The evolution of robotic arm-assisted arthroplasty in Greece.

BACKGROUND: The robotic arm-assisted (Mako) arthroplasty was introduced in Greece in January 2014, through the years of financial crisis. The purpose of this study is to demonstrate its evolution per procedure throughout the years. MATERIALS AND METHODS: Data regarding type of procedure: partial knee arthroplasty (PKA), total knee arthroplasty (TKA) and total hip arthroplasty (THA) were collected from the official distributor of the Mako platform in Greece. The number of Mako arthroplasties were calculated annually and monthly per procedure type from January 2014 to December 2018. RESULTS: A total of 1081 robotic arm-assisted arthroplasties have been performed in Greece in two private hospitals. Mako cases showed overall 163.06% increase, while THA showed 235.1% increase, during the study period. On the other hand PKA showed 61% decrease, while in during one year (2017-2018) TKA showed 402% increase. CONCLUSIONS: Introducing robots into the orthopedic operating theater may improve precision, could lead to lower complication rates and finally may offer higher patient satisfaction scores. However, the total growth of robotic arm-assisted arthroplasties in Greece should be interpreted with caution, since all surgeries were performed in private institutions and, therefore, the economic burden of these procedures may have been withstood by specific social class patients.

Topical use of tranexamic acid in primary total knee arthroplasty: a comparative study.

INTRODUCTION: Perioperative blood management represents a major issue in knee arthroplasty. The aim of the present observational study is to compare two different methods of topical tranexamic acid (TXA) administration (periarticular and intraarticular) in primary knee arthroplasty. PATIENTS AND METHODS: The present is an observational comparative study. A total of 66 consecutive patients receiving topical injection of TXA after unilateral primary knee arthroplasty due to osteoarthritis were recorded. Patients were divided into two groups: group 1; periarticular injection of TXA and group 2; intraarticular injection. RESULTS: Transfusion rate in group 1 was found to be 15%, compared to 44% in group 2 (p-value= 0.015). In transfused patients the mean received blood units were 1.2 (SD=0.44) in group 1, compared to 1.06 (SD=0.24; p-value=0.34) in group 2. The mean hospital stay of group 1 patients was 7.94 days (SD=2.79), compared to 9.58 days (SD=3.26; p-value=0.03) in group 2. DISCUSSION: The main findings of the study are that statically significant higher transfusion rates, as well as longer in-hospital stay were found in the intraarticular group, when compared to the periarticular group. According to these two parameters the present study has shown that the topical periarticular TXA injection is superior to the intraarticular one. Further research is of utmost importance in order to conclude to the optimum combination of knee arthroplasty perioperative blood management.

Insights in clinical examination and diagnosis of Athletic Pubalgia.

Athletic pubalgia presents with groin and/or pubic pain mainly in athletes. The purpose of this review is to analyze, by evaluating current literature, the clinical examination and differential diagnosis of athletic pubalgia, in an effort to better understand this clinical entity. Diagnosis is challenging due to the anatomical complexity of the groin area, the biomechanics of the pubic Romasymphysis region and the large number of potential sources of groin pain. Clinical examination and medical history are of utmost importance. Differential diagnosis includes intra-and-extra-articular hip and intra-abdominal pathology, as well as non-myoskeletal disorders, such as femoroacetabular impingement (FAI), acetabular labral tears, osteitis pubis, adductor muscles injuries and true inguinal hernia. A thorough clinical examination should be performed in such cases, including the "Resisted sit-up" and the "Single or Bilateral Resisted Leg Adduction" test. Regarding imaging, Magnetic resonance imaging (MRI) should be performed when athletic pubalgia is suspected, especially in athletes. Other imaging techniques, such as plain radiographs and ultrasonography may add to the diagnostic process.

Effectiveness of a preventive bundle of measures for reducing surgical site infections in patients undergoing elective orthopedic procedures in a Hellenic Air Force Hospital.

BACKGROUND: Bundles of preventive measures may improve patient outcomes. The aim of this study is to investigate if a surgical site infections (SSIs) preventive bundle in orthopedic surgery patients can result in reduction of such infections, hospitalization length and cost. METHODS: The present is a retrospective cohort study. A total of 1299 patients was admitted to hospital for an elective orthopedic procedure during 2012-2015. The patients were subjected to either an integrated three-stage SSIs preventive protocol or standard preventive measures. The two groups were compared for incidence of SSIs, median hospitalization length and median cost. RESULTS: The incidence of SSIs was lower in the new-protocol group, when compared to the old protocol one (p=0.102). Median (md) hospitalization length was significantly lower in the new protocol group (md = 2) compared to "old-protocol" group (md= 5) [U = 280520, p<0.001]. Regarding arthroscopies, the median cost in the new protocol patients (md= 1500) was significantly lower compared to "old-protocol" patients (md= 1585) [(U= 112660), p < 0.001]. Knee arthroplasties' median costs did not differ (both mds= 4400, U = 2002, p > 0.05). For hip arthroplasties, the new protocol's patient median cost (md= 3000) was significantly lower than that of "old-protocol" (md = 4000) [U = 19680, p < 0.001]. CONCLUSIONS: The use of a bundle of measures for the prevention of SSIs in a hospital's orthopedic operations proved effective, since it resulted in substantial decrease of SSIs, statistically significant decreased hospitalization length, as well as cost.

Modular megaprosthesis as definite treatment of femur osteomyelitis.

Chronic osteomyelitis represents a challenging to treat clinical entity. A case of a whole femur chronic osteomyelitis, definitely treated with total femur resection and a positioning of a modular megaprosthesis in 2 stages is presented. An 81-year-old female, with hip hemiarthroplasty and internal fixation plate of the distal femur presented with signs and symptoms of femur osteomyelitis. Based on the clinical, radiologic and laboratory findings, the diagnosis of chronic femur osteomyelitis was established. Multiple bone cultures from different femur sites revealed the same methicillin resistant S. aureus. The patient was subjected to a two stage femur reconstruction operation. At the first stage, radical debridement, total femur resection and the application of a custom made vancomycin loaded spacer was performed. After a total of 6 weeks i.v. and 3 months oral proper causative antimicrobial treatment a modular megaprosthesis was applied. The patient was definitely treated from total femur chronic osteomyelitis and has returned to her daily activities. Chronic osteomyelitis demands a multidisciplinary approach, including the right causative long-term antimicrobial treatment, as well as the proper surgical treatment, aiming for eradication of infection and best possible postoperative limb function.

The burden on public emergency departments during the economic crisis years in Greece: a two-center comparative study.

OBJECTIVES: The effects of the Greek economic crisis on the emergency departments (EDs) of public hospitals have not been evaluated. The study aims to evaluate the burden of the financial crisis on public hospital's EDs. STUDY DESIGN: The present study is a retrospective two-center comparative study. METHODS: ED visits, related admissions per year, and the admissions/visits ratio at two public Greek hospitals, the Sismanogleio of Athens (SHA) and the University Hospital of Crete (UHC), from 2008 to 2016 were retrospectively studied. A linear model was fitted for each variable, and the slope values of the linear equations were calculated and compared between the two institutions. RESULTS: ED visits of the UHC exhibited 8.9% increase during the study period, whereas related admissions and admissions/visits ratio increased by 23.4% and 12.5%, respectively. ED visits at the SHA exhibited 5.4% increase, whereas related admissions showed 6% decrease and the admissions/visits ratio was decreased by 8%. Significant differences between the rates of admissions (P < 0.001) and admissions/visits ratio (P = 0.001) among the two hospitals were observed. CONCLUSIONS: Both institutions showed similarly increased ED visits. However, the UHC serving mainly rural, but also suburban and urban population, exhibited different changes regarding admissions and admissions/visits ratio compared with the SHA serving mainly an urban and suburban one, reflecting the way the crisis affected each social group. Depression has amplified the Greek National Health System structural problems and exposed the problematic urban primary health care. Improvement of primary urban health care, autonomy of EDs, and establishment of emergency medicine as independent specialty in Greece could serve better patients seeking care in public hospitals' EDs.

Bilateral overuse myositis ossificans of the triceps: report of an unusual case.

Overuse myositis ossificans is considered an extremely rare diagnosis, with only a few cases reported so far. A case of a 54-year-old firefighter, involved regularly in training exercises, with bilateral myositis ossificans of the triceps, is presented. The patient had a 4 year history of painful masses at the posterior region of both arms. He never experienced any traumatic event, while physical examination revealed firm masses extending longitudinally within the lateral head of the triceps, bilaterally. The patient had painful restricted range of motion at both sides. Plain X-ray views of the humerus showed linear lobulated heterogeneous masses posterolateral. Surgical resection of both masses, which extended intramuscularly through the whole lateral triceps' head, was performed. Histological examination confirmed the diagnosis of myositis ossificans. Myositis ossificans represents a benign, relative rare clinical entity, defined as heterotopic ossification of the soft tissues. Only 5 cases of myositis ossificans due to overuse have been described so far. The present case is unique, since it is the first one describing bilateral appearance of two masses which extended through the whole length of the lateral head of the triceps. A detailed medical history, as well as imaging examination seem to be necessary in order to establish the diagnosis. Treatment should be decided upon the stage of the lesion. For mature lesions surgical treatment is advised.

Safety and Efficacy of Inferior Vena Cava Reconstruction During Hepatic Resection.

BACKGROUND AND AIMS: Patients with liver tumors involving the inferior vena cava have a poor outcome without surgery. Liver resection en bloc with inferior vena cava resection and reconstruction is now performed in many centers. The purpose of this study is to investigate the safety and efficacy of inferior vena cava reconstruction during hepatic resection. MATERIALS AND METHODS: A review of 12 centers reporting 240 patients with combined hepatectomy and inferior vena cava resection and reconstruction for malignant tumors was performed. Sample size, patient characteristics, histological type of the tumor, method of reconstruction, complications, and long-term survival (1-, 2-, and 5-year survival) were evaluated. RESULTS: A total of 240 patients from 12 institutions (male 58%) with mean age 54 years underwent combined liver resection and inferior vena cava resection and reconstruction for colorectal liver metastases (43%), cholangiocarcinomas (26%), hepatocellular carcinomas (19%), leiomyosarcomas (4%), and other tumors (7.9%). Reconstruction included primary closure (35.8%), patch repair (13.3%), or interposition graft (50.8%) In-hospital mortality was 6.25% and overall morbidity was 42.1%. 1- and 10-year survival rates were 79.7% and 28.9%, respectively. CONCLUSION: Tumors arising in or extending to inferior vena cava that require liver resection should be considered for surgery as it can be performed with an acceptable mortality and morbidity in centers with liver transplantation and hepato-pancreato-biliary facilities.

Mesothelial cyst of the round ligament.

Mesothelial cyst of the round ligament is a rare finding in females, with only a few cases reported so far. A case of a 25 year old female patient presenting with a palpable mass in her right inguinal region is presented. The preoperative investigation through ultrasound (U/S), computed tomography (CT) and magnetic resonance imaging (MRI) revealed the presence of an intraabdominal cystic lobular mass in the inguinal canal, in contact with the femoral vessels. The mass was excised and the diagnosis of a benign mesothelial cyst was made through pathological examination. Even though it is a rare condition, it is advisable that clinicians consider in the differential diagnosis when evaluating a non-reducible mass in the inguinal region of a female patient.

Multidrug-resistant Gram-negative osteomyelitis: a 10-year study.

AIM: Few series of osteomyelitis due to multi-drug (MDR) or extensively-drug resistant (XDR) gram-negative bacteria exist. A retrospective study of MDR and XDR gram-negative osteomyelitis cases was performed, aiming to investigate causative organisms, proper surgical and medical management, as well as outcome. PATIENTS AND METHODS: All patients, treated at the University hospital of Crete between 2007 and 2016 for acute osteomyelitis, due to MDR or XDR gram-negative pathogens were evaluated. RESULTS: A total of 14 patients (8 males) were identified with a mean age of 50.6 years. Five Acinetobacter baumanii cases, 3 XDR and 2 MDR, were found. Furthermore, 3 MDR Klebsiella pneumoniae and 3 MDR Enterobacter cloacae isolates were identified. Additionally, 2 MDR Escherichia coli, as well as 2 Pseudomonas aeruginosa, 1 XDR and 1 MDR, were isolated. One case of Roseomonas gilardii was also identified. In 5 cases the same pathogen was also isolated from blood. Five out of the 14 patients were smokers, 6 were suffering severe injury, 4 had diabetes-mellitus, 2 chronic renal disease and 2 were obese. Most causative organisms had hospital origin. All patients received first line empirical combination antimicrobial treatment, proven effective in 4. Thirteen patients were also subjected to surgical treatment. The study included mainly young individuals, most likely due to the high incidence of traffic accidents involving young adults in Crete. CONCLUSIONS: Antimicrobial regimens are important supplements to surgical treatment of acute osteomyelitis. However, due to emergence of resistant microorganisms, compliance with strict rules of antimicrobial strategy is of utmost importance.

Transrectal ultrasonography of perianal fistulas: a single center experience from a surgeon's point of view.

AIM: Two-dimensional transrectal ultrasonography can nowadays be safely used for preoperatively evaluation of perianal fistulas. The aim of this study is to demonstrate its efficacy by comparing the results of this imaging technique with the surgical findings, as well as recurrence rates. PATIENTS AND METHODS: A 4-year retrospective study with a mean follow-up of 4.7 years was performed, including patients treated surgically for a perianal fistula at the surgical department of a tertiary secondary hospital. All these patients underwent preoperatively a transrectal ultrasound with H2O2 for surgery planning, while 12 of them had also a MRI-scan. RESULTS: The sample was consisted of 53 patients with a mean age of 32.4 years and a 0.3 female/male ratio. During the mean 4.7 years follow up 2 patients (3,8%) had a recurrence, while in none of these cases an anal-sphincter muscle trauma was noted. The operative findings were in all cases consisted with the transrectal ultrasonography Results. The MRI-scan failed to demonstrate the presence of a fistula in 3 out of the 12 patients (25%). CONCLUSIONS: Our data support that the use of ultrasound with H2O2 preoperatively, for a safe surgery planning, leads to an accurate surgical procedure and fewer recurrence rates.

Combined Littre and Richter's femoral hernia: an extremely rare intra-operative finding.

Littre hernia is defined as the herniation of a Meckel's diverticulum, while Richter's hernia is the herniation of a portion of the bowel wall. An extremely rare case of a combined Littre and Richter's femoral hernia is reported. An 82-year-old male presented at the emergency department with a painful golf ball-like mass at the right inguinofemoral region. With the diagnosis of incarcerated femoral hernia, he was urgently taken to the operating room. Intraoperatively, an incarcerated Littre, as well as a Richter's hernia were revealed. Enterectomy and side-to-side small bowel anastomosis were performed. The patient made an uneventful recovery. To the best of our knowledge, the present is the first report of a combined Littre and Richter's femoral hernia. Such findings should be reported to raise the awareness of surgeons for complicated cases. It is of utmost importance to have a high suspicion index for strangulated hernias, to minimize the time between admission and surgery.

Malakoplakia of the large intestine: an incidental extremely rare finding.

Malakoplakia is a rare inflammatory disease, most commonly found in the urinary tract. It appears be related to a functional deficiency of macrophages, resulting in an inability to destroy digested bacteria and it is associated with various conditions that cause immunodeficiency. A rare case of malakoplakia of the colon in a healthy 68-year old male is presented. The patient underwent emergency surgery with colon resection and an end stoma with closure of the distal bowel (Hartmann's procedure), due to incarcerated ventral hernia and sigmoid-colon rupture. He underwent reversal of the Hartmann's procedure four months after the initial operation. The histological examination from the anastomotic rings revealed Michaelis-Gutmann bodies that are pathognomonic of malakoplakia. He received per os ciprofloxacin, bethanecol and ascorbic acid for 12 months. Follow-up endoscopy did not exhibit any signs of the disease. A case of a healthy patient presenting with malakoplakia without any underlying disease that causes immunodeficiency is extremely rare. Treatment of malakoplakia involves the eradication of microorganisms. Cholinergic agonists, such as bethanechol and ascorbic acid, as well as antimicrobial treatment with trimpethoprim/sulphamethoxazol and rifampicin are most commonly being used. Long-term antimicrobial treatment has been reported (6 months to 3 years).

Epidural abscess imitating recurrent pilonidal sinus: a case report.

Pilonidal sinus or pilonidal cyst is a common benign disease, affecting mostly young working men. We present the first case of an epidural abscess imitating pilonidal sinus. A 33-year old male, suffering from previously undiagnosed and untreated diabetes mellitus (DM), presented to our emergency department (ER), one month after open surgical treatment of pilonidal sinus, due to weakness and fever. After re-operation of the pilonidal cyst and due to post-operative pus production and continuation of fever a computer tomogr aphy (CT )scan was performed revealing an epidural abscess extending from the thoracic vertebrae 12 (T-12) to the sacrococcygeal area. At that point he underwent new surgery for drainage of the epidural abscess. The patient received intravenous antimicrobial treatment and was discharged on the 23rd postoperative day without signs or symptoms of infection. At follow up for a whole year no signs of recurrence have been observed.

Spontaneous splenic artery aneurysm rupture in a 38-year old female: a case report.

Splenic artery aneurysm (SAA) is a rare and extremely difficult diagnosis. A rare case of a ruptured SAA in a 38-year old female, firstly treated with endovascular embolization and then with splenectomy, is presented. A 38-year old female presented to the emergency department with epigastric pain and fainting episodes. Direct catheter angiography revealed a ruptured SAA and distal, as well as proximal coil embolization was performed. Due to abdominal compartment syndrome the patient underwent open surgery with splenic artery ligation and splenectomy. Postoperative she showed signs of sepsis and was treated with i.v. fluids, steroids, packed red blood cells, platelets, fresh frozen plasma and antimicrobial treatment. Additionally, a multidrug resistant Acinetobacter baumanni was yielded from the urine culture. She had a satisfactory recovery. She is followed up a total of 5 years with no signs of overwhelming post-splenectomy infection syndrome. Direct catheter angiography is a very helpful option in diagnosis, as well as treatment, but a close monitoring after embolization is essential. Furthermore, post-splenectomy sepsis is a severe disease with high mortality rates that requires immediate appropriate treatment.