Exploring consistent ratios in morphometry of the proximal tibia: insights for knee arthroplasty.

INTRODUCTION: The current study, which delves into proximal tibia morphometric parameters in a Greek sample, not only analyzes whether specific linear distance ratios are consistent but also paves the way for a potential novel metric system for knee arthroplasty imaging studies using constant ratios. These findings could have significant implications for future enlarged research and clinical practice. METHODS: A total of 38 dried tibiae were evaluated by two independent investigators. The following distances were measured with a digital Vernier sliding caliper: (1) the mediolateral distance of the proximal surface (A), (2) the anteroposterior distance of the proximal surface (B), (3) The longitudinal length of the bone (C), (4) the line connecting the anterior margin of the proximal surface with the highest peak of the tibia tuberosity (D), (5) the depth of the proximal margin of the medial articular facet (AF) (medial plateau) (E) and (6) the depth of the proximal margin of the lateral AF (lateral plateau) (F). RESULTS: The A, B, C, D, E, and F mean distances were 71.3 mm, 47.4 mm, 340.2 mm, 37.1 mm, 42 mm, and 35.9 mm. Reliability analysis for each observer on all measurements revealed an interclass correlation (ICC) score of 0.975 (observer 1) and 0.971 (observer 2). The ratio A/B was 1.5, A/C was a constant 0.2, and D/C was 0.1. The ratio E/F was 1.2. The six measurements (A-F) showed excellent inter-observer reliability (all ICC values > 0.990). CONCLUSIONS: The study established constant ratios of the studied linear distances around the proximal tibia. Considering these ratios, asymmetrical tibial components in knee arthroplasty seem to replicate the native anatomy more closely. Furthermore, the distance from the anterior margin of the proximal surface to the tibial tuberosity peak, constituting one-tenth of the longitudinal length of the tibia, shows promise as a metric system for imaging studies, especially in assessing lesions around tibial components.

Press-fit vs threaded acetabulum components for total hip arthroplasty - A systematic review with metanalysis.

Background: Threaded acetabular components (TACs) have been shown to offer greater initial stability compared to press-fit acetabular components (PFACs). Despite these biomechanical advantages, the use of threaded cups remains. This study compares the outcomes of TACs to PFACs in total hip arthroplasty (THA), providing evidence-based data regarding their failure rates and radiological evaluation. Methods: A meticulous research of PubMed and MEDLINE databases, following the PRISMA guidelines, was conducted, to identify all articles regarding the outcome of the use of TCAs compared to PFACs in THA. Subsequently, statistical analysis with metanalysis concerning: 1) the instances of revision due to aseptic loosening and 2) the radiological evaluations of TACs compared to PFACs and sensitivity analysis were performed. Results: This metanalysis encompassed seven studies, enrolling 7878 cases of THA utilizing PFAC, and 6684 cases using TAC. The overall odds ratio (OR) for revision due to aseptic loosening in THA using PFAC compared to TAC was 3.10 (95 % CI 0.37-25.72). Additionally, when assessing radiolucency findings across the same categories, the pooled OR was 0.53 (95 % CI 0.26-1.08). An examination of studies with larger sample sizes revealed no statistically significant variance. After adjusting for age, no substantial difference was detected. However, upon gender adjustment, it was observed that females undergoing THA with PFAC had a 5-fold risk of revision (OR = 5.26, 95 % CI 0.25-111.91, p-value = 0.29) compared to females with TAC, although without reaching statistical significance. Moreover, females exhibited a slightly elevated risk for revision due to aseptic loosening post-PFAC THA compared to males [(OR = 5.26, 95 % CI 0.25-111.91) (OR = 2.51, 95 % CI 0.01-1051.68) respectively], and for radiolucency findings [(OR 0.74, 95 % CI 0.20-1.11) (OR 0.29, 95 % CI 0.03-3.36) respectively]. Conclusions: The PFACs remain the main option for total hip reconstruction, while TACs might be a viable alternative, especially in cases of osteoporosis.

Interdepartmental miscommunication regarding radiology: Addressing chronic challenges and exploring solutions.

Effective communication and collaboration among healthcare professionals are crucial for delivering high-quality patient care. Interdepartmental miscommunication poses a significant challenge to healthcare systems, potentially undermining the quality of healthcare services provided. In the same manner, communication barriers between referring physicians and radiologists can specifically affect radiology services and patient outcomes. This article attempts to put the spotlight on the ever-present chronic challenges of this issue and prompt readers to recognize the relevant potential pitfalls in their daily clinical practice. Practical solutions are explored and proposed, which should be tailored to the specific needs and issues that each individual institution may face.

Survivorship and Outcomes of Robotic Arm-Assisted Medial Unicompartmental Knee Arthroplasty at a Minimum of 5-Year Follow-Up.

PURPOSE: This study aimed to evaluate implant survivor-ship, complications, and re-operation rates following robotic arm-assisted unicompartmental knee arthroplasty (UKA) at mid-term follow-up. METHODS: Patient satisfaction, clinical outcome, and knee alignment restoration were evaluated. All patients undergo-ing robotic arm-assisted medial UKA during a 2-year period were prospectively enrolled. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, varus-valgus deformity, and knee range of motion were studied pre- and postoperatively. Revisions and surgery-related complications were recorded. RESULTS: Eighty-five patients were included in the study (mean age: 71.2 years). The mean follow-up was 74.7 months. One conversion to total knee arthroplasty was performed due to periprosthetic fracture 4.5 years after initial surgery result-ing in a survivorship rate of 98.8%. Overall satisfaction was excellent; 97.7% of patients were satisfied or very satisfied, while none was dissatisfied or very dissatisfied. WOMAC score in total, as well as in each component, exhibited sig-nificant improvement postoperatively. Additionally, knee alignment in the coronal plane as well as flexion contracture were significantly improved following the procedure. CONCLUSIONS: The outcomes of the present cohort revealed that precise prosthesis implantation through the robotic arm-assisted system in UKA provided excellent overall satisfac-tion rates and clinical outcomes at mid-term follow-up.

Extended Interportal Capsulotomy for Hip Arthroscopy, a Single-Center Clinical Experience.

Background and Objectives: The number of hip arthroscopy procedures is on the rise worldwide, and awareness regarding proper management of the hip capsule has increased. No capsulotomy shape is agreed upon as a standard approach, with literature supporting both isolated interportal and T-shaped capsulotomies. The aim of this retrospective cohort study is to report the clinical results of a standardized extended interportal capsulotomy (EIPC) during hip arthroscopy. Materials and Methods: Patients operated on between 2017 and 2020 with a hip arthroscopy were eligible. The inclusion criteria were ages 18-60 years, failed non-operative treatment, and at least a 2-year follow-up. Exclusion criteria were bilateral femoroacetabular impingement syndrome (FAS) cases or labral lesions, ipsilateral knee injury, history of ipsilateral hip surgery, and significant spine lesions. Data regarding demographic characteristics such as age, gender, operation date, BMI, but also Beighton score, presence of postoperative pudendal nerve damage, and revision for any reason were gathered from patients' records. All patients were evaluated preoperatively with a visual analog scale (VAS), the Hip Disability and Osteoarthritis Outcome Score (HOOS), and the modified Harris Hip Score (mHHS). Results: Of the 97 patients operated on with a hip arthroscopy between the defined dates, only 90 patients were included. The mean age was 37.9 ± 9.8, and 58.9% of patients were male. The most frequent surgical indication was an isolated FAS lesion (73.3%), followed by FAS associated with a labral tear (12.2%), an isolated labrum tear (10.0%), synovitis (3.3%), and a loose body (1.1%). The mean follow-up for the study cohort was 39.3 months. The majority of the patients had uneventful surgeries (76.7%), while there were three cases of sciatic nerve neuropraxia and 12 cases of pudendal nerve neuropraxia. Two patients underwent revision surgery during the study period. Comparison between preoperative and postoperative clinical scores showed a significant improvement with a final mHHS mean value of 67.7 ± 18.2, an HOOS value of 74.1 ± 13.2, and a low VAS score of 1.3 ± 1.2. Conclusions: A hip arthroscopy procedure with a standardized and unrepaired, extended interportal capsulotomy is a safe procedure with satisfactory mid-term results and high overall patient satisfaction. At a minimum of 2 years and a mean of 39.2 months, patients showed improved clinical scores and a low revision rate.

Renal Artery Triplication: An Unusual Morphological Variant.

Renal vasculature depicts great morphological variability and clinical significance due to the great number of procedures performed on kidneys. The current imaging report presents a right-sided renal artery (RA) triplication and origin from the abdominal aorta (AA), which was incidentally identified during computed tomography angiography (CTA). The typical RA corresponded to the main hilar artery (MHA), the second RA corresponded to the superior polar artery (SPA), and the third RA corresponded to the inferior polar artery (IPA). RA triplication occurs in 0.9%-4.5% and depicts wide morphological variability. The current report corresponds to one superior polar, one inferior polar, and a main hilar renal artery, which represents a rare morphological type of RA triplication. Kidney transplantation surgery, endoscopic surgery, and renal angiography require adequate knowledge of RAs and their variants to avoid pitfalls and iatrogenic lesions from clinicians.

A bilateral gastrocnemius tertius coexisting with a unilateral two-headed plantaris muscle.

The current cadaveric report aims to present a coexistence of two uncommon variants of the posterior leg compartment. The variations were detected, during classical dissection in an 84-year-old donated male cadaver. On the left lower limb, the gastrocnemius muscle was identified as having a third head that was attached to the lateral head. This variant is known as gastrocnemius tertius muscle and was bilaterally identified. The left-sided plantaris muscle had two distinct heads that fused into a common tendon that was inserted into the calcaneal tuberosity. Knowledge of these variants is important, due to their close relationship with the popliteal neurovascular bundle. Clinicians should be aware, to avoid pitfalls and take them into account in their differential diagnosis.

Systematic Review and Meta-analysis of Suprascapular Notch Morphological Variability: Do We Know Everything?

The suprascapular notch represents a depression on the lateral part of the superior border of the scapula, medially to the coracoid process. The current paper presents a systematic review with a meta-analysis of the suprascapular notch morphological variability. Related clinical implications were further discussed as well to emphasize the value of the topic. A total of 31 articles were included in the meta-analysis, which depicted great heterogeneity. Thus, due to the different classification systems, difficulties were faced in creating a complete and united classification. All the problems and pitfalls that arise from each classification system were discussed, and we concluded with the most complete one. The knowledge of the suprascapular notch morphological anatomy is of great importance, especially for orthopedic surgeons, due to its relationship with the suprascapular nerve. Thus, further research in this area is adequate.

Rotational Thromboelastometry as a Diagnostic Tool for Persistent Infection in Two-Stage Exchange Arthroplasty.

Background/Objectives: There is a lack of reliable biomarkers for diagnosis of infection eradication prior to second-stage reimplantation in two-stage exchange arthroplasty for periprosthetic joint infections (PJIs). The aim of this study was to assess the diagnostic accuracy of rotational thromboelastometry (ROTEM) for persistent infection in two-stage exchange arthroplasties. Methods: A pilot, retrospective analysis was performed including 70 patients who underwent a two-stage exchange arthroplasty for PJI. They were categorized as patients without (n = 64) or patients with persistent infection (n = 6) prior to reimplantation. Definition of persistent infection prior to reimplantation was based on the 2018 ICM criteria. Conventional coagulation biomarkers and ROTEM parameters were compared between groups. Results: Higher FIBTEM MCF values were associated with persistent infection (odds ratio [OR], 1.30, 95% confidence interval [CI], 1.04-1.63; p = 0.020), and FIBTEM MCF had the highest diagnostic accuracy for persistent infection prior to second-stage reimplantation (AUC, 0.907; 95% CI, 0.812-1.000). A cut-off value ≥ 18 mm for FIBTEM MCF was found to have 100.0% sensitivity and 73.4% specificity for diagnosing persistent infection prior to second-stage reimplantation. Moreover, the diagnostic accuracy of FIBTEM MCF was higher than that of fibrinogen levels (p = 0.036) and D-dimer (p = 0.006). Conclusions: Our findings indicate that ROTEM parameters have the potential to identify persistent infections before reimplantation in two-stage exchange arthroplasties for PJI. Such coagulation biomarkers could provide guidance regarding the optimal timing for reimplantation. Further studies in larger populations are warranted to validate the diagnostic accuracy of ROTEM parameters for persistent PJI.

A Bilateral Symmetrical Variant Formation of the Sural Nerve.

Typically, the sural nerve is formatted by the connection of the lateral sural cutaneous nerve (branch of the common fibular nerve) and the medial sural cutaneous nerve (branch of the tibial nerve). The current cadaveric report aims to describe a quite unusual symmetrical variant of the sural nerve. Classical dissection was performed on an 84-year-old donated male cadaver. On both sides, the sural nerve was formatted directly by the sciatic nerve. After its emanation, it continued its typical course between the gastrocnemius muscle heads. Sural nerve formation has been extensively studied due to its great clinical significance. The identified variant corresponds to one of the rarest types of sural nerve formation. Knowledge of sural nerve variants may play a crucial role in lower limb surgery and nerve harvest for reconstruction.

Post-Discectomy Infection: A Critical Review and Suggestion of a Management Algorithm.

Postoperative discitis (POD) accounts for 20% to 30% of all cases of pyogenic spondylodiscitis, while POD may be mis-or-under-diagnosed, due to the vague related symptomatology and the non-specific imaging findings. Most studies report infection rate of less than 1%, which increases with the addition of non-instrumented fusion to 2.4% to 6.2%. It remains controversial whether POD is caused by an aseptic or infectious process. Positive cultures are presented only in 42-73% of patients with Staphylococcus species being the most common invading organisms, while Staphylococcus aureus is isolated in almost 50% of cases. The onset of POD symptoms usually occurs at 2-4 weeks after an apparently uneventful operation. Back pain and muscle spasms are usually refractory to bed rest and analgesics. Magnetic Resonance Imaging (MRI) is the most sensitive and specific imaging diagnostic technique. Antimicrobial therapy depends on the results of tissue cultures, and along with bracing represents the mainstay of management. Surgical intervention is necessary in patients failing conservative treatment. For the majority of cases, extensive surgical debridement, antibiotic therapy, and orthosis immobilization are effective in eliminating the infection. According to this, we recommend an Algorithmic approach for the management of POD. Postoperative infections after spinal surgery pose a certain clinical challenge, and in most cases can be treated conservatively. Nevertheless, disability may be persistent, and surgery could be necessary. The purpose of this concise review is to describe the manifestation of post-discectomy infection, its pathogenesis and particularly a rational approach for its management.

Diagnosis, Treatment, and Outcome of Coccidioidal Osseous Infections: A Systematic Review.

Extrapulmonary infections by Coccidioides spp., though rare, can occur via dissemination, affecting singular or multiple sites, including the skin and musculoskeletal system. Skeletal involvement often manifests as osteomyelitis, particularly in the axial skeleton. The present systematic review evaluates all documented cases of skeletal coccidioidomycosis to assess the diagnostic and treatment strategies alongside the outcomes, drawing insights from an analysis of 163 verified cases. A systematic review following PRISMA guidelines identified all studies reporting skeletal infections by Coccidioides spp. up to 2023 from the PubMed and Scopus databases. Eligible studies evaluated osteoarticular infections from Coccidioides spp. Data extraction included demographics, microbiological data, diagnostic methods, and treatment outcomes. Of the 501 initially identified records, a total of 163 patients from 69 studies met the inclusion criteria. Most cases were from the USA, predominantly males, while the median age of the population was 36 years. Diabetes mellitus was the common comorbidity (14.7%). C. immitis was the most prevalent pathogen. The spine and hand were common sites of infection (17.5% and 15.1%, respectively). Osteomyelitis by Coccidioides spp. was diagnosed, in most cases, by positive cultures (n = 68; 41.7%), while, in 49 (30.9%), both the histological examination and cultures yielded the fungus. Surgical debridement was performed in 80.9% of cases. A total of 118 (72.3%) patients were treated with monotherapy, while combination therapy with two or more antifungal agents was reported in 45 (17.7%). Amphotericin B (either liposomal or deoxycholate) was the most commonly given agent as monotherapy in 51 (31.2%) patients, while 30 (18.4%) patients received itraconazole as monotherapy. The rate of infection's resolution was higher in patients undergoing surgical debridement (79.5%), compared to those treated only with antifungal agents (51.6%, p = 0.003). Treatment outcomes showed complete resolution in 74.2% of patients, with a mortality rate of 9.2%. Coccidioidal osseous infections present diagnostic and therapeutic challenges. Surgical intervention is often necessary, complementing antifungal therapy. Vigilance for Coccidioides spp. infections, especially in regions with endemicity, is crucial, particularly when bacterial cultures yield negative results.

Restoring Hip Joint Anatomy With the Robotic Arm-Assisted System in Hip Fractures: Expanding the Applications for Hip Surgery.

Total hip arthroplasty (THA) has improved the life quality of osteoarthritic patients, yet challenges persist. The robotic arm-assisted system, integrated into THA, aims to refine implant positioning, enhance precision, reduce errors, and restore the hip joint's anatomy, including hip center, femoral offset, and limb length. We present the first use of the system for the treatment of a subcapital femoral neck hip fracture. A 62-year-old female suffering a left subcapital hip fracture underwent THA using the robotic arm-assisted system. After acetabular registration, accurate component placement was achieved, and a 9-mm limb length discrepancy was addressed. The patient had an unremarkable recovery with a reported Harris hip score of 96.5 at 18 months postsurgery. Robotic-guided navigation in THA, as showcased in this case, ensures accurate implant positioning by restoring the anatomical features of the hip joint. Its potential extends beyond conventional applications, hinting at future use in trauma, revision, and oncology cases. While promising, future adaptations should consider soft tissue dynamics to ensure joint stability and overall success.

Robotic Arm-Assisted Total Knee Arthroplasty: Anatomical Alignment and Mid-Term Outcomes from the First Cohort Originating in Greece.

Robotic arm-assisted total knee arthroplasty (RATKA) represents a haptic assistive robotic arm used for bone preparation. The purpose of this study was to present implant survivorship, complications and evaluate patients' satisfaction, clinical and functional outcome of RATKA with a minimum of 1-year follow-up. The Oxford Knee Score was recorded preoperatively and at last follow-up. Patients' satisfaction rates, as well as complications and re-operations were studied. Anatomical alignment including varus, valgus deformities and flexion, extension, pre-and postoperatively were evaluated. A total of 156 patients with mean age = 71.9 years were included in the study. The mean follow-up was 35.7 months, while one revision was performed due to infection. Statistically significant improvement of the Oxford Knee Score, as well as of the knee alignment deformities were recorded, while 99.4% of patients reported to be "very satisfied" or "satisfied" with the procedure. RATKA seems to be a safe, as well as reproductible procedure at short-and mid-term follow-up, while the accurate implant positioning may lead to favorable long-term outcomes.

Current Therapeutic Approaches for Multidrug-Resistant and Extensively Drug-Resistant Acinetobacter baumannii Infections.

The treatment of Acinetobacter baumannii infections remains a challenge for physicians worldwide in the 21st century. The bacterium possesses a multitude of mechanisms to escape the human immune system. The consequences of A. baumannii infections on morbidity and mortality, as well on financial resources, remain dire. Furthermore, A. baumannii superinfections have also occurred during the COVID-19 pandemic. While prevention is important, the antibiotic armamentarium remains the most essential factor for the treatment of these infections. The main problem is the notorious resistance profile (including resistance to carbapenems and colistin) that this bacterium exhibits. While newer beta lactam/beta-lactamase inhibitors have entered clinical practice, with excellent results against various infections due to Enterobacteriaceae, their contribution against A. baumannii infections is almost absent. Hence, we have to resort to at least one of the following, sulbactam, polymyxins E or B, tigecycline or aminoglycosides, against multidrug-resistant (MDR) and extensively drug-resistant (XDR) A. baumannii infections. Furthermore, the notable addition of cefiderocol in the fight against A. baumannii infections represents a useful addition. We present herein the existing information from the last decade regarding therapeutic advances against MDR/XDR A. baumannii infections.

The anterior communicating artery variants: a meta-analysis with a proposed classification system.

Morphological and morphometric variants of the anterior communicating artery (AComA) have been described by multiple studies; however, a complete classification system of all possible morphological variants with their prevalence is lacking. The current systematic review with meta-analysis combines data from different databases, concerning the AComA morphological and morphometric variants (length and diameter). Emphasis was given to the related clinical implications to highlight the clinical value of their knowledge. The typical AComA morphology occurs with a pooled prevalence (PP) of 67.3%, while the PP of atypical AComA is 32.7%. The identified AComA morphological variants (artery's hypoplasia, absence, duplication, triplication, differed shape, fenestration, and the persistence of a median artery of the corpus callosum- MACC) were classified in order of frequency. The commonest presented variants were the AComA hypoplasia (8%) and the anterior cerebral artery (ACA) fusion (5.9%), and the rarest ones were the MACC persistence (2.3%), and the AComA triplication (0.7%). The knowledge of those variants is essential, especially for neurosurgeons operating in the area. Given the high prevalence of AComA aneurysms, an adequate and complete classification of those variants is of utmost importance.

A bilateral four-headed brachialis muscle with a variant innervation: a cadaveric report with possible clinical implications.

PURPOSE: Anterior compartment muscles of the arm present high morphological variability, with possible clinical significance. The current cadaveric report aims to describe a bilateral four-headed brachialis muscle (BM) with aberrant innervation. Emphasis on the embryological background and possible clinical significance are also provided. METHODS: Classical upper limb dissection was performed on an 84-year-old donated male cadaver. The cadaver was donated to the Anatomy Department of the National and Kapodistrian University of Athens. RESULTS: On the left upper limb, the four-headed BM was supplied by the musculocutaneous and the median nerves after their interconnection. On the right upper limb, the four-headed BM received its innervation from the median nerve due to the musculocutaneous nerve absence. A bilateral muscular tunnel for the radial nerve passage was identified, between the BM accessory heads and the brachioradialis muscle. CONCLUSION: BM has clinical significance, due to its proximity to important neurovascular structures and frequent surgeries at the humerus. Hence, knowledge of these variants should keep orthopedic surgeons alert when intervening in this area. Further dissection studies with a standardized protocol are needed to elucidate the prevalence of BM aberrations and concomitant variants.

Comparison of Glenoid Dimensions Between 3D Computed Tomography and 3D Printing.

INTRODUCTION: Glenoid dimensions can be measured in vivo with various imaging methods including two-dimensional (2D) and three-dimensional computed tomography (CT) and magnetic resonance imaging scans. Printing of three-dimensional (3D) models of the glenoid using imaging data is feasible and can be used to better understand skeletal trauma and complex skeletal deformations such as glenoid bone loss in patients with shoulder instability. The purpose of this study was to compare measurements of glenoid dimensions on 3D CT scan reconstructed models and 3D printed models of the glenoid. METHODS: CT scans from 62 young, male adults acquired for non-trauma-related causes were evaluated. Following volume rendering, a stereolithography model of each scapula was constructed and a 3D model was printed. Additionally, 3D CT models of each glenoid were reconstructed using dedicated software. Measurements of the maximum glenoid height and width were performed on both the 3D printed and the 3D reconstructed models. To assess intra- and interrater reliability, measurements of 15 glenoids were repeated by two observers after three weeks. The measurements of the 3D printed and 3D reconstructed models were compared. RESULTS: Inter- and intra-rater reliability was excellent or perfect. Analysis of height and width values demonstrated a strong correlation of 0.91 and 0.89 respectively (p<0.001) for both the 3D printed models and the 3D reconstructed models. There was a strong correlation between the height and width, but no significant difference between the glenoid width and height in both models. There was no statistical significance between height and width when measurements on the two models were examined (p=0.12 and 0.23 respectively). CONCLUSION: 3D printed glenoid models can be used to evaluate the glenoid dimensions, width, and height, as they provide similar accuracy with 3D reconstructed models as provided from CT scan data.