Elbow Reconstruction with Megaprosthesis: An Effective Strategy for Salvage Surgery in Trauma Patients.

Delayed fracture healing can have devastating functional consequences, including pseudoarthrosis. Many factors can contribute to delayed healing, including decreased vascularity, micro-motion at the fracture site, large fracture gaps, multiple traumas at the same site, compromised metabolic status, surgical complications, and other conditions. A 61-year-old female patient was referred to our hospital with left distal humeral pseudarthrosis, accompanied by chronic pain and disability. Two years prior, the patient suffered a traumatic incident. At another medical facility, the patient underwent open reduction and internal fixation surgery with simultaneous ulnar nerve transposition. She showed favorable postoperative recovery. Unfortunately, approximately one year later, the patient sustained a second trauma to the same arm. This led to peri-implant fracture and post-traumatic aseptic degradation of the osteosynthesis system which was subsequently removed. Twelve months after the last surgery, the patient was referred to our hospital and, after thorough consideration of the therapeutic options, we decided to perform left elbow arthroplasty with left distal humeral reconstruction by using Zimmer's Comprehensive Segmental Revision System. This approach is generally reserved for tumors, and only a handful of cases of megaprostheses for non-tumoral indications have been previously reported. The surgery and perioperative care of our patient were optimal, there were no complications, and the patient recovered arm functionality following rehabilitation.

Etiology of Total Knee Arthroplasty Revisions: A Two-Decade Institutional Perspective.

Total knee arthroplasty (TKA) implant survival time is determined by various patient and implant-related factors and varies significantly in recent worldwide reports. In our study, we have included 247 TKA revisions in 203 patients performed in our hospital over the last 20 years. Multiple etiologies of revisions were identified and classified into 10 categories. Time to failure was analyzed with regard to etiology, patient demographics, and other relevant data. The overall average time to revision was 44.08 months (95% confidence interval (CI) between 33.34 and 49.82 months). Age at primary implant was negatively correlated with time to revision (hazard ratio (HR) = 1.0521 and 95% CI of HR = 1.0359 to 1.0685) and female patients showed a 1.59 times higher risk of implant failure than males. Periprosthetic joint infection was the cause of 46.56% (n=115) of revisions (out of which 12.55% (n=31) were early infections, diagnosed within the first three months), while aseptic loosening was found in 31.98% (n=79) of cases. Infection correlated with a shorter time to revision compared to aseptic loosening (p<0.05). These findings emphasize the need to intensify efforts to deliver the best patient care, select the best antibiotic regimen, and improve surgical techniques to decrease the incidence of infectious complications.

Biologics for Chronic Rhinosinusitis-A Modern Option for Therapy.

Chronic rhinosinusitis (CRS) is an important ENT pathology which affects about 5-12% of the general population. The treatment of CRS can be pharmacological (nasal sprays, douches, systemic antibiotics and steroids), surgical (endoscopic sinus surgery) or immunological according to established algorithms. CRS was divided for many years into CRS with nasal polyps (CRSwNP) and CRS without nasal polyps (CRSsNP). New ways of classifying CRS by endotypes (presence of neutrophilia, eosinophilia, fibrosis, glandular hypertrophy and epithelial dysmorphisms) appeared after the most recent understandings of the pathophysiology of the disease. Other classifications divide CRS into primary and secondary forms, localized/diffuse types and anatomical presentation. A new type of treatment has been administered in the last years, biologics. For the moment, biologics are indicated just in the cases of the patients who have undergone ESS or have contraindications for surgery and have bilateral polyps and meet a minimum of three of the following criteria: the necessity for systemic therapies with oral or parenteral corticosteroids or contraindications to systemic steroids, significant loss of smell or impaired QoL score, comorbid asthma and type 2 inflammation. This article aims to present the most relevant studies which used the three types of biologics (anti-IgE, anti-IL5 and anti-IL4/IL3) and wishes to increase the awareness of this new type of treatment that can be used in some CRS cases.

Initial Learning Curve for Robot-Assisted Total Knee Arthroplasty in a Dedicated Orthopedics Center.

Background and objectives: Our study aimed to assess the learning curve for robot-assisted (RA) total knee arthroplasty (TKA) in our hospital, compare operative times between RA-TKAs and manual TKAs, and assess the early complications rate between the two approaches. Methods: We included 39 patients who underwent RA-TKA and 45 control patients subjected to manual TKA in the same period and operated on by the same surgical staff. We collected demographic and patient-related data to assess potential differences between the two groups. Results: No statistical differences were recorded in regard to age, BMI, sex, Kellgren-Lawrence classification, or limb alignment between patients undergoing RA-TKA and manual TKA, respectively. Three surgeons transitioned from the learning to the proficiency phase in our study after a number of 6, 4, and 3 cases, respectively. The overall operative time for the learning phase was 111.54 ± 20.45 min, significantly longer compared to the average of 86.43 ± 19.09 min in the proficiency phase (p = 0.0154) and 80.56 ± 17.03 min for manual TKAs (p < 0.0001). No statistically significant difference was recorded between the global operative time for the proficiency phase TKAs versus the controls. No major complications were recorded in either RA-TKA or manual TKA groups. Conclusions: Our results suggest that experienced surgeons may adopt RA-TKA using this platform and quickly adapt without significant complications.

Overall Accuracy of Radiological Digital Planning for Total Hip Arthroplasty in a Specialized Orthopaedics Hospital.

Preoperative radiological planning is a key factor in the prediction of implant size and positioning that influences surgical time, the risk of complications, and functional outcomes. We have tested the accuracy of the digital templating performed in our hospital for a sample of 215 patients that underwent total hip arthroplasty. We assessed the accuracy of correctly predicting implant size for the femoral and acetabular components, as well as the stem neck length. We found that our method of templating proved accurate (within one size) in 95.8% of cases for the stem and 94.9% for the cup when using the anteroposterior view only, while the lateral view was accurate in 95.8% of cases for the stem and 97.2% for the cup. Exact prediction of the stem size was obtained in 77.7% of cases using the anteroposterior view and 67.0% of cases on the lateral view, and 73.0% and 74.4% of cases for the cup on the AP and LL views, respectively. Stem neck size was predicted exactly in 75.35% of cases and within one size in 93.49% of cases. We concluded that our method of digital templating using dedicated software is highly effective in accurately predicting implant size.

Management of Aesthetic and Functional Deficits in Frontal Bone Trauma.

Frontal bone trauma has an increasing incidence and prevalence due to the wide-scale use of personal mobility devices such as motorcycles, electric bicycles, and scooters. Usually, the patients are involved in high-velocity accidents and the resulting lesions could be life-threatening. Moreover, there are immediate and long-term aesthetic and functional deficits resulting from such pathology. The immediate complications range from local infections in the frontal sinus to infections propagating inside the central nervous system, or the presence of cerebrospinal fluid leaks and vision impairment. We review current trends and available guidelines regarding the management of cases with frontal bone trauma. Treatment options taken into consideration are a conservative attitude towards minor lesions or aggressive surgical management of complex fractures involving the anterior and posterior frontal sinus walls. We illustrate and propose different approaches in the management of cases with long-term complications after frontal bone trauma. The team attending to these patients should unite otorhinolaryngologists, neurosurgeons, ophthalmologists, and maxillofacial surgeons. Take-home message: Only such complex interdisciplinary teams of trained specialists can provide a higher standard of care for complex trauma cases and limit the possible exposure to further legal actions or even malpractice.

Current approach to branchial remnants in the neck.

Congenital branchial fistulas and cysts are an interesting subject in cervical pathology. There are congenital malformations with late expression in young adults that require correct diagnosis and appropriate treatment. We review essential notions of cervical embryology to understand the mechanism of occurrence of these malformations and their clinical expression. The most common cases present vestiges from the second branchial arch, with the appearance of a cystic tumor or a fistulous orifice on the anterior edge of the sternocleidomastoid muscle, at the level of the hyoid bone. Performant imagery is mandatory for appropriate diagnosis, so we recommend a cervical computed tomography (CT) scan or cervical magnetic resonance imaging (MRI) to evaluate the relations with great vessels of the neck or other lesions. The treatment implies complete surgical excision because otherwise there is a high risk of recurrence of the lesion. The differential diagnosis includes cystic lymphangioma, dermoid cyst, tuberculous adenopathy, cystic hygroma, lateral cervical cystic metastases. Histological examination is mandatory for a definite diagnosis. Also, there is a small percentage of malignancy of these malformations, but it is very important to check that all the histological diagnostic criteria for a primary branchiogenic carcinoma are accomplished. Therefore, although it is a benign cystic cervical pathology, the diagnosis and treatment must be made very accurately for a complete cure, and this review aims to summarize the current approach to branchial remnants of the neck.

Demographic, anthropometric, and metabolic characteristics of obstructive sleep apnea patients from Romania before the COVID-19 pandemic.

Obstructive sleep apnea (OSA) syndrome is one of the major pathologies of modern life, with multiple etiologies intertwining: the increase in life expectancy, facial and dental changes, metabolic syndrome, and others. The current diagnosis is based on sleep studies, flexible endoscopy, imaging studies and a complete differential diagnosis from other possible pathologies. We present a retrospective study of 80 cases with OSA managed in 2019 prior to the beginning of the COVID-19 pandemic. We analyzed various demographic, anthropometric and metabolic data recorded in our study group. Some of the results, such as high levels of cholesterol and triglycerides, were consistent with worldwide literature. However, regarding the anthropometric data, we underline a general decrease in height in the Romanian population. In addition, demographic data have changed in the last decade due to the work immigration in the European Union. This data will be used in a future analysis for comparison with variables recorded from cases with OSA during the COVID-19 pandemic. Current cases with OSA are not a priority for healthcare systems, and patients avoid referral to a specialist as much as possible.

Current diagnosis and treatment of rhinosinusal aspergilloma (Review).

There are numerous types of sinusitis caused by fungal strains, some of which already colonize the nasal cavity. Mild forms present fungus balls growing inside a preexisting sinus cavity. The invasive type ranges from chronic manifestations to acute aggravated episodes. The latter scenario is encountered in cases with reduced immune responses, such as patients with diabetes, individuals receiving any form of transplant, AIDS cases and chemotherapy patients. Without the control of immunosuppression, the infection is aggravated and extends to the orbit and inside the skull base, regardless of the prompt surgical and medical treatment. This is the most common pathogenic fungus on the nasal sinuses level. It can occasionally enter the sinus cavity during dental procedures. The pathogenesis is enhanced by anaerobic conditions in poorly ventilated sinus cavities. Rhinosinusal aspergilloma has a slow, insidious evolution over months and even years. Our experience revealed the presence of both a dental problem and previous self-administered antibiotic regimens in almost every case. The initial symptoms are common with sinusitis of dental origin, but aspergilloma should be considered when a patient with a competent immune system does not respond to standard antibiotic treatment. The final diagnosis of rhinosinusal aspergilloma is conducted on a pathology sample with silver staining. The bacteriology exam of the sinus secretion rarely reveals a fungus infection; however, as revealed in our clinical experience, there may be coinfection with other multidrug-resistant bacteria. Surgical treatment must establish a wide exposure of the sinus cavity and correct drainage regardless of the external, combined or endoscopic approach. Early diagnosis and emergency surgical debridement along with administering systemic antifungal compounds in some cases represent the key to the successful treatment of invasive aspergilloma.

Magnetic resonance imaging of brain anomalies in adult and pediatric schizophrenia patients: Experience of a Romanian tertiary hospital.

Schizophrenia is a severe mental illness with a significant impact on the life of both the patient and the patient's family. Magnetic resonance imaging has proven a useful tool for studying structural changes of the brain in schizophrenia. However, interpreting the published literature presents several challenges. Despite thorough research in recent years, which has included anatomopathological, imaging, electrophysiological, and genetic studies, the intimate pathophysiological mechanisms of this disease are not yet fully elucidated. The present study included patients with schizophrenia diagnosed in the psychiatric clinics from the 'Prof. Dr. Alexandru Obregia' Clinical Psychiatry Hospital between September 2019 and December 2020. Three Tesla magnetic resonance neuroimaging studies were performed. In a significant number of cases, the neuroimaging studies showed association of cerebral modifications such as enlargement of the Virchow spaces, lesions of the white matter with demyelinating appearance, and inflammatory sinus reactions. Cortical atrophy and hemosiderotic spots were present in a statistically significant proportion in the patient group with an age range of 29-61 years. MRI is indicated as a useful technique in the follow-up process of schizophrenia patients. However, whether the anomalies revealed in this disorder can be utilised as diagnostic biomarkers is still being debated.

Solanum melongena allergy (A comprehensive review).

The Solanaceae family, including, among other, eggplants, represents the sixth most widely cultivated crops around the globe. We review the current data regarding allergies to Solanum melongena (eggplants), generating symptoms that range from gastrointestinal to respiratory allergic reactions. Currently, there are more than 4 mechanisms and molecules presumably involved in triggering allergic reactions to Solanum melongena: The lipid transfer protein (LTP) pathway, the profilin pathway, polyphenol oxidase (PPO) mechanism and other molecules. Allergies may be triggered both by pollen respiratory reactions and fruit intake. There is also an important cross-reactivity mechanism revealed by recent studies. Our literature review revealed many case series studies, some with in-depth molecular analysis of the triggering mechanism. However, wide population studies are still scarce. Current geographical distribution of the crops and population migrations should enhance the awareness of allergy and immunology specialists, ENT specialists, emergency physicians and pediatricians to the need for proper routine laboratory testing for possible Solanum allergy.

Respiratory allergies: Salicaceae sensitization (Review).

Seasonal allergic rhinitis (SAR) is one of the most frequent chronic conditions of the modern world. Pollen carried by the wind from pollinated trees is a major source of SAR. Betulaceae, Oleaceae and Platanus are the most important sources of airway sensitization with regard to tree pollen and, therefore, they are included in the official recommendations of skin prick testing by different official societies. Salicaceae pollen is a moderate source of pollen sensitization. Conversely, large areas are covered with poplars and willows around the world. A number of studies from many countries showed that in some particular situations (large and compacted areas covered by Salicaceae, weather conditions, air pollution, urban ornamental vegetation), poplar and willow pollens may become of local importance in producing SAR. The aim of this review was to present a synthesis of information regarding Salicaceae pollen allergy showing that, if various unfavorable aspects are brought together, a minor problem (Salicaceae sensitization) can became a public health problem.

Ultrasonography used in the diagnosis of chronic rhinosinusitis: From experimental imaging to clinical practice.

There is an increasing incidence of sinusitis cases in outpatient clinics; therefore, new methods for screening and triage are required. Performance of sinus sonography in our outpatient protocol was assessed in order to ascertain the specificity and sensitivity of this imaging method to detect rhinosinusitis. A total of 81 consecutive cases with clinical signs of sinusitis were collected and clinical data compared with sinus sonography results. Moreover, sinus sonography enhanced referral for further computed tomography scans. The results showed that sonography may be a screening method in sinus pathology, with a high sensitivity of 78.3% and a specificity of 93.1%. In the context of the COVID-19 pandemic, the use of ultrasound for paranasal sinus imaging should be reconsidered as in the case of lung sonography. According to data of the present study, sinus ultrasound may be implemented in the emergency departments with no access to standard ENT services and it could be efficient in managing sinusitis in pregnant women and pediatric cases.

Ultrasonography of the larynx: Novel use during the SARS-CoV-2 pandemic (Review).

Few articles have been published on the subject of laryngeal ultrasonography. However, considering the increased power and accuracy of ultrasound technology, this imaging modality should be reevaluated. The present review aimed to increase the awareness of fellow specialists regarding the use of this imaging tool in healthcare units that do not benefit from onsite ear, nose and throat (ENT) service. We illustrate the ultrasonographic examination protocol for the larynx along with the relevant anatomic landmarks. We review cases with laryngeal tumoral pathology that underwent ultrasonographic examination for improved management. All findings were confirmed through computerized tomography (CT) and endoscopy performed by the ENT specialist. The ultrasound of the larynx has potential utility in diagnosis (e.g., laryngeal abnormalities, speech and swallowing abnormalities, identification of endotracheal tube placement), treatment (e.g., guidance of percutaneous tracheostomy and cricothyrotomy) and prognosis (e.g., prediction of postextubation stridor and difficult intubation). This imaging modality could be useful in the current SARS-CoV-2 pandemics in reducing the exposure to invasive maneuvers producing aerosol, such as endoscopy.

Urban allergy review: Allergic rhinitis and asthma with plane tree sensitization (Review).

Respiratory allergies represent a major public health issue in the modern world. Pollens are among the most significant causes of seasonal allergic rhinitis, with pollens of wind-pollinated trees representing an important cause. Members of the Platanaceae family (Platanus acerifolia, Platanus orientalis) are well-recognized sources of allergenic pollens worldwide, due to their high capacity of sensitization and widespread usage as ornamental urban trees. Air pollution, characteristic to all important urban conglomerates in the world and provoked by diesel exhaust gases, industrial and domestic fumes, and biogenic volatile organic compounds represents another major public health issue. Plane trees, along with other species of trees, are one of the main sources of volatile compounds. Recent studies have demonstrated a strong correlation between air pollution and respiratory allergies, with airway chemical compounds intensifying the capacity of sensitization to allergenic pollens. This study presents an overview of the known negative elements on public health of the Platanus family.

Correlations between ultrasonography performed by the ENT specialist and pathologic findings in the management of three cases with thyroglossal duct cyst.

Thyroglossal duct cyst (TDC) has an increasing incidence. We present a series of three cases that benefited from the use of ultrasonography performed first hand by the ENT specialist. All cases underwent Sistrunk procedure and the diagnosis was confirmed by pathology results: one uncomplicated TDC, a thyroglossal duct carcinoma, and an infected TDC with the risk of becoming a diffuse cervical suppuration. Ultrasonography performed first hand by the ENT specialist enables a quick and thorough planning of the surgical procedure and management of the case.

Ultrasonographic anatomy of head and neck--a pictorial for the ENT specialist.

An increased pressure on ENT departments has evolved as head and neck pathology is showing a higher incidence and prevalence. Therefore, the ENT specialist should develop good skills in ultrasonographic examination of patients with head and neck masses. The aim of this paper is to enable the ENT specialist to identify anatomical landmarks on ultrasonographic images in order to expedite the diagnosis with a higher degree of certainty. We describe the steps for a proper ultrasound examination of the patient. We illustrate the following anatomical areas: submandibular gland, thyroid gland, parathyroid glands, oropharinx, larynx, parotid glands, etc. Moreover we emphasize the differential diagnosis that should be taken into account when examining pathology in these regions. Ultrasonographic examination of head and neck pathology is cost efficient, non irradiating and permits fast follow up with serial examination of the lesions. Furthermore one can perform an initial TNM staging of the case prior to other expensive imaging studies such as CT and MRI. We hope to raise the awareness of fellow ENT specialists in performing ultrasonography as future developments such as elastography and CEUS will increase the specificity and sensitivity of this diagnostic method.

Frontal epidural empyema (Pott's puffy tumor) associated with Mycoplasma and depression.

UNLABELLED: A 37-year-old male has left exophthalmia, which gradually evolved in the last two years, finally with a deviation of left eye (LE), down side and out, with gradually decrease of visual acuity (VA). These symptoms are accompanied with headache and psychiatric manifestations with irritability, decreased attention, anxiety, insomnia, depressed mood. Brain Computed Tomography (CT) shows a tumor mass in air leakage sinus, bilateral frontal and bilateral ethmoidal, with left orbital invasion. This tumor mass lysis by pressure the supero-posterior wall of the left orbit, with the delimitation of a frontal epidural process with a capsule and calcifications. Additionally, it has been shown there is a bilateral maxillary sinusitis. The surgical intervention removed the infection focal spots rearranging the left eyeball, recovering the VA. The sinuses were drained. The psychiatric symptoms in the post operatory phase disappeared. Histopathological examination of the excised tissue revealed sinus ciliated respiratory mucosa with mixed acute and chronic inflammatory infiltrate and focal squamous metaplasia. The lamina propria is edematous and contains large numbers of neutrophils, lymphocytes and plasma cells. Histopathological diagnosis is acute and chronic sinusitis. CONCLUSIONS: An untreated infection of the aerial sinuses can lead to a complication like Pott's puffy tumor. When signs such as ophthalmologic, psychiatric and intense headaches appear, it suggests the presence of the Pott's puffy tumor (PPT). The clinical signs are reversible once the tumor has been removed.

Anatomical considerations on the corona mortis.

The corona mortis (CMOR) represents the vascular connection of the obturator and external iliac systems. We aimed to evaluate by dissections the morphological possibilities of the CMOR and their individual combinations. For the study we used 20 human adult cadavers that were bilaterally dissected (40 hemipelvises), with evidences of the vascular elements at the level of the superior pubic branch in 32 (80%) of hemipelvises. The morphological patterns we identified were classified in three types (I-III): I. arterial CMOR (10 hemipelvises): I.1. obturator artery (OA) from the external iliac artery (EIA); I.2. OA from the inferior epigastric artery (IEA); I.3. anastomosis of the OA and IEA; I.4. pubic branches of the OA, in the absence of any anastomosis with the EIA system; II. venous CMOR (6 hemipelvises): II.1. obturator vein (OV) draining into the external iliac vein (EIV); II.2. OV draining into the inferior epigastric vein (IEV); II.3. venous anastomosis of the OV and IEV and III combined, arterial and venous CMOR (16 hemipelvises). We classified the combined coronae mortis in nine different subtypes that mainly (but not exclusively) correspond to various combinations of types I and II. The surgical relevance of the vascular relations of the superior branch of pubis (in trauma, orthopedic approaches, hernia repair, embolizations and intra-arterial infusions) recommends a detailed knowledge of the morphological and topographical possibilities of the crown of death and the individual evaluation of this risky anatomical structure.