Journal of Orthopaedics and Traumatology

Published by SpringerOpen
Online ISSN: 1590-9999
Print ISSN: 1590-9921
Surgical and hospital episode-related factors for both groups 
Background An increasing number of elderly patients are managed with long-term antiplatelet therapy. Such patients often present with hip fracture requiring surgical intervention and may be at increased risk of perioperative bleeding and complications. The aim of this study was to ascertain whether it is necessary to stop clopidogrel preoperatively to avoid postoperative complications following hip hemiarthroplasty surgery in patients with intracapsular hip fracture. Materials and methods A retrospective review of 102 patients with intracapsular hip fracture with either perioperative clopidogrel therapy [clopidogrel group (CG)] or no previous clopidogrel exposure [no clopidogrel group (NCG)] who underwent hip hemiarthroplasty surgery was undertaken. Statistical comparison on pre- and postoperative haemoglobin, American Society of Anesthesiologists (ASA) grade, comorbidities, operative time, transfusion requirements, hospital length of stay (LOS), wound infection, haematoma and reoperation rate between the two groups was undertaken. Regression analysis was undertaken to ascertain the risk ratios (RR) of complications and transfusion associated with clopidogrel. Results There was no difference with respect to ASA grade, comorbidities (except cardiac comorbidities), pre- and postoperative haemoglobin levels, operation time, age or gender between the two groups. Four and two patients, respectively, required transfusion postoperatively in the CG and NCG (p = 0.37). There was no difference with respect to LOS, wound infection, haematoma or reoperation rate between the two groups postoperatively. The covariate-adjusted RR for complications and transfusion while being on clopidogrel were 0.43 [95 % confidence interval (CI) 0.07–2.60] and 3.96 (95 % CI 0.40–39.68), respectively. Conclusion Continuing clopidogrel therapy throughout the perioperative period in patients with intracapsular hip fracture is not associated with an increased risk of complications following hip hemiarthroplasty surgery.
Background Proximal hamstring tendinopathy typically afflicts athletes. The poor knowledge of this pathology can lead to late diagnosis and late treatment, which in chronic cases could be challenging. Surgical treatment could resolve the symptoms and could permit the return to full sport activity also in chronic cases. Materials and methods We retrospectively evaluated 17 high-level athletes surgically treated for proximal hamstring tendinopathy. Symptoms lasted for an average of 23 months and were resistive to conservative treatment. Results The follow-up period averaged 71 months. Return to run without pain occurred at a mean of 2.4 months (range 1–4) after surgery. All patients returned to sports at their pre-symptom level at a mean of 4.4 months after surgery. Results were excellent in 15 patients (88 %) and good in two patients (12 %). No results were fair or poor. Conclusions Surgical treatment to manage chronic proximal hamstring tendinopathy in high-level athletes showed excellent results in terms of relief from symptoms and return to previous sport level.
Placement of dynamic hip screw over guide wire. b Intertrochanteric osteotomy done just above the lesser trochanter and pre-calculated wedge resected. c Gap after osteotomy reduced by fixation of 120° double angle barrel plate
Patient information
Radiograph showing non-union fracture neck of femur (21 weeks old). b Immediate postoperative radiograph showing more horizontal fracture line with valgus osteotomy fixed by dynamic hip screw and 120° double angle barrel plate. c Union achieved after 10 weeks of valgus osteotomy
Head preservation is the mainstay of management in younger patients with neglected or ununited intracapsular fracture neck of femur. Very few reports have dealt with the results of valgus intertrochanteric osteotomy and fixation with dynamic hip screw in such cases. In this prospective study, we have tried to evaluate the role of valgus osteotomy and fixation with dynamic hip screw and 120 degrees double angle barrel plate in neglected or ununited intracapsular fracture neck of femur in patients below 60 years of age and whose time since injury is equal to or more than 3 weeks. We treated 16 such cases with valgus intertrochanteric osteotomy and fixation achieved with dynamic hip screw and 120 degrees double angle barrel plate, with mean age of 36.4 years. The cases were evaluated radiologically and clinically at a mean of 19 months. In 14 of the 16 patients, the fracture went on to satisfactory union after an average of 14.7 weeks (10-26.7 weeks). The average Harris hip score increased from 66.6 points (range 55-75 points) before surgery to 88 points (range 75-95 points). All the patients with united fractures were able to sit cross-legged, squat and do one-leg stance. Pain and limitation of motion improved remarkably. Two patients had unfavourable outcome; both had cut-through of the implant, out of the head. Valgus intertrochanteric osteotomy is a very cheap and effective procedure to achieve union in neglected and ununited fracture neck femur in young patients. We propose fixation with dynamic hip screw and 120 degrees double angle barrel plate as it provides additional compression and, with valgus osteotomy, improved stability of internal fixation, with few complications.
Even though there are multiple studies documenting the outcome of the Charnley low-friction arthroplasty as well as abundant studies on uncemented arthroplasties, there is a dearth of comparative studies of the uncemented acetabular component and a cemented component. In this study we aimed to document the long-term clinical and radiographic outcome as well as component survival in a randomized controlled trial. Two hundred fifteen patients (240 hips) were randomly allocated to receive a cemented Charnley cup or uncemented Duraloc 1200 cup. All patients received cemented Charnley stems and were evaluated clinically and radiographically after 6 months, and 2, 5, and 10 years. Harris Hip Scores improved from 48.3 [95% confidence interval (CI) 45.0-51.6] to 90.2 [95% CI 87.9-92.6] in the Charnley group and from 49.3 [95% CI 86.9-91.3] in the Duraloc group at 6 months. After 10 years, the Charnley group's Harris Hip Score was 89.8 [95% confidence interval (CI) 87.0-92.6], and the Duraloc group's score was 87.3 (95% CI 84.1-90.6). In the radiographic analysis after 10 years, there was no statistical difference in the prevalence of radiographic signs of loosening. Nine cups were revised in the Charnley group, and five cups were removed in the Duraloc group. The difference was not statistically significant. There was no statistical difference between the cups when aseptic loosening was the end-point, nor in survival analyses. There is no statistically significant difference in clinical or radiological outcome between the Charnley cup and the Duraloc after 10 years, and no difference in implant survival after 12-14 years. The uncemented Duraloc cup is as good as the cemented Charnley cup after 10 years.
Bi-planar RSA-setup with the two X-ray tubes at right angles and the patients right knee placed in the calibration knee cage. To gain overview scatter grids and X-ray film cassettes are not mounted
Translations along the three cardinal axes after 3, 6 and 12 months for the two groups. P-values (Mann–Whitney U test) indicates significant findings. To gain visual overview mean values are presented with 95% CL
Bioactive coating of uncemented total knee arthroplasty (TKA) is believed to increase bone ingrowth and enhance early fixation of the TKA. In a prospective randomized study using radiostereometric analysis (RSA) we examined migrations of the tibial implant, in an uncemented TKA with and without bioactive coating. The study was performed according to new RSA guidelines, and focus was put on some important methodological issues. Twenty-three patients with osteoarthrosis of the knee received an uncemented Duracon TKA either with bioactive (hydroxyapatite or periapatite) coating (+HA) or without bioactive coating (-HA). Patients had RSA examinations postoperatively and at 3, 6 and 12 months. Nine patients were excluded during the study resulting in 14 knees for final analysis. At 12 months follow-up we found no significant differences in migrations between the two groups. However, in general the -HA group migrated more than the +HA group, and we found a significant larger variation in migration pattern in the -HA group. In the +HA group the tibia component stabilized after 6 months, whereas the -HA group showed continuous migration. Subsidence and posterior tilt were the main migration patterns in both groups. Bioactive coating of TKA seems to enhance early stabilization of the tibia component. Similar results are found in previous studies.
Preoperative images showing a mass in the medial aspect of the distal femur. d Postoperative X-rays showing the prosthesis at the site
X-rays showing a nondisplaced fracture; b CT scan showing correct fragment apposition; c T1-weighted MRI image showing no metastasis on the proximal right femur
Postoperative check showing that the fracture had been stabilized by cannulated screws
X-rays showing that the fracture had healed at one year of follow up
Non-weight-bearing, pre- and postsurgical immobilization, neoadjuvant and adjuvant chemotherapy are known to act on bone turnover, causing osteoporosis over short and long time periods. Treatment of fracture insurgence is very difficult because it really depends on being able to choose the right time (i.e., when immunodeficiency is less important). We report a case of spontaneous neck femur fracture during adjuvant chemotherapy in a young girl treated with resection and prosthesis reconstruction for distal femur osteosarcoma. Possible prevention and the correct approach and surgical timing are emphasized considering immunodeficiency following chemotherapy.
Torsional malalignment syndrome (TMS) is a well defined condition consisting of a combination of femoral antetorsion and tibial lateral torsion. The axis of knee motion is medially rotated. This may lead to patellofemoral malalignment with an increased Q angle and chondromalacia, patellar subluxation and dislocation. Conservative management is recommended in all but the most rare and severest cases. In these cases deformity correction requires osteotomies at two levels per limb. From 1987 to 2002 in our institution three patients underwent double femoral and tibial osteotomy for TMS bilateral correction (12 osteotomies). All patients were reviewed at mean follow-up of 16 years. At final follow-up no patients reported persistence of knee or hip pain. At clinical examination both lower limbs showed a normal axis and a normal patella anterior position. Pre-operative femoral version measurement showed an average hip internal rotation of 81.5° (range 80°-85°) and average hip external rotation of 27.2° (10°-40°). Thigh-foot angle measurement showed an average value of 38.6° (32°-45°). At final follow-up femoral version measurement showed an average hip internal rotation of 49° (range 45°-55°) and average hip internal rotation of 44.3° (20°-48°) (Figs. 1, 2, 3, 4, 5, 6). Thigh-foot angles measurement showed an average value of 21.6° (18°-24°) outward. We recommend a clinical, radiographical and CT scan evaluation of all torsional deformity. In cases of significant deformity, internally rotating the tibia alone is not sufficient. Ipsilateral outward femoral and inward tibial osteotomies are our current recommendation for TMS, both performed at the same surgical setting.
Kaplan–Meier curve of survival rate with failure with implant revision as the endpoint. Time reported in months
Kaplan–Meier curve of survival rate with Hospital for Special Surgery (HSS) total knee score of ≤60 as the endpoint (limit between satisfied and dissatisfied patients). Time reported in months
Comparison between resurfaced patella (group 1, continuous line) and unresurfaced patella (group 2, dotted line) total knee arthroplasties. Kaplan–Meier curve of survival rate with failure with revision as the endpoint. Time reported in months
Total knee arthroplasty (TKA) is the appropriate treatment for degenerative pathology of the knee. Implant surveillance is mandatory to improve clinical results. We present the long-term results of a series of consecutive TKA Press Fit Condylar (J&J), cemented fixed bearing with selective patellar resurfacing in nonselected patients. In this prospective case series, 223 TKA were clinically and radiographically evaluated using the Hospital for Special Surgery (HSS) knee score and the Knee Society Roentgenographic Evaluation and Scoring System. There were 197 patients, with an average age of 68.4 years [95% confidence interval (CI) 52.7-84.1 years]; 49 arthroplasties were implanted in men (21.1%) and 184 (78.9%) in women. The average follow-up was approximately 13.5 years (162.1 months; 95% CI 132.3-191.9), and it was possible to evaluate 179 implants (76.8% of the implanted prosthesis) in 176 patients. The average HSS score increased from 61.5 (95% CI 60.4-62.7) to 89.4 (95% CI 87.7-.93.5) points. The cumulative average survival rate at 15 years (the endpoint being failure with revision) was 90.6% ± 2% standard deviation. Resurfacing the patella did not make a difference in terms of implant survival. Progressive radiolucent lines were observed around 20 implants (14.3%); all were revised. The PFC system is an excellent prosthetic solution. Early clinical complications, mechanical axis and patellar resurfacing do not correlate with implant failure, whereas progressive radiolucent lines do.
Fenestrated cannulated pedicle screw
Test statistics
a Screw too short: risk of epidural leakage. b Epidural leakage of the cement
M.B., 77 years. a Osteoporotic fracture of L3. VAS: 9. Unable to stand or walk. b Short fixation with fenestrated screws and cement augmentation. Vertebroplasty of L3. Immediate recovery of function. 40-month follow-up: VAS: 1. Able to walk without support
This prospective mixed cohort study was designed to evaluate the middle- to long-term purchase of cement-augmented pedicular screws in patients with poor bone quality. The growing number of surgical procedures performed in the spine has highlighted the problem of screws loosening in patients with poor bone stock due to osteoporosis and/or tumors. Different methods of increasing screw purchase have been reported in the literature, including polymethylmethacrylate (PMMA) augmentation. From September 2006 to April 2008, 21 patients with a poor bone stock condition due to osteoporosis or tumor underwent posterior stabilization by fenestrated pedicle screws and PMMA augmentation. Pain improvement and long-term clinical outcome were assessed by visual analogue scale (VAS) score and SF-36 health survey (SF-36) questionnaire. Implant stability was evaluated by plain radiography and CT scans performed three days after surgery and every three months thereafter. After the first 12 months, radiologic controls were taken once a year in all surviving patients. Complications were evaluated in all cases. All patients were clinically and radiographically followed up for a mean of 36 months. VAS scores and SF-36 questionnaires showed a statistically significant reduction in pain and improvement in the quality of life. No radiological loosening or pulling out of screws was observed. In two cases, cement leakage occurred intraoperatively: one patient who suffered from a transitory nerve root palsy improved spontaneously, while the surgeon immediately removed the excess cement before setting in the other case. In three cases, the post-op CT scan revealed a small amount of cement in the canal without clinical relevance. Fenestrated screws for cement augmentation provided effective and lasting purchase in patients with poor bone quality due to osteoporosis or tumors. No case of loosening was recorded after a mean follow-up of 36 months. The only clinical complication strictly related to PMMA screw augmentation did not require further surgery.
Photographs of the patient with chronic unreduced shoulder dislocation showing, on the right side, a tumefaction below the coracoid process and prominence of the lateral border of the acromion  
A 73-year-old woman presented with a very long-standing anterior dislocation of her right shoulder. She had no pain, mild impairment of active shoulder motion and clinical features suggesting no tear of the rotator cuff. CT 3D reconstructions showed a newly formed glenoid cavity below the coracoid process. This case indicates that an anterior shoulder dislocation lasting even decades may be compatible with an almost normal shoulder function.
Demographic data
The presence of a large Hill–Sachs lesion is well detected in internal rotation and is an indication for the open Latarjet procedure
Bernageau view shows the exact anterior contour of the glenoid socket. Blunted angle sign refers to the loss of the sharp profile of the anteroinferior glenoid rim
Postoperative X-ray control: AP view (a) and Bernageau view (b), showing that the graft has perfect positioning, with no overhang into the joint
Background Glenohumeral instability is a common problem in young and active patients. Both open and arthroscopic procedures have proven to be effective options. In cases with large bone defects on the glenoid side or on the humeral head or in contact sports, arthroscopy leads to a high risk of recurrence. We report the results of the modified Latarjet procedure in a population of 26 soccer players affected by chronic anterior instability. To our knowledge there are no previous reports on the results of this procedure when used in a homogeneous group of sportsmen. Materials and methods Twenty-six patients (28 shoulders) were retrospectively reviewed. We analyzed the roles of the players, the levels at which they played, and the average amount of hours that they trained before their injury and after surgery. Moreover, the type of bone loss detected on a preoperative imaging study and its relevance to the patient’s sporting comeback was recorded. Results Eight-five months after surgery the mean Duplay score was 89.3; most of the players came back to the play at the same sporting level. Ninety-three percent of the patients were happy or very happy with their functional results. One patient underwent a redislocation. Conclusions Our series is the first in the literature to refer to a homogeneous group of soccer players. According to our results, and other series, the Latarjet procedure seems to be the gold standard in the treatment of chronic anterior instability in patients with large bone defects and in sportsmen playing contact sports.
Use of 28 and 32-mm femoral heads during 2002-2009
Kaplan-Meier survival from dislocation for 28 and 32-mm femoral heads
Dislocation after primary total hip arthroplasty (THA) is a significant complication that occurs in 2-5% of patients. It has been postulated that increasing the femoral head diameter may reduce the risk of dislocation. The purpose of this paper is to report our experiences with a change from a 28 to a 32-mm femoral head. The retrospective cohort study includes 2572 primary THA performed with a 28 or 32 mm diameter femoral head in the period February 2002 to July 2009. All patients were operated with a posterolateral approach, and all except 18 were operated because of osteoarthritis. Cemented stems were used in 1991 cases and uncemented stems in 581 cases. Cemented cups were used in 2,230 cases and uncemented cups in 342 cases. The patients have been routinely followed for 1-8 years in the 28-mm femoral head group and from 0.5-7.5 years in the 32 femoral head group. We defined a dislocation as an event in which the hip required reduction by a physician. Dislocation occurred in 49 hips with a 28-mm femoral head and in 4 hips with a 32-mm femoral head with an odds ratio of 6.06 (95% CI = 2.05-17.8) (P < 0.001). Otherwise, there were no significant associations between sex, age, diagnosis and type of prosthesis. Multivariate analyses of patients operated at our hospital indicate a significant association between femoral head diameter and dislocation after THA. There were no significant associations between dislocation and sex, age, diagnosis, or type of prosthesis.
Bicondylar tibial plateau fracture model
Schatzker V: plastic deformation, no significant differences noted
Biomechanical testing construct
Schatzker VI: plastic deformation, no significant differences noted
Load to failure, significantly higher load to failure in the Schzatker V model (P = 0.05), and a trend noted in the Schaztker VI model
Evolution of periarticular implant technology has led to stiffer, more stable fixation constructs. However, as plate options increase, comparisons between different sized constructs have not been performed. The purpose of this study is to biomechanically assess any significant differences between 3.5- and 4.5-mm locked tibial plateau plates in a simple bicondylar fracture model. A total of 24 synthetic composite bone models (12 Schatzker V and 12 Schatzker VI) specimens were tested. In each group, six specimens were fixed with a 3.5-mm locked proximal tibia plate and six specimens were fixed with a 4.5-mm locking plate. Testing measures included axial ramp loading to 500 N, cyclic loading to 10,000 cycles and axial load to failure. In the Schatzker V comparison model, there were no significant differences in inferior displacement or plastic deformation after 10, 100, 1,000 and 10,000 cycles. In regards to axial load, the 4.5-mm plate exhibited a significantly higher load to failure (P = 0.05). In the Schatzker VI comparison model, there were significant differences in inferior displacement or elastic deformation after 10, 100, 1,000, and 10,000 cycles. In regards to axial load, the 4.5-mm plate again exhibited a higher load to failure, but this was not statistically significant (P = 0.21). In the advent of technological advancement, periarticular locking plate technology has offered an invaluable option in treating bicondylar tibial plateau fractures. Comparing the biomechanical properties of 3.5- and 4.5-mm locking plates yielded no significant differences in cyclic loading, even in regards to elastic and plastic deformation. Not surprisingly, the 4.5-mm plate was more robust in axial load to failure, but only in the Schatzker V model. In our testing construct, overall, without significant differences, the smaller, lower-profile 3.5-mm plate seems to be a biomechanically sound option in the reconstruction of bicondylar plateau fractures.
Background A cervical Torg ratio of 0.8 has been used as a screening tool to determine the presence of cervical spinal stenosis. However, there have been no studies done to define the Torg ratio in the lumbar spine for predicting lumbar spinal stenosis (LSS). Torg ratios have never been correlated with the actual calculated canal area as derived from anatomic specimens. The aim of this study was to provide an analysis of the utility of the lumbar Torg ratio for predicting LSS based on objective measurements of skeletal specimens. Materials and methods 420 adult skeletal specimens from the Hamann Todd Collection in the Cleveland Museum of Natural History were selected. Digital calipers were used to measure the sagittal diameter (SCD), interpedicular distance, pedicle length, and vertebral body diameter. The canal area at each level was calculated using a geometric formula. A standard distribution curve for canal area and Torg ratio was created, and values that were that is less than the mean minus two standard deviations (SD) below the mean were considered stenotic. Regression analysis was performed to determine if the Torg ratio was correlated with canal area, and if a “below normal” Torg ratio was predictive of LSS. Results The Torg ratio for 2SD below the mean was defined as 0.43 at L1, 0.43 at L2, 0.41 at L3, 0.38 at L4, 0.37 at L5. Regression analysis revealed a significant association of the Torg ratio with canal area (p < 0.01). A Torg ratio that was less than the mean − 2SD predicted canal stenosis at L2, L3, L4, and L5 (p < 0.01). Using a Torg ratio of <0.5 predicted stenosis with a sensitivity of 86 % and specificity of 52 % at all lumbar levels. Conclusions Based on the results of our study, we have defined the lower limit of the normal Torg ratio at each level. A Torg ratio of <0.5 predicts LSS and could be a useful radiological tool for LSS screening.
Magnetic resonance imaging (MRI) is often used to evaluate low back pain; however, MRI in the supine position does not always reveal degenerative spondylolisthesis. The existence of a linear correlation between increased fluid in the facet joints seen on the supine axial T2 MRI of the lumbosacral spine and lumbar instability seen on standing lateral flexion-extension lumbosacral radiographs has recently been reported. The objective of this prospective study was to determine the incidence of increased fluid in the lumbar facet joints seen on the supine axial T2 MRI, and to evaluate the correlation of this finding with radiographic evidence of lumbar instability. We prospectively analyzed weight-bearing flexion-extension lumbosacral radiographs and lumbosacral MRI in the supine position for 52 patients (mean age 64.7 years) seen at our institution for low back pain and/or radiculopathy. The statistical analysis was performed with Fisher's exact test. A difference was considered statistically significant if P < 0.05. In all but 5 of the 52 patients, degenerative disc disease and facet joint disease were observed on the supine MRI of the lumbosacral spine. Fifteen patients had exaggerated fluid in the lumbar facets on the axial T2 MRI (28.8%). Radiographic signs of degenerative lumbar spondylolisthesis were observed in 12 patients (23.1%), and the degenerative spondylolisthesis was not evident on the supine sagittal MRI in 10 of these 12 patients (83.3%). Among these 12 patients, the axial T2 MRI showed exaggerated fluid in the facet joints at the corresponding level in 8 patients (66%). Increased fluid in the lumbar facet joints was present on the supine axial T2 MRI in 7 patients (13.4%), even though there were no radiographic signs of corresponding lumbar instability. We observed a statistical correlation between increased fluid in the lumbar facet joints on the supine axial T2 MRI and degenerative spondylolisthesis seen on standing lateral flexion-extension lumbosacral radiographs.
Patients recruited to the study
Complications associated with our cohort of patients
Western Ontario and McMaster (WOMAC) osteoarthritis index pain outcome scores, subsidence and follow-up times
Paproski scores versus subsidence
Percentage change in Western Ontario and McMaster (WOMAC) scores versus subsidence
The long-stem Exeter femoral component is commonly used in revision hip surgery. Subsidence of the femoral stem in primary hip arthroplasty has been studied extensively, but much less is known about its significance in revision surgery. This prospective study examined the relationship between radiological subsidence, Western Ontario and McMaster (WOMAC) osteoarthritis index pain score, patient satisfaction and complication rates for the long-stem Exeter hip prosthesis. Data was prospectively collected for a single-surgeon series of 96 patients undergoing revision surgery with a mean follow-up period of 36 months. Pre- and post-operative clinical evaluation was carried out using the validated WOMAC osteoarthritis index. Radiographic evaluation was carried out on magnification-adjusted digital radiographic images. Data from 57 patients were analysed. The mean rate of subsidence recorded was 0.43 mm/year, with a mean total subsidence of 0.79 mm [95% confidence interval (CI) 0.57-1.01] at 36.3 months. There was no correlation between subsidence and post-operative WOMAC score, complication rate or patient satisfaction. There was a statistically significant reduction between pre-operative and post-operative WOMAC scores, with means of 33.5 and 10.7, respectively (P < 0.001), and high patient satisfaction. Our subsidence rates for long-stem revision femoral components are lower than the published data but demonstrate the same plateau. Radiographic subsidence does not appear to relate to functional outcome or complication rates in our data.
General patient characteristics (n = 394) 
Anemia and clinical outcome 
We have reported that the functional outcome in elderly with hip fracture is related to age at admission, dementia, and anemia. In this study, we examined the relationship between hemoglobin level at admission and walking ability, as well as survival outcome at discharge. We studied 394 patients aged 60 years or older treated at our hospital for hip fracture since 1997. Anemia was defined as an admission hemoglobin level <13.0 g/dl for men and <12.0 g/dl for women. The relationships between anemia status with age at admission, gender, fracture type, residence before injury, walking ability at discharge, length of hospital stay, and survival outcome were analyzed. Anemia was observed in 266 of 394 patients. Univariate analysis identified no relationship between the status of anemia and age, gender, walking ability before injury, treatment modality, or length of hospital stay. On the other hand, 106 of 266 patients in the anemic group were residing in institutions, and as many as 72.9% of patients in the anemic group had trochanteric fracture. For walking ability at discharge, 92 of 128 patients without anemia were ambulatory compared with only 130 of 266 patients with anemia, with a significant difference between the two groups. Furthermore, there were 15 in-hospital deaths in the anemic group compared with one death in the nonanemic group. Multivariate analysis identified three independent items: age, fracture type, and walking ability at discharge, as related to the status of anemia. Hemoglobin level at admission is related to outcome in patients with hip fracture.
Patient characteristics 
Detailed report of the study cohort 
Over 75 % of patients presenting with a proximal humerus fracture are 70 years or older. Very little is known about the outcome after operative treatment of these fractures in very old patients. This study was performed to gain more insight in safety and functional outcome of surgical treatment of proximal humerus fractures in the elderly. In this observational study, we analyzed all operatively treated patients, aged 75 or older, with a proximal humerus fracture between January 2003 and December 2008 in our center. Patient selection was on clinical grounds, based on physical, mental, and social criteria. Complications were evaluated. We used the DASH Questionnaire to investigate functional outcome, pain, and ADL limitations. Sixty-four patients were treated surgically for a displaced proximal fracture of the humerus: 15 two-part, 32 three-part, and 17 four-part fractures. Mean DASH scores were 37.5, 36.9, and 48.6, respectively. Regarding the operative methods, overall good results were obtained with the modern locked plate osteosynthesis (mean DASH 34.4). Prosthetic treatment, mostly used in highly comminuted fractures, often resulted in poor function (mean DASH 72.9). Persistent pain and ADL limitations were more present in more comminuted fractures (64 and 50 % in patients with 4-part fractures vs. 14 % in 2-part fractures). There were no postoperative deaths within 3 months of surgery, and fracture-related and non-fracture-related complication rates were low (non-union 3 %; 1 myocardial infarction). This study shows that it is safe and justifiable to consider surgical treatment of a severely dislocated proximal humerus fracture in selected patients aged 75 and older. According to OCEBM Working Group, Level IV.
Physiological and operative severity assessment in the orthopaedic POSSUM system
Comparison of physiological scores taken at admission and at surgery Orthopaedic POSSUM scores and predicted mortality and morbidity for each group
Orthopaedic POSSUM scores and the stratification of the effect of delay in surgery on patient mortality
Observed versus predicted mortality stratified according risk bands
Observed versus predicted morbidity stratified according risk bands: a comparison of actual morbidity and mortality for the individual surgical periods
Patients in the extremes of old age with a femoral neck fracture represent a challenging subgroup, and are thought to be associated with poorer outcomes due to increased numbers of comorbidities. Whilst many studies are aimed at determining the optimum time for surgical fixation, there is no agreed consensus for those over 90. The aim of this study is to report the surgical outcome of this population, to understand the role surgical timing may have on operative outcomes using the orthopaedic POSSUM scoring system and to identify whether medical optimization occurs during the period of admission before surgery. We conducted a prospective observational study; data was collected from two district general hospitals over 32 consecutive months. All patients aged 90 and above who were deemed suitable for surgical fixation were included. Each one had their orthopaedic POSSUM score calculated at admission and at surgery, using their computerised and paper medical records. Assessment of outcome was based on morbidity and mortality at 30 days. A total of 146 consecutive patients above the age of 90 underwent surgery and were followed. The average age of the patients was 93 years, 123 (84 %) were female and 23 (16 %) male. Sixty-one patients were operated on within 24 h from admission, 52 patients within 24 and 48 h and 33 had surgery after 48 h from admission. In total, 21 deaths (14.4 %) were recorded and 81 patients (55.5 %) had a post-operative complication within 30 days. The orthopaedic POSSUM scoring system predicted 30-day mortality in 23 patients and morbidity in 83 patients. This gave observed to predicted ratios of 0.91 and 0.98 respectively. Overall, there was a small improvement in physiological scores taken just prior to surgery compared to those at admission. Mortality and morbidity rates were higher for those operated on or after 24 and 48-h cutoffs compared to those proceeding to surgery within 24 h (P = 0.071 and P = 0.021 respectively and P = 0.048 and P = 0.00011 respectively). When stratified according to their POSSUM scores, patients with scores of 41+ and surgery after 48 h had a significantly higher mortality rate than if they had surgery earlier (P = 0.038). Morbidity rates rose after 24 h of surgical delay (P = 0.026). Patients with a total POSSUM score between 33 and 40 exhibited a higher morbidity after a 24-h delay to surgery (P = 0.0064). As life expectancy increases, older patients are becoming commoner in our hospital systems. We believe the orthopaedic POSSUM scoring system can be used as an adjuvant tool in prioritising surgical need, and allow for a more impartial evaluation when changes to practice are made. Our findings show that timing of surgery has an important bearing on mortality and morbidity after hip surgery, and older patients with higher orthopaedic POSSUM scores are sensitive to delays in surgery.
Treatment protocol
A 35-year-old man, involved in car accident, reported an unstable pelvic fracture (tile C1.1), femoral fracture, proximal humeral fracture and a mesenterial lesion. Pelvic fixation was performed a X-ray in anteroposterior view, b in outlet view and c in inlet before laparotomy d
A comparison of the protocols presented in literature
Abdomino-pelvic injuries often present a challenge for the emergency department. Although literature reports several protocols on the treatment of abdomino-pelvic injuries aiming at defining the most advisable treatment line, optimal treatment is still controversial. This paper describes a protocol that has been used to treat abdomino-pelvic injuries in our hospital since 2002. In literature different protocol of abdomino-pelvic injuries are described and comparing them most of the difference are the timing of CT scan, the angiography and the laparotomy when treating a lesion of pelvic ring. If patient is haemodynamically instable and presents a lesion of pelvic ring our protocol suggest the simplest and fastest stabilization (pelvic external fixator) in emergency room and delay exam such as CT scan as second level exam. In the presence of an abdominal injury, with a positive focused assessment with sonography for trauma test, the first step should be a pelvic ring stabilization, as laparotomy decreases the abdominal pressure and reduces the tamponade effect on the retroperitoneum. According to presented protocol the angiography is not be a first choice treatment. This protocol was applied to 58 cases of abdomino-pelvic injury with unstable pelvic lesions from October 2002 to December 2005. Mean injury severity score was 27.2 (CI 24.1-30.3). Five patients (8%) died, three due to haemorrhagic shock and two due to pulmonary embolization. Four patients (6.9%) had a partial or complete cauda equina syndrome, four patients (6.9%) complained of mild incontinence, whilst 1 (1.7%) complained of urinary retention with multiple cystitis. Two patients (3.4%) with retention and multiple cystitis, had a malunion and a painful non-union of the fracture. Seven patients (12.3%) had neurological impairment: 5 (8.6%) sciatic nerve palsy, 1 (1.7%) lumbosacral root lesions in a C2-type fracture and there was one case (1.7%) of inconstant lumbago with sciatic pain. Twelve patients reported different levels of sexual dysfunction (20.7%). Although validation with a larger cohort is required, our preliminary clinical data are similar to, or better than, those reported in the most recent publications on this question, suggesting that this protocol could well reduce both the mortality rate and the long term complications of abdominopelvic injuries.
Although various congenital abnormalities have been described, congenital absence of calf musculature is extremely rare, with only one report on its complete absence. We are the first to describe a case of congenital absence of muscles of the superficial posterior compartment of the calf presenting in a toddler. The child presented with a history of a painless limp, however no significant difference was found in functional gait analysis. We suggest that such cases should be monitored and parents can be reassured that no immediate treatment is required.
We report a rare case of congenital absence of the L5-S1 facet joint, which was associated with a conjoined nerve root. Combination of these two anomalies has been quite rarely reported in the literature. A 39-year-old man presented with acute low back pain and right leg radiating pain. Muscle weakness and sensory disturbance of the right leg were also apparent in the region innervated by L5 and S1 nerve roots. Preoperative multidetector three-dimensional computed tomography (3D-CT) showed complete absence of the right S1 superior articular process. Magnetic resonance (MR) images showed lumbar disc herniation at right L5-S1 level that migrated cranially. Intraoperative findings revealed that the right L5 nerve root and S1 nerve root were conjoined, and the conjoined nerve root was compressed by L5-S1 disc herniation, which led to impairment of the conjoined nerve root by a single-level lumbar disc herniation. After removal of the disc herniation, his right leg pain immediately subsided, however muscle weakness and sensory disturbance persisted. Surgeons should be aware of this nerve root anomaly when examining a patient who shows an unusual clinical presentation and/or congenital osseous anomaly.
Example of DEXA of the Nanos™ (right) and Metha™ (left) prosthesis with defined modified Gruen zones
The aim of this prospective randomized study was to analyze migration and strain transmission of the Metha™ and Nanos™ femoral prostheses. Between 1 January 2011 and 2 April 2013, 50 patients were randomized to receive short-stemmed femoral prostheses. Metha™ stems were implanted in 24 patients (12 female, 12 male; mean age 58.7 years; mean body mass index [BMI] 27.4) and Nanos™ stems in 26 patients (10 female, 16 male; mean age 59.7 years; mean BMI 27.1). Longitudinal stem migration, varus-valgus alignment, changes of center of rotation (COR), femoral offset and caput-collum-diaphyseal angle, leg length discrepancy, periprosthetic radiolucent lines incidence, and dual-energy X-ray absorptiometry (DEXA) scans were analysed after an average of 98 and 381 days. There was no significant change of varus-valgus alignment or clinically relevant migration of the Metha™ or Nanos™ prostheses during postoperative follow-up. After 12.3 months, the DEXA scans showed small but significant differences of bone mineral density in Gruen zones 1 (minus ~8 %) and 6 (plus ~9 %) for the Metha™ and in Gruen zone 1 (minus ~14 %) for the Nanos™ (paired t test). Visual analog scale (VAS) and Harris Hip Score (HHS) improved significantly for both implants (Nanos™/Metha™ 12.3 months postoperatively HSS 96.5/96.2; VAS 0.7/0.8, respectively). COR or offset did not change significantly after surgery. Neither implant showed signs of impaired osseointegration. DEXA demonstrated proximally located load transfer with only moderate proximal stress shielding. LEVEL OF EVIDENCE: II.
Studies have found that tip apex distance (TAD) is the strongest independent predictor of lag screw cut-out following hip fracture fixation. The objective of this study was to understand the importance of introducing the concept of TAD to surgeons. The null hypothesis was that there were no differences between fractures fixed before awareness of TAD compared with fractures fixed after awareness of TAD. This study involved assessing 75 consecutive radiographs retrospectively (before introduction of "tip apex distance" to surgeons) and 83 consecutive radiographs prospectively (after introduction of "tip apex distance" to surgeons). Radiographs were measured using a radiograph digitizer and software. Average TAD in radiographs measured retrospectively was 22.6 mm compared with 9.7 mm in radiographs analysed prospectively (P </= 0.001). The power of this study was 97%. This study demonstrates that introducing the concept of "TAD" to surgeons, will improve the accuracy of lag screw placement during fixation of an extracapsular fracture. The improvements in lag screw placement will undoubted reduce cut-out of the implant post-surgery.
It has been indicated that, in the long term, the rate of wear and the degree of osteolysis observed with uncemented acetabular components are greater than those associated with cemented cups, but most studies which compare the wear characteristics of cementless with cemented cups have used historical controls. We report a direct comparison of wear of a cemented and an uncemented cup with similar design, polyethylene, and sterilization method. The study cohort includes 92 patients who were operated in 1997 with primary total hip replacement and have been followed for a period of 9-10 years. All patients were operated by posterolateral approach. In patients 70 years or older we used a cemented cup, in those 60 years or younger we used an uncemented cup, and in patients between 60 and 70 years we used either a cemented or uncemented cup as decided by the surgeon. At follow-up, radiographic imaging was obtained as standard anterioposterior view of the pelvis, and mean wear was determined as described by Livermore et al. The overall wear of the cemented acetabular components was 1.07 ± 0.78 mm, and that of the uncemented cups was 1.18 ± 0.61 mm (P = 0.529). Wear was significantly associated with male sex (P = 0.003), younger age (P = 0.003), and degree of inclination (P < 0.001), but wear was not significantly associated with cemented versus uncemented cup (P = 0.437). Our findings in this 9-10-year follow-up study suggest that cementless cups wear no more than cemented cups of similar design.
Recurrent instability after primary and revision total hip arthroplasty (THA) is a disastrous complication for the surgeon and the patient. Dislocation after revision total hip arthroplasty has been reported to be as high as 20 % in some series [1]. Patients who suffer from recurrent dislocations are challenging because historical treatment options, including constrained liners, have had disappointing results [2]. Dual mobility acetabular cups were initially introduced to reduce dislocation rates after primary total hip arthoplasty [3]. While dual mobility acetabular components have been shown to improve stability in primary THA, few studies have examined the outcomes of dual mobility bearings in revision THA for persistent dislocation [4].The current study by van Heumen et al. [5] was a retrospective cohort study with 49 consecutive patients (50 hips) that underwent an isolated acetabular revision with a dual mobility cup (Avantage; Biomet, Warsaw, IN, USA) for recurrent instability w ...
Patient and fracture characteristics by outcome
Kaplan–Meier survival curve with reoperation—be it total hip replacement or hip arthrodesis—as the endpoint after acetabular fracture affecting the posterior wall. Thin lines delimit the 95 % confidence interval. Tick marks indicate cases that were censored as dictated by the availability of follow-up
Background The general outcome of posterior wall acetabular fractures is still the source of discussion. Posterior wall fractures are recognized throughout the literature as being difficult to treat. The aim of the present study was to analyze in our own patients the relevance of the classical prognostic criteria for the outcome of isolated posterior wall fractures and those with associated lesions. Materials and methods A prospective cohort of 33 consecutive patients treated operatively between 1996 and 2006 in a single level 1 trauma center for a posterior wall fracture of the acetabulum was analyzed retrospectively. Included were posterior wall acetabular fractures or associated posterior wall fractures, such as the combinations of posterior column with posterior wall, transverse with posterior wall, or T-shaped fracture with posterior wall fracture. Outcome measurement of the postoperative survival of the hip joints until the primary outcome reoperation (total hip replacement or fusion) and secondary outcome diagnosis of symptomatic osteoarthritis were performed. Results Twenty-six of the 33 patients with posterior wall fractures also had a dislocated joint. Twelve had isolated and 21 associated fractures. Six patients were reoperated with a THA (four patients within 2 years and one after 10 years), and one arthrodesis was done to treat a hematogenous septic arthritis in a degenerative hip joint. Secondary arthritis was observed in 10 patients. Conclusions No difference was found between the outcome in cases of isolated posterior wall acetabular fracture and the outcome in those with associated lesions. The classical prognostic criteria were not found to be relevant to the outcome for our group.
The use of uncemented hip arthroplasty prostheses with ceramic articulations are popular, especially in the young, because of a perceived reduction in wear. We highlight a complication of ceramic on polyethylene articulating couples not previously described in the Furlong replacement. Despite widespread metalosis and particulate debris, osteolysis was not initially seen. The contamination compromised subsequent revision.
Serf Novae® Dual Mobility uncemented acetabular socket components
Details of patients included in the study
Intra-operative clinical photographs of socket-only revision being performed
Pre- and post operative radiographs of staged bilateral dual-mobility socket primary THA in a 73-year-old male with severe Parkinson’s disease
Immediate postoperative radiograph of an 86-year-old female’s revision THA for recurrent dislocation showing satisfactory socket position. b 6 months postoperative radiographs depicting change in the socket orientation. c Radiograph at 30 months postoperative period with no further change in cup position
Background: The concept of a dual-mobility hip socket involves the standard femoral head component encased in a larger polyethylene liner, which in turn articulates inside a metal shell implanted in the native acetabulum. The aim of this study was to assess outcomes from using a Serf Novae(®) Dual Mobility Acetabular cup (Orthodynamics Ltd, Gloucestershire, UK) to address the problem of instability in primary and revision total hip arthroplasty (THA). Materials and methods: A retrospective review was carried out of all hip arthroplasties performed in a District General Hospital utilising the dual-mobility socket from January 2007 to December 2012. Clinical and radiological outcomes were analysed for 44 hips in 41 patients, comprising 20 primary and 24 revision THA. The average age of the study group was 70.8 years (range 56-84 years) for primary and 76.4 years (range 56-89 years) for revision arthroplasty. Among the primary THA, always performed for hip osteoarthritis or in presence of osteoarthritic changes, the reasons to choose a dual mobility cup were central nervous system problems such as Parkinson's disease, stroke, dementia (10), hip fracture (5), failed hip fracture fixation (2), severe fixed hip deformity (2) and diffuse peripheral neuropathy (1). The indications for revisions were recurrent dislocation (17), aseptic loosening with abductor deficiency (4), failed hemiarthroplasty with abductor deficiency (2) and neglected dislocation (1). Results: At a mean follow-up of 22 months (range 6-63 months), none of the hips had any dislocation, instability or infection and no further surgical intervention was required. Radiological assessment showed that one uncemented socket in a revision arthroplasty performed for recurrent dislocation had changed position, but was stable in the new position. The patient did not have complications from this and did not need any surgical intervention. Conclusions: Even though postoperative hip stability depends on several factors other than design-related ones, our study shows promising early results for reducing the risk of instability in this challenging group of patients undergoing primary and revision hip arthroplasty. Level of evidence: IV.
The natural history of osteonecrosis of the femoral head is generally thought to be one of progressive deterioration if no intervention is undertaken. However, it is unknown whether surgical intervention is beneficial for patients with a small region of osteonecrosis. We observed rapid improvement of MRI findings after rotational acetabular osteotomy (RAO) was performed in a young patient with osteonecrosis of the femoral head. The band-like low signal area on T2-weighted images almost resolved by six months after surgery. He returned to work as an electrician by six months after surgery. Early surgical intervention such as RAO that alters the mechanical force acting on the necrotic region of the femoral head may accelerate the recovery of osteonecrosis and the improvement of symptoms.
Recent publications have shown an infection rate of 5-7 % for acetabular fractures treated with the Kocher-Langenbeck (K-L) approach. Using metallic staples to close hip skin incisions has been considered the gold standard. The purpose of this study was to answer the following: (1) will closure of a K-L incision after acetabular fracture surgery with a running subcuticular monocryl suture, then sealing the wound with 2-octyl cyanoacrylate (OCA), result in a lower infection rate compared to metallic staple closure? (2) Do incisions closed with subcuticular monocryl and OCA exhibit decreased drainage? (3) Is there a cost difference between these two methods? In a prospective clinical study, 103 patients with acetabular fractures treated using the K-L approach were randomized into two groups: skin closure with metallic staples (n = 52) versus subcuticular running monocryl suture sealed with OCA (n = 51). Two postoperative deep infections (4 %) in the staples group required multiple debridements; no infections developed in the OCA group. However, there was no statistical difference between the groups, (p = 0.495). There was a statistically significant difference (p = 0.032) comparing days from surgery to a dry incision favoring OCA (4.2 versus 5.85 days). The patient charge was approximately $900 greater on average in the OCA group due to the increased time in the operating room required for the subcuticular closure. Closure with OCA and subcuticular monocryl showed no clinical disadvantages and appears to have a clinical advantage when compared to standard metallic staple skin closure in acetabular fracture surgery. However, additional patient costs may be incurred. LEVEL OF EVIDENCE: II.
The purpose of this study was to evaluate the medium-term clinical and radiological outcomes of two metal-backed acetabular cups with metal-on-metal and metal-on-polyethylene joint couples, in patients unselected for age. Seventy-five metal-on-polyethylene CLS expansion cups were implanted in 70 patients and 66 metal-on-metal Fitek cups were implanted in 65 patients. The average age at surgery in the two groups was 63 years (range, 25 to 72 years) and 58 years (range, 32 to 68 years), respectively. Data regarding 64 of 75 CLS cups (85%) and 58 of 66 Fitek cups (88%) were collected at a minimum 36-month and maximum 144-month follow-up. The Harris hip score showed excellent results in 86% of the CLS cups, good results in 7%, and fair results in 7%. No poor results were recorded. For metal-on-metal acetabular components, excellent results were recorded in 84% of the cups, good results in 8%, fair results in 5%, and poor results in 3%. Fifty-five patients with 57 of 64 CLS cups (89%) and 50 patients with 51 of 58 Fitek cups (88%) were fully satisfied with their prosthesis. No acetabular reconstructions were revised for aseptic loosening. No radiolucent lines greater than 2 mm were observed, either about CLS or Fitek cups, and low incidence of osteolysis and polyethylene wear was noted in metal-on-polyethylene articulations. Post-operative three-phase bone scanning was obtained in 51 patients and this examination did not show increased uptake in blood pool or bone phase indicating aseptic loosening of CLS and Fitek cups. In conclusion, we found similar rates of excellent and good results using two acetabular components with different bearing surfaces, in patients of unselected age. Therefore, the less expensive implant should be selected for total hip arthroplasty in elderly or low-demand patients.
X-ray of the pelvis showing fracture of upper part of the ischium in the lateral part of the obturator foramen. b, c Computed tomography (CT) showing the impacted fragment of the articular surface and comminution of the lamina quadrilatera. d–f 3D CT highlighting the well-impacted articular fragment and involvement of the lamina quadrilatera. The anterior and posterior columns are intact
Postoperative computed tomography highlighting reduction of the intra-articular impacted fragment
X-ray after 3 years showing a good clinical result
Surgical treatment of a unusual acetabular fracture is described. This fracture was characterized by impaction and breaking down of the posterior articular surface and comminution of lamina quadrilatera lower portion, without cortical fracture of both columns. The fracture was treated surgically through the Kocher-Langenbeck approach. A small hole was created in the acetabulum posterior wall, the impacted fragment was reduced, and the bone defect was filled with autologous bone from the greater trochanter. A plate was shaped in order to fix both bone graft and fractured fragment.
Background Zone I ruptures of the Achilles tendon and chronic ruptures in zone II with a gap of more than 6 cm are difficult to treat. We describe a technique that is very well suited to this type of rupture. Materials and methods Seventy-eight patients with chronic rupture of the Achilles tendon were operated on between January 1996 and December 2010. We used a modification of the Bosworth technique in which a strip of the gastrocnemius aponeurosis was taken, made into a tendon-like structure and passed through the calcaneum after making a drill hole; then it was sutured back to the proximal stump. The Leppilahti scoring system was used to evaluate these patients. Results Sixty-two patients had excellent results, 8 had good results, 4 had fair results, 2 had poor results, and 2 were lost to follow-up at the end of 1 year. Nearly all patients resumed work at 6 months postoperatively, had normal walking and stair climbing, and regained normal dorsiflexion. Conclusion Our technique is ideally suited to zone I ruptures (where no distal stump is available for repair) and ruptures in zone II where end-to-end repair is not possible.
A termino-terminal tenorrhaphy was then possible, but only with the foot flexed in the full equinus position, utilizing the plantaris gracilis tendon as an augmentation (grasped with the clamp)
Posttraumatic neglected Achilles tendon ruptures in a young patient have not been described in the literature to our knowledge; indeed, neglected ruptures of the Achilles tendon have only rarely been described in adults. We present the case of a 7 year old girl with posttraumatic neglected rupture of the Achilles tendon that was operated on 8 weeks after the trauma.
Dissection of the hamstring tendons demonstrating a double pes anserinus
An anatomical variant of the pes anserinus encountered during anterior cruciate ligament reconstructive surgery which has not been previously described is discussed. During routine harvesting, the sartorius fascia was incised and the semitendinosus and gracilis tendons were identified. At the distal portion, it was noted that each tendon gave off an additional tendinous slip. The slip from the semitendinosus tendon had attached to the gracilis tendon and vice versa, thereby creating a double pes anserinus. This variant was used to construct the graft, and at 1 year review the patient had returned to full sporting activities with no complications encountered.
The pivot-shift phenomenon as detected by a navigator: tibial antero-posterior diagram and rotation in a knee with intact ACL (a) and in an ACL-deficient knee (b)
Although ACL reconstructions provide satisfactory clinical results nowadays, regardless of the type of graft or the surgical technique used (out-in vs in-out or single- vs double-bundle), the residual rotatory instability which is often detected at clinical follow-ups is still a matter of concern among surgeons. In this paper we try to analyze all the aspects which might contribute to this phenomenon by summarizing the biomechanical functions of the two bundles of the ACL, and by evaluating all the other factors strictly related to the rotatory instability of a reconstructed knee, such as the anatomical positioning of the single- or double-bundle new ACL, or the importance of a valid lateral compartment (LCL, ALTFL). Clinical, biomechanical and cadaver studies are discussed in order to contribute to better understanding of the origin of post-operative residual rotatory instability.
Although nonoperative treatment is considered the standard of care for the treatment of grade I and II acromioclavicular joint injuries, the treatment of grade III injuries is controversial. There are as many methods of nonoperative treatment as there are for operative stabilization. That is why we conducted a literature research to find out the best evidence regarding the treatment of acute grade III acromioclavicular dislocation. The research was limited to RCTs, systematic review and meta-analysis in the most representative databases. Even if research identifies more than 600 articles, only five were included in the study because there were RCTs, and systematic reviews, but no meta-analysis articles were found. Moreover, no meta-analysis was performed because of differences of data published in the three RCTs (different type of surgical treatments and different outcome measures). From the literature evaluation, clinical results seem to be comparable between the operative and the conservative treatments, but complications are more evident in the surgery group. Since there is not a preponderance of positive papers showing the benefits of a surgical technique over conservative therapy, the nonoperative treatment is still considered a valid procedure in the grade III acromioclavicular separation. More prospective randomized studies using validated outcome measures are needed to identify the suitable operation techniques for the acute injuries.
Forest plot illustrating constant score
Forest plot illustrating cosmetic outcome
Forest plot illustrating duration of sick leave
Whilst there is little debate over the treatment of Rockwood grade V and VI acromioclavicular dislocation, the management of grade III acromioclavicular dislocation remains less clear. The purpose of this study was to compare the clinical outcomes of patients managed operatively and non-operatively following grade III acromioclavicular dislocation. A systematic review of published and unpublished material was conducted. All included studies were reviewed against the PEDro appraisal tool. Where appropriate, a meta-analysis of pooled results was conducted. Among 724 citations, six studies met the eligibility criteria. All six studies were retrospective case series (level 4 evidence). The findings of this study indicated that operative management of grade III acromioclavicular dislocation results in a better cosmetic outcome (P < 0.0001) but greater duration of sick leave compared to non-operative management (P < 0.001). There was no difference in strength, pain, throwing ability and incidence of acromioclavicular joint osteoarthritis compared to non-operative management. Only one study recorded and showed a higher Constant score for operative management compared to non-operative management (P = 0.003). There is a lack of well-designed studies in the literature to justify the optimum mode of treatment of grade III acromioclavicular dislocations.
Patient demography 
Pre-and postoperative Constant score 
Pre and postoperative antroposterior view 
Pre and postoperative antroposterior view 
Acromioclavicular joint dissociation may not be a common injury, yet it may cause limitations in activity. Types IV, V, and VI dissociations need operative repair. In this study, a simple technique is advocated to reduce and maintain reduction of the acromioclavicular joint using no. 5 nonabsorbable suture material while the resutured coracoclavicular (CC) ligament heals. Twenty-one patients (16 men and five women) with types IV and V acromioclavicular joint dissociation were studied. In all cases, acromioclavicular joint was reduced and reduction was maintained using no. 5 nonabsorbable suture material passed as a loop under the knuckle of the coracoid process and through a tunnel drilled through the lateral third of the clavicle. The CC ligament was then resutured. Patients were followed up over a period of 6-9 years. At the final follow-up, all patients had returned to their preinjury level of activity, with significant improvement in the University of California Los Angeles (UCLA), American Shoulder and Elbow Surgeons Shoulder (ASES), and the Constant scores. This technique provided good results with no loss of reduction, except in a single case, during the long follow-up period. We could not prove that the good results are due to the healing of the CC ligament. However, patients were able to return to their daily activities and even contact sports without any noticeable deformity, feeling of weakness, pain, or limitation of range of motion (compared with the contralateral side). This technique does not involve the use of metallic implants, which require another surgery to remove them, the use of expensive synthetic graft, or a graft harvested from a distant donor site.
Background Acromioclavicular (AC) dislocation involves complete loss of articular contact; it is defined as chronic when it follows conservative management or unsuccessful surgical treatment. Materials and methods The study compared the clinical and radiographic outcomes of AC joint stabilization performed in 40 patients with chronic dislocation using a biological allograft (group A) or a synthetic ligament (group B). Demographic data included: M/F: 25/15; mean age: 35 ± 3.2 years; previous surgery in 11 patients, including Weaver–Dunn (3), coracoacromial ligament repair (4), stabilization with K-wires (4). Dislocation was type III in 14 (35 %) and type IV in 26 (65 %) patients. Clinical assessment was with the Constant–Murley score (pre- and postoperative) and with the modified UCLA score. Enrollment started in January 2004 and was completed in March 2008. Patients were evaluated at 1 and 4 years. Postoperative X-rays were examined to assess joint stability in the coronal and axial planes, coracoclavicular ossification, and signs of AC joint osteoarthritis and distal clavicular osteolysis. Results The “biological” group achieved significantly better clinical scores than the “synthetic” group at both 1 and 4 years. Poor subjective satisfaction and lower clinical scores were found in the 3 patients (1 from group A and 2 from group B) who experienced complete postoperative dislocation. No significant correlations were found with other radiographic parameters. Conclusions The biological graft afforded better clinical and radiographic outcomes than the synthetic ligament in patients with chronic AC joint instability. Fixation to the clavicle constitutes the main weakness of both approaches and needs improving.
Maximum breaking force in the vertical traction biome- chanical test for each cadaveric piece
Scheme for anatomic repair of the coracoclavicular ligaments in a “V” configuration. Note the arrangement of a single CC suspension device with two tunnels in the clavicle and one in the coracoid
The best treatment option for some acromioclavicular (AC) joint dislocations is controversial. For this reason, the aim of this study was to evaluate the vertical biomechanical behavior of two techniques for the anatomic repair of coracoclavicular (CC) ligaments after an AC injury. Eighteen human cadaveric shoulders in which repair using a coracoclavicular suspension device was initiated after injury to the acromioclavicular joint were included in the study. Three groups were formed; group I (n = 6): control; group II (n = 6): repair with a double tunnel in the clavicle and in the coracoid (with two CC suspension devices); group III (n = 6): repair in a "V" configuration with two tunnels in the clavicle and one in the coracoid (with one CC suspension device). The biomechanical study was performed with a universal testing machine (Electro Puls 3000, Instron, Boulder, MA, USA), with the clamping jaws set in a vertical position. The force required for acromioclavicular reconstruction system failure was analyzed for each cadaveric piece. Group I reached a maximum force to failure of 635.59 N (mean 444.0 N). The corresponding force was 939.37 N (mean 495.6 N) for group II and 533.11 N (mean 343.9 N) for group III. A comparison of the three groups did not find any significant difference despite the loss of resistance presented by group III. Anatomic repair of coracoclavicular ligaments with a double system (double tunnel in the clavicle and in the coracoid) permits vertical translation that is more like that of the acromioclavicular joint. Acromioclavicular repair in a "V" configuration does not seem to be biomechanically sufficient.
Bio-activity of samples D and E
Use of antibiotic-loaded acrylic bone cement to treat orthopaedic infections continues to remain popular, but resistance to routinely used antibiotics has led to the search for alternative, more effective antibiotics. We studied, in vitro, the elution kinetics and bio-activity of different concentrations of meropenem-loaded acrylic bone cement. Meropenem-loaded bone cement cylinders of different concentrations were serially immersed in normal saline. Elution kinetics was studied by measuring the drug concentration in the eluate, collected at pre-determined intervals, by high-performance liquid chromatography. Bio-activity of the eluate of two different antibiotic concentrations was tested for a period of 3 weeks against each of the following organisms: Staphylococcus aureus ATCC 2593 (MSSA), Enterococcus faecalis ATCC 29212, Pseudomonas aeruginosa ATCC 27853, Escherichia coli ATCC 25922, S. aureus ATCC 43300 (MRSA) and Klebsiella pneumoniae ATCC 700603 (ESBL). Meropenem elutes from acrylic bone cement for a period of 3-27 days depending on the concentration of antibiotic. Higher doses of antibiotic concentration resulted in greater elution of the antibiotic. The eluate was found to be biologically active against S. aureus ATCC 2593 (MSSA), P. aeruginosa ATCC 27853, E. coli ATCC 25922 and K. pneumoniae ATCC 700603 (ESBL) for a period of 3 weeks. The elution of meropenem is in keeping with typical antibiotic-loaded acrylic bone cement elution characteristics. The use of high-dose meropenem-loaded acrylic bone cement seems to be an attractive option for treatment of resistant Gram-negative orthopaedic infections but needs to be tested in vivo.
Frequency distribution of tibial fractures and ACSs during the study period
We sought to examine the occurrence of acute compartment syndrome (ACS) in the cohort of patients with tibial diaphyseal fractures and to detect associated risk factors that could predict this occurrence. A total of 1,125 patients with tibial diaphyseal fractures that were treated in our centre were included into this retrospective cohort study. All patients were treated with surgical fixation. Among them some were complicated by ACS of the leg. Age, gender, year and mechanism of injury, injury severity score (ISS), fracture characteristics and classifications and the type of fixation, as well as ACS characteristics in affected patients were studied. Of the cohort of patients 772 (69 %) were male (mean age 39.60 ± 15.97 years) and the rest were women (mean age 45.08 ± 19.04 years). ACS of the leg occurred in 87 (7.73 %) of all tibial diaphyseal fractures. The mean age of those patients that developed ACS (33.08 ± 12.8) was significantly lower than those who did not develop it (42.01 ± 17.3, P < 0.001). No significant difference in incidence of ACS was found in open versus closed fractures, between anatomic sites and following IM nailing (P = 0.67). Increasing pain was the most common symptom in 71 % of cases with ACS. We found that younger patients are definitely at a significantly higher risk of ACS following acute tibial diaphyseal fractures. Male gender, open fracture and IM nailing were not risk factors for ACS of the leg associated with tibial diaphyseal fractures in adults. Level IV.
Bedside fasciotomy patients
Fasciotomy for compartment syndrome is an emergent procedure that is usually done in the operating theater under general anesthesia. Delay in performing the procedure can lead to worse outcome. Various reasons can cause delay in performing the surgery. Bedside fasciotomy under local anesthesia can be done in these cases to avoid delay in compartment release. This was a retrospective study of 34 cases of acute compartment syndrome for which fasciotomy was done at the bedside under local anesthesia. The minimum follow-up period was 6 months. All patients had immediate and marked improvement in pain. Thirty-three patients regained their normal muscle strength. Thirty-two patients regained normal range of motion of adjacent joints. One patient developed flexion contracture of the great toe. There was no deep infection, chronic osteomyelitis, or amputation. Superficial wound infection was noted in three patients; one patient had persistent foot drop. Bedside fasciotomy under local anesthesia is a feasible, safe, and effective choice for treating compartment syndrome in patients with delayed presentation or those with anticipated delay to undergo surgery in the operating theater under general or regional anesthesia. The results of this study are encouraging, as all wounds healed satisfactory and there were no cases of deep infections. The formal release of compartments in the operating room under general anesthesia continues to be the standard of care. This is the first description in the literature for bedside fasciotomy under local anesthesia with a relatively large number of patients.
Fast spin echo (FSE) T2-weighted magnetic resonance images (MRI) in the sagittal plane. Lumbosacral angle and lumbar lordosis angle are average values. a Supine position: lumbosacral angle
Background Patients with low back pain frequently demonstrate recumbent magnetic resonance imaging (MRI) alterations not always related to homogeneous clinical symptoms. The purpose of this study was to evaluate and quantify the statistical significance of variations of some anatomical parameters of the lumbosacral spine and reveal occult disc pathologies from recumbent to upright position in patients with acute and chronic low back pain. Materials and methods Fifty-seven patients complaining of low back pain (27 women, 30 men) underwent dynamic lumbosacral MRI with a 0.25-T tilting system (G-scan Esaote). We settled five parameters for which variations have been evaluated: lumbosacral angle, lordosis angle, L3–L4 intersomatic disc height, L3–L4 interspinous processes distance, and widest anteroposterior dural sac diameter. Images were obtained in both recumbent and upright positions. Results Statistically significant differences [one-way analysis of variance (ANOVA), p = 0.0043] were found between each pair of values of parameters sampled in recumbent and upright positions. In 70 % of patients, on visual qualitative analysis only, an increment of disc protrusions and/or spondylolisthesis was found in the upright position; in three cases, in the upright position only, an interarticular pseudocyst was found. Conclusions Dynamic MRI with an open-configuration, low-field tilting MRI system is a feasible and promising tool to study degenerative pathology of the spine. Moreover, in cases of low back pain with negative MRI in the recumbent position or in patients with pain in the upright position only, tilting MRI permits visualization of occult spine and disc pathologies in patients with acute or chronic low back pain.
Case 1. a Femoral stabilization with external monolateral fixator after urgent laparotomy. b One year after the accident, radiograph shows severe hip osteoarthritis. c Intraoperative view of screw’s hole during hip prosthesis implant. d Postoperative radiograph after surgical debridment
We report two cases of acute infection of an uncemented femoral component in a hip prosthesis implanted after external fixation of a femoral fracture. In both cases, the surgical access did not cross over the pin scars. When the prosthesis was implanted the stem crossed one or more pin tracts. The preoperative clinical examination, laboratory tests and bone scintigraphy with marked granulocytosis did not show signs of local infection in either case. We suggest that every patient destined to receive a prosthesis after external fixation should be treated with a staged procedure, the first step being excision of the soft tissues around the pin tracts and curettage or drilling of the bony holes, followed by prosthesis implant.
The external rotation method for the reduction of an acute anterior dislocation of the shoulder. a The patient is in the supine position with the elbow in 90° flexion. b The arm is adducted to the side of the chest and the shoulder is placed in 20° forward flexion. c The shoulder is externally rotated until the forearm is in the coronal plane. d The arm is internally rotated to bring the forearm into the abduction position
Shoulder dislocations account for almost 50% of all joint dislocations, and are most commonly anterior (90-98%) and occur due to trauma. This prospective study was conducted to report our experiences of using the external rotation method (ERM) in the reduction of acute anterior shoulder dislocation. Between August 2006 and April 2007, ERM was applied to 31 patients who presented with traumatic anterior shoulder dislocation to the Emergency Department of our Hospital which is a level 2 trauma centre. We evaluated the type of dislocation, the effectiveness of the procedure in achieving reduction, the need for premedication, the ease of performing the reduction, and complications, if any. Of the 31 patients, 29 had a successful reduction. No premedication was required in 25 patients who had a successful reduction, and the average time required for reduction in 25 was less than 2 min. Only five patients reported severe pain during the process of reduction. The method was not successful in two patients in whom the reduction was achieved under narcosis. We experienced a success rate of 89% at the first attempt. None of the patients encountered any complication. ERM for the reduction of acute anterior dislocation of the shoulder is a safe and reliable method, mainly without requirement for any sedatives or opiate analgesics, that can be performed relatively painlessly for anterior shoulder dislocations. As no single method has a 100% success rate, ERM is a useful one to know.
Anatomy: 1 nail plate, 2 nail bed, 3 nail matrix, 4 eponychium, 5 hyponychium, 6 proximal nail fold, 7 nail root
The fingernail has an important role in hand function, facilitating the pinch and increasing the sensitivity of the fingertip. Therefore, immediate and proper strategy in treating fingernail injuries is essential to avoid aesthetic and functional impairment. Nail-bed and fingertip injuries are considered in this review, including subungual hematoma, wounds, simple lacerations of the nail bed and/or matrix, stellate lacerations, avulsion of the nail bed, ungual matrix defect, nail-bed injuries associated with fractures of the distal phalanx, and associated fingertip injuries. All these injuries require careful initial evaluation and adequate treatment, which is often performed under magnification. Delayed and secondary procedures of fingernail sequelae are possible, but final results are often unpredictable.
Top-cited authors
Simone Cerciello
  • Casa di Cura Villa Betania. Roma
Kristian Bjorgul
  • Aleris Health, Oslo
Nikolaos G Lasanianos
  • National and Kapodistrian University of Athens
Friedemann Awiszus
  • Otto-von-Guericke-Universität Magdeburg
Géza Pap
  • Park-Krankenhaus, Leipzig