retroperitoneal Abscess in Cases of Hip Periprosthetic Joint Infections?

Hip periprosthetic joint infections (PJIs) with concomitant retroperitoneal abscesses may not be common clinical situations but they can be easily misdiagnosed affecting the effectiveness of infection control and eradication interventions. We present the case of a 75-year-old female patient with a late hip PJI complicated with iliopsoas abscess that was barely discovered intraoperatively. Literature review supports our recommendation of a high index of suspicion in cases of hip PJI and even routinely imaging examination of pelvis and abdomen for retroperitoneal involvement exclusion.

Evaluating the "Patella-Friendly" Concept in Total Knee Arthroplasty: A Minimum 15-Year Follow-Up Outcome Study Comparing Constant Radius, Multiradius Cruciate-Retaining, and Nonanatomical Cruciate-Retaining Implants.

BACKGROUND: Patella-friendly femoral components were developed in order to reduce anterior knee pain and patellofemoral complications in total knee arthroplasty (TKA), but their effect on long-term outcome is still unclear. METHODS: We retrospectively evaluated prospectively collected data from 3 groups consisting of 100 patients (100 knees in each). In group A, the constant radius a-MP, in group B the multiradius cruciate-retaining Genesis II, and in group C the nonanatomic, multiradius, cruciate-retaining AGC TKA was implanted. Patients of all groups were matched for age, gender, side, body mass index, and length of follow-up. Preoperative and postoperative clinical outcome data in the form of Knee Society System (KSS), Short Form-12, Western Ontario and McMaster University Osteoarthritis Index, and Oxford Knee Score were available at regular intervals for groups A and B. For patients of group C, KSS score data were available at the same time intervals. In all groups, the patellofemoral compartment was assessed using the Clinical Patella Score scale. Anterior knee pain, secondary patella resurfacing, implant failure, and radiological outcome were assessed in patients of all groups. RESULTS: At 10-year and 15-year follow-up, patients of group A showed statistically significant (s.s.) higher (all P = .000) KSS values as compared to those of groups B and C. At 15-year follow-up, patients of group B showed s.s. higher (P = .001) KSS values as compared to those of group C. At 10-year and 15-year follow up, patients of group A showed s.s. higher (all P = .00) Western Ontario and McMaster University Osteoarthritis Index and Oxford Knee Score values as compared to those of group B. At 15-year follow-up only, patients of group A showed s.s. higher (P = .00) Short Form-12 (physical) values as compared to those of group B. In terms of Clinical Patella Score, patients in group A had s.s. higher values (P = .05) when compared to those of groups B and C. Anterior knee pain was recorded in 4.4% of TKAs in group A, 7.5% in group B, and 17.2% in group C. One (1.1%) patient in group A, 3 (3.25%) in group B, and 7 (8%) in group C underwent secondary resurfacing. CONCLUSION: Anatomical, patella-friendly, constant radius femoral components outperform others in reducing anterior knee pain and patella complications in TKA in which the patellae are left nonresurfaced.