Bilateral Femoral Neck Pseudarthrosis in an Adolescent Girl With Congenital Spondyloepiphyseal Dysplasia. The Treatment Journey: A Case Report.

CASE: We describe the surgical management of a girl with dwarfism and congenital spondyloepiphyseal dysplasia, who presented in adolescence with coxa vara and bilateral pseudarthrosis between the femoral neck and the diaphysis, with asymmetric distal migration at both sites and leg length discrepancy. The patient at 16 years underwent valgus osteotomy in situ and femoral neck fixation in the left hip. The right hip was operated 19 months later. CONCLUSION: Hip dysplasia is common in spondyloepiphyseal dysplasia, but a debilitating nontraumatic bilateral pseudarthrosis at the base of the femoral neck has not been previously reported. Valgus corrective osteotomies of the femur in situ led to union and allowed the patient to walk.

Characteristics, Management, and Outcomes of Inferior Scapula Angle Fractures: A Systematic Review of the Literature.

Fractures of the inferior angle of the scapula represent a rare entity, with few cases published in the literature to date. Their optimal management is still unclear. A systematic literature search was conducted in PubMed and Google Scholar of reports published between 1977 and 2022. Inclusion criteria were cases presenting inferior scapula angle fractures (ISAF) and reporting management and outcomes. Extracted data included patient demographics (age, sex), mechanism of injury, associated injuries, management, procedures performed, and outcomes. Seventeen studies (22 cases; 19 males and three females) were included. The mean age was 33 years (15 adult and seven pediatric cases). High energy injuries were the most common mechanism of injury (77%). Displacement of the fragment was reported in 64%. The most common initial treatment was conservative (77%); of these cases, more than half failed initial treatment (53%). Of the displaced ISAF cases, 89% failed conservative treatment, contrary to 83% of the nondisplaced cases that were successfully treated conservatively. Surgery yielded 100% success both as initial treatment and after failed conservative management. Displaced fractures should be approached surgically, while conservative management should be reserved for nondisplaced fractures.

Factors predisposing to thrombosis after major joint arthroplasty.

BACKGROUND: Total joint arthroplasty is one of the most common options for end stage osteoarthritis of major joints. However, we must take into account that thrombosis after hip/knee arthroplasty may be related to mutations in genes encoding for blood coagulation factors and immune reactions to anticoagulants [heparin-induced thrombocytopenia (HIT)/thrombosis]. Identifying and characterizing genetic risk should help to develop diagnostic strategies or modify anticoagulant options in the search for etiological mechanisms that cause thrombophilia following major orthopedic surgery. AIM: To evaluate the impact of patients' coagulation profiles and to study specific pharmacologic factors in the development of post-arthroplasty thrombosis. METHODS: In 212 (51 male and 161 female) patients that underwent primary total hip arthroplasty (100) or total knee arthroplasty (112) due to osteoarthritis during a period of 1 year, platelet counts and anti-platelet factor 4 (PF4)/heparin antibodies were evaluated pre/postoperatively, and antithrombin III, methylenetetrahydrofolate reductase, factor V and prothrombin gene mutations were evaluated preoperatively. In a minimum follow-up of 3 years, 196 patients receiving either low-molecular-weight heparins (173) or fondaparinux (23) were monitored for the development of thrombocytopenia, anti-PF4/heparin antibodies, HIT, and thrombosis. RESULTS: Of 196 patients, 32 developed thrombocytopenia (nonsignificant correlation between anticoagulant type and thrombocytopenia, P = 0134.) and 18 developed anti-PF4/heparin antibodies (12/173 for low-molecular-weight heparins and 6/23 for fondaparinux; significant correlation between anticoagulant type and appearance of antibodies, P = 0.005). Odds of antibody emergence: 8.2% greater in patients receiving fondaparinux than low-molecular-weight heparins. Gene mutations in factor II or V (two heterozygotes for both factor V and II) were identified in 15 of 196 patients. Abnormal low protein C and/or S levels were found in 3 of 196 (1.5%) patients, while all patients had normal levels of von Willebrand factor, lupus anticoagulant, and antithrombin III. Four patients developed HIT (insignificant correlation between thrombocytopenia and antibodies) and five developed thrombosis (two had positive antibodies and two were heterozygotes for both factor II & V mutations). Thrombosis was not significantly correlated to platelet counts or HIT. The correlation of thrombosis to antibodies, factor II, factor V was P = 0.076, P = 0.043, P = 0.013, respectively. CONCLUSION: Screening of coagulation profile, instead of platelet monitoring, is probably the safest way to minimize the risk of post-arthroplasty thrombosis. In addition, fondaparinux can lead to the formation of anti-PF4/heparin antibodies or HIT.

Association Between Serum Lipid Levels in Greek Children with Dyslipidemia and Mediterranean Diet Adherence, Dietary Habits, Lifestyle and Family Socioeconomic Factors.

Background: Childhood dyslipidemia is an important risk factor for developing cardiovascular disease in adulthood. Our study aimed to investigate a possible correlation between nutritional, lifestyle, behavioral and socioeconomic factors and serum lipid levels in children with dyslipidemia. Methods: In this retrospective, observational study, in 31 children with dyslipidemia, aged 3-14 years, dietary habits, physical activity, hours watching television or playing video games, family's socioeconomic status, weight of children and parents, and duration of breastfeeding were recorded. The children's adherence to the Mediterranean diet was also evaluated by KidMed index. Statistical analysis was performed using SPSS.22. Results: Children with increased physical activity had lower triglyceride levels, compared to those with lower physical activity (p = 0.001). Children who consumed only one meal per day, had increased levels of total cholesterol (p = 0.01), LDL-cholesterol (p = 0.01), ApoB (p = 0.001) and lipoprotein (a) (p=0.018), compared to those who consumed more than 3 meals per day (p < 0.05). Children who were breastfed less than 6 months had significantly increased LDL-C levels (p = 0.022), compared to children who were breastfed more than 6 months. All other parameters investigated did not differ significantly. Conclusions: This study showed association between lipid profile of children with dyslipidemia and specific nutritional and socioeconomic factors, such as increased physical activity, increased meals consumption during the day, and exclusive breastfeeding for more than 6 months. Nevertheless, further research is needed, in order to confirm these findings.

Infections of Deep Hand and Wrist Compartments.

The human hand is the most exposed part of the body to highest risk for injuries, loss of the skin integrity, and to the inoculation of bacteria, most commonly Staphylococcus aureus, Streptococcus ß-haemolytic, and gram-negative. In case of an infection, the mobile anatomical structures and the synovial membranes in close proximity to each other may spread the pus towards deep spaces and compartments. Mild early infections without an abscess formation may respond to antibiotics, but at more advanced stage, erythema, swelling, stiffness, and severe pain may ensue. Abscess formation will cause debilitating pain, fever, systemic symptoms, and even sepsis. Necrotizing infections may threaten not only the limb, but also patient's life. Therefore, an initially "trivial" hand injury should never be neglected, as it might turn into a deep space infection, which must be treated immediately with drainage, wound debridement, and i.v. antibiotics. Delay in diagnosis and inadequate initial management might rapidly lead to abscess formation, destruction of the gliding surfaces and the normal anatomy, and irreparable functional deterioration.

Closed-space hand infections: diagnostic and treatment considerations.

Despite modern diagnostic methods, surgical advances and antibiotics evolution, acute closed-space hand infections still remain a therapeutic challenge. The aim of this review is to present its special clinical features and the current therapeutic management based on the infection site, the type of the infecting pathogen and the host-type. Anatomic pathways facilitate the spread of the infection towards spots of decreased resistance. The accumulation of purulent material subsequently raises the pressure within the closed-space, leading to ischemia and necrosis. These infections are usually attributed to gram-positive cocci and clinicians should also consider the local spread of community-acquired methicillin resistant S. aureus and the host's comorbidities (immunosuppression, diabetes) before choosing the appropriate antibiotics. Surgical treatment including drainage and irrigation is imperative. The knowledge of anatomy, closed-space pathophysiology and current updates in microbiology and drainage/irrigation techniques are prerequisites for prompt diagnosis and optimal treatment of acute closed-space hand infections.

Functional gains after surgical procedures in spastic upper extremity: a comparative study between children and adults.

Thirty-four patients with spastic upper extremity secondary to cerebral palsy underwent operative treatment with bony and soft tissue procedures including osteotomies, capsulotomies tendon transfers, lengthening and releases. The follow-up ranged from 24 months to 9 years with a mean of 52 months. For the evaluation of the surgical outcome patients were classified into two age groups, one younger (4-14 years) and one older (15-34 years). All patients in both the groups presented with significant improvement postoperatively. Patients who were operated early (first group) had statistically better results in a series of tasks that were used for evaluation. We suggest early intervention with all necessary surgical steps which should be individualized depending on patient's situation and needs.

Infection following operative treatment of ankle fractures.

UNLABELLED: Information on the microbiology of infections after operative ankle fractures, on the details of a treatment protocol used when the ankle joint is preserved, and on the outcome of this protocol will be helpful for the physicians managing patients with this complex problem. We therefore determined the most common pathogen of these infections, the infection recurrence rate, and the amputation rate. We retrospectively reviewed 26 patients of a mean age of 43 years with infections following operative treatment of ankle fractures. Twenty-one of 26 patients (81%) were compromised hosts according to the Cierny-Mader classification. Patients presenting up to 10 weeks postoperatively were treated by débridement and either hardware retention (if implants were judged stable) or hardware removal (if implants were loose). All patients presenting more than 10 weeks postoperatively underwent débridement and hardware removal, with the exception of one patient who underwent below knee amputation. Staphylococcus aureus was identified in 17 patients (65%) and was oxacillin-resistant in six (23%). The infection recurred in five of 18 patients who were followed up for 8 months on average. Three recurrent infections were controlled with repeat débridement. The remaining two patients underwent below-knee amputation, resulting in amputations in 3 of 18 patients. Infection after operative treatment of ankle fractures is a limb-threatening complication, especially in patients with comorbidities, such as diabetes mellitus. Treatment is challenging with high infection recurrence and amputation rates. LEVEL OF EVIDENCE: Level IV, therapeutic study case series.

Relapsed clubfoot correction with soft-tissue release and selective application of Ilizarov technique.

The Ilizarov technique is an alternative for the treatment of complex foot deformities in children. The authors retrospectively reviewed children with relapsed clubfoot deformity, treated with soft tissue procedures and additional correction with an Ilizarov frame. Twelve consecutive patients (13 feet) with relapsed clubfoot deformity after previous surgical correction were reviewed. Treatment included open releases. An Ilizarov frame was applied as an adjunct in seven patients (mean age of 7.8 years) with severe deformity where complete intraoperative correction was not achieved. Clinical and radiographic assessment was undertaken. The mean Laaveg-Ponseti score, for the 7 feet treated with the Ilizarov frame, was 85.1 after minimum 4 years follow-up. One recurrence of forefoot deformity required metatarsal osteotomies. Postoperative radiographic measurements revealed values that can be considered as normal. Complications included pin tract infections (12% of inserted wires). Flat-topped talus was observed in 3 feet. Deformity correction was possible when soft tissue procedures were combined with the use of Ilizarov technique, in order to support and gradually improve surgical correction.

Clinical and epidemiological features of upper-extremity infections caused by Staphylococcus aureus carrying the PVL gene: a four-year study in Greece.

BACKGROUND: All Staphylococcus aureus isolated during 2003-2006 at a university hospital in Thessalia, central Greece, from ulcerative upper-extremity infections were tested for the presence of PVL gene and for possible clonal relationship to validate the role of PVL toxin in the clinical features of these infections and also to establish preventive measures towards limiting the spread of such strains among close contacts. MATERIAL/METHODS: Of 305 bacterial cultures obtained from consecutive patients suffering from purulent musculoskeletal infections of an upper extremity, 207 revealed the presence of S. aureus (81 methicillin-resistant and 126 methicillin-sensitive). Seventy of the 207 cultures were found to be positive for the PVL gene. RESULTS: The PVL gene was detected in 12.1% (2003), 46.7% (2004), 34% (2005), and 53% (2006) of upper-extremity staphylococcal infections, indicating a statistically significant increase between 2003 and 2004-2006. However, there was a significant decrease in readmissions during 2005 and 2006 and also in the number of relatives diagnosed with PVL-positive infections during the same period of time. The localization of these infections, their higher incidence during summer, and the transmission to family members indicated that contact was the means of spread of PVL-positive S. aureus. Most isolates belonged to the ST-80 clone, predominant in Europe. CONCLUSIONS: The emergence of new MRSA and also MSSA clones carrying the PVL gene and the decreases in readmissions and number of infected "close contacts" emphasizes the need for closer systematic surveillance and the implementation of preventive measures.

Compartmental infections of the hand.

Suppurative conditions of the hand-wrist compartments result in a "vicious circle" of infection and increase in compartmental pressure that reduces perfusion of soft tissues and facilitates spreading of the infection. We have assessed the outcome of such infections in relation to the infecting pathogen, delay in diagnosis, and method of treatment. Fifty-nine patients were treated with drainage, irrigation, and antibiotics and followed up for 6-58 (median 18) months. Staphylococcus aureus was detected in 29 of 39 cultures (74%) that grew pathogens. At the latest follow-up results were excellent in 49 cases. Sixteen required reoperation or readmission. There was a significant association between final range of movement (ROM) and extent of infection (p=0.01). The type of pathogen was also significantly associated with a worse outcome (p=0.03 for ROM, p=0.04 for DASH). These infections have poor results when treatment is delayed or inadequate, as a result of the extended infection, inadequate drainage or inappropriate antibiotic treatment of certain types of bacteria.

Low-molecular-weight heparin for prevention of thrombosis: inverted role.

BACKGROUND: Heparin induced thrombosis (HIT) after low-molecular-weight (LMWH) administration for thrombosis prevention is a limb and life threatening condition. METHODS: Two previously healthy individuals, with nonviable forearm amputation and knee osteoarthritis, suffered from multiple arterial thromboses (>2 sites each) after postoperative administration of LMWH. RESULTS: Both patients suffered from thrombocytopenia on the first postoperative days (4-7) and had signs of arterial occlusions on the 9th and 10th postoperative days. The patient with the initially successful forearm replantation was finally amputated below the elbow, whereas the lower extremity of the patient with total knee arthroplasty and contralateral femoral artery occlusion was salvaged with foot fingers amputation only. CONCLUSIONS: Early recognition of the syndrome by monitoring daily platelet counts during heparin therapy is essential. In case of postheparin (LMWH or unfractionated) platelet decrease, heparin administration should be ceased after emergency testing for heparin induced antibodies. When HIT syndrome is confirmed to have occurred, heparin/LMWH must be replaced with thrombin-specific inhibitors.