Efficient hip joint distraction using the AO large femoral distractor in treating acetabular fractures associated with marginal impaction and intraarticular incarcerated fragments.

PURPOSE: The results after acetabular fracture are primarily related to the quality of articular reduction. Using the AO large femoral distractor, incarcerated fragments can be easily removed, and marginally impacted fragments can be elevated under direct visualization without further re-dislocating the joint. The current study aimed to evaluate our early results of using the AO large femoral distractor as an assisting tool during ORIF of acetabular fractures associated with marginal impaction or intraarticular incarcerated fragments. METHODS: Eighteen patients were included in this retrospective case series study diagnosed with an acetabular fracture associated with either marginal impaction injury or an intraarticular incarcerated fragment. On a usual operative table, all patients were operated upon in a prone position through the Kocher Langenbeck approach. The AO large femoral distractor was used to facilitate hip joint distraction. Postoperative fracture reduction and joint clearance were assessed in the immediate postoperative CT scans. RESULTS: The average age of the patients was 30 ± 8.2 years; 13 (72.2%) were males. All cases had a posterior wall fracture, and it was associated with transverse fractures, posterior column fractures, and T-type fractures in five (27.8%), two (11.1%), and one (5.6%) patients, respectively. Intraarticular incarcerated fragments were present in 13 (72.2%) cases and marginal impaction in five (27.8%). Fracture reduction measured on the postoperative CT scans showed an anatomical reduction in 14 (77.8%) patients, imperfect in four (22.2%), and complete clearance of the hip joint of any incarcerated fragments. CONCLUSION: The use of the AO large femoral distractor is a reliable and reproducible technique that can be applied to assist in the removal of incarcerated intraarticular fragments and to ease the reduction of marginally impacted injuries associated with acetabular fractures.

Primary arthrodesis for diabetic ankle fractures using a modified retrograde femoral intramedullary locking nail combined with lateral plating, surgical technique, and early results of a pilot study.

PURPOSE: We aimed to report the early results of performing acute ankle arthrodesis using a modified retrograde femoral intramedullary locking IMN concomitant with plating at the same setting for managing diabetic patients' acute ankle fractures. METHODS: We prospectively included patients who presented acutely with ankle fractures, where hemoglobin A1C (HbA1C) on admission was > 7%, and the Adelaide Fracture in the Diabetic Ankle (AFDA) algorithm score was 5 or above. All patients were treated by acute ankle arthrodesis using a modified retrograde femoral IMN combined with lateral plating. Functional assessment was reported according to a modified American Orthopaedic Foot and Ankle Society ankle hindfoot scale (AOFAS), and complications were documented. RESULTS: Six patients had an average age of 55.7 years (37-65). The average HbA1C on admission was 7.9 (7.3-9), and the average AFDA score was 7.3 (6-8). The average operative time was 79.2 min (70-90). All patients, except for one, achieved union at the arthrodesis site after an average of 10.3 weeks (8-14). After an average last follow-up of 9 months (6-12), the average modified AOFAS was 73.2 (82 to 62); four patients had an excellent score and one good. Complications developed in two, one deep infection after 2 weeks treated by metal removal and Ilizarov, and the other patient developed a stress fracture at the tibial end of the nail, which was treated by open reduction and internal fixation using a plate and screws. CONCLUSION: Using a modified femoral IMN combined with lateral plating is a promising technique to achieve ankle arthrodesis in diabetic patients with acute ankle fractures with acceptable outcomes; however, further studies with larger numbers are needed. LEVEL OF EVIDENCE: IV.

Femoral head avascular necrosis in COVID-19 survivors: a systematic review.

The current systematic review aimed to document published cases of femoral head avascular necrosis (FHAVN) post-COVID-19, to report the COVID-19 disease characteristics and management patients received, and to evaluate how the FHAVN were diagnosed and treated among various reports. A systematic literature review was performed per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines through a comprehensive English literature search on January 2023 through four databases (Embase, PubMed, Cochrane Library, and Scopus), including studies reporting on FHAVN post-COVID-19. Fourteen articles were included, ten (71.4%) were case reports, and four (28.6%) case series reported on 104 patients having a mean age of 42.2 ± 11.7 (14:74) years, in which 182 hip joints were affected. In 13 reports, corticosteroids were used during the COVID-19 management plan for a mean of 24.8 ± 11 (7:42) days, with a mean prednisolone equivalent dose of 1238.5 ± 492.8 (100:3520) mg. A mean of 142.1 ± 107.6 (7:459) days passed between COVID-19 diagnosis and FHAVN detection, and most of the hips were stage II (70.1%), and concomitant septic arthritis was present in eight (4.4%) hips. Most hips (147, 80.8%) were treated non-surgically, of which 143 (78.6%) hips received medical treatment, while 35 (19.2%) hips were surgically managed, 16 (8.8%) core decompression, 13 (7.1%) primary THA, five (2.7%) staged THA and three (1.6%) had first stage THA (debridement and application of antibiotic-loaded cement spacer). The outcomes were acceptable as regards hip function and pain relief. Femoral head avascular necrosis post-COVID-19 infection is a real concern, primarily attributed to corticosteroid usage, besides other factors. Early suspicion and detection are mandatory, as conservative management lines are effective during early stages with acceptable outcomes. However, surgical intervention was required for progressive collapse or patients presented in the late stage.

To Bury or Not to Bury the K-wires After Fixation of Both Bone Forearm Fractures in Patients Younger Than 11 Years Old: A Randomized Controlled Trial.

PURPOSE: The primary objective was to compare the re-fracture incidence of both radius and ulna fracture in 2 groups treated using intramedullary Kirschner wires (K-wires) where the wires were exposed in group I and buried in group II. The secondary objective was to compare the final functional outcomes and complications incidence. METHODS: Between March 2019 and February 2021, 60 pediatric patients with unstable radius and ulna fractures amenable to surgical intervention using intramedullary K-wires were randomized into group I (K-wires were exposed above the skin by 2 cm) or group II (K-wires were buried under the skin). In group I, K-wires were removed in the outpatient clinic, while in group II, they were removed under general anesthesia as a day-case procedure. Functional outcome per Price criteria was reported at 1-year follow-up. RESULTS: Included patients had a mean age of 7.6 years (range: 5 to 10 y). The mean operative time was significantly higher in group II (32.33±7.51 vs. 36.77±8.70 min, P =0.03), with no difference regarding intraoperative x-ray exposure (43.12±15.52 vs. 41.6±11.96 s, P =0.67). Fracture union was achieved after a mean of 44±2.6 days in group I and 43±1.87 days in group II, with no difference between both groups ( P =0.34). One patient had re-fracture in group I and no patients in group II; however, the difference was insignificant ( P =0.12). Infection occurred in 2 patients in each group. All patients reported excellent scores per Price criteria and achieved full wrist and elbow range of motion compared with the contralateral noninjured side. CONCLUSIONS: Exposed implants are a safe option when dealing with forearm fractures in patients younger than 11 years old, with the added advantage of fewer hospital admissions. Furthermore, it had a similar complication rate and functional outcomes compared with buried implants. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT03906929. LEVEL OF EVIDENCE: Level II.

The evolution of surgical hip dislocation utilization and indications over the past two decades: a scoping review.

PURPOSE: To assess the evolution of surgical hip dislocation (SHD) utilization over the past 20 years, concentrating mainly on the patients' population (adults vs. paediatric), the hip conditions treated using this approach, and reporting on complications of this procedure. METHODS: This scoping review was conducted according to Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. A PubMed database search was performed using specific search terms for articles related to SHD published between January 2001 and November 2022. RESULTS: Initial search revealed 321 articles, of which 160 published in 66 journals from 28 countries were eligible for final analysis. The number of publications increased by 10.2 folds comparing the period from 2001 to 2005 with 2018 to 2022. USA and Switzerland contributed to more than 50% of the publications. Case series studies represented the majority of publications (65.6%). Articles including adult patients represented 73.1% of the publications while 10% were on paediatric patients; however, there was 14 folds increase in publications on paediatric patients comparing the first with the last five years. Managing non-traumatic conditions was reported in 77.5% of the articles, while traumatic conditions in 21.9%. Femoroacetabular impingement (FAI) was the most treated non-traumatic condition reported in 53 (33.1%) articles. In contrast, femoral head fractures (FHF) were the most treated traumatic condition, which was reported in 13 articles. CONCLUSION: The publications on SHD and its usage for managing traumatic and non-traumatic hip conditions showed an increasing trend over the past two decades from worldwide countries. Its use in adult patients is well established, and its utilization in treating paediatric hip conditions is becoming more popular.

Joint preservation surgery for correcting adolescents' spasmodic flatfoot deformity: early results from a specialized North African foot and ankle unit.

PURPOSE: We aimed to report early results of performing joint-preserving surgeries for managing spasmodic flatfoot deformity (SFFD) in adolescents. METHODS: A prospective case series study including 24 patients (27 feet) diagnosed with idiopathic SFFD not responding to conservative management. After reassessment under anesthesia, surgical procedures included soft tissue releases (Achilles tendon (AT), peroneus brevis (PB), peroneus tertius (PT) (if present), and extensor digitorum longus (EDL)), bony osteotomies (lateral column lengthening (LCL), medial displacement calcaneal osteotomy (MDCO), and double calcaneal osteotomy (DCO)), and medial soft tissue reconstruction or augmentation if needed. Functional evaluation was performed per the American Orthopedic Foot and Ankle Society (AOFAS) score, while radiological parameters included talo-navicular coverage angle (TNCA), talo-first metatarsal angle (AP Meary's angle), calcaneal inclination angle (CIA), talo-calcaneal angle (TCA), talo-first metatarsal angle (Lat. Meary's angle), and tibio-calcaneal angle (TibCA). The preoperative parameters were compared to the last follow-up using the Wilcoxon signed test. RESULTS: The mean age was 15.37 ± 3.4 years, 18 (75%) were boys, and the mean BMI was 28.52 ± 3.5 (kg/m2). Release of AT and fractional lengthening of PL, PT, and EDL were performed in all patients. LCL was needed in eight feet (29.6%), MDCO in 5 (18.5%), and DCO in 14 (51.9%). FDL transfer was required in 12 (44.4%) feet, and repair of the spring ligament in seven (25.9%). The mean operative time was 99.09 ± 15.67 min. All osteotomies were united after a mean of 2.3 ± 0.5 months. After a mean follow-up of 24.12 ± 8.88 months (12 and 36 months), the AOFAS improved from a preoperative mean of 43.89 ± 11.49 to a mean of 87.26 ± 9.92 (P < 0.001). All radiological parameters showed significant improvement, AP Meary's angle from a mean of 20.4 ± 5.3 to a mean of 9.2 ± 2.1, Lat. Meary's angle from - 15.67° ± 6.31 to - 5.63° ± 5.03, TNCA from - 26.48° ± 5.94 to 13.63° ± 4.36, CIA from 12.04° ± 2.63 to 16.11° ± 3.71, TibCA from - 14.04° ± 3.15 to - 9.37° ± 3.34, and TCA Lat. from 42.65° ± 10.68 to 25.60° ± 5.69 (P ≤ 0.001). One developed wound dehiscence (over an MDCO), managed with daily dressings and local antibiotics. Another one developed lateral foot pain after having LCL managed by metal removal. CONCLUSION: Careful clinical and radiological evaluation for the correct diagnosis of SFFD is paramount. Joint-preserving bony osteotomies combined with selective soft tissue procedures resulted in acceptable functional and radiological outcomes in this young age group.

Total hip arthroplasty for post-firearm hip arthritis complicated by coloarticular fistula: A case report.

Hip firearm injuries are rare injuries that could lead to serious complications, such as posttraumatic hip arthritis and coloarticular fistula. We report a case of a 25-year-old male who sustained a pelvic injury caused by a single bullet which led to a bilateral acetabular fracture, concomitant with a colon injury treated on an emergency basis by a diverting colostomy; acetabular fractures were treated conservatively by traction. After the patient recovered from the abdominal injury, he was presented with bilateral hip pain and limited motion; plain radiographs showed bilateral hip arthritis with proximal migration of the femoral head and bilateral acetabular defect classified as Paprosky type ⅢA. Reconstruction of the hips was performed using the same technique: impaction bone grafting for acetabular defect reconstruction and a reversed hybrid total hip arthroplasty (THA) 6 months apart. The patient presented with loosening of the left THA acetabular cup 3 years later, which was revised; then he presented with a discharging sinus from the left THA with suspicion of coloarticular fistula, which was confirmed using CT with contrast material. A temporary colostomy and fistula excision were performed, and a cement spacer was applied to the hip. After clearing the infection, a final revision THA for the left hip was performed. Treating post-firearm hip arthritis by THA is challenging, especially in the situation of neglected cases with the presence of an acetabular defect. Concomitant intestinal injury increases the risk of infection with the possibility of coloarticular fistula formation, which could present later. Working with a multidisciplinary team is paramount.

Are the outcomes of single-stage open reduction and Dega osteotomy the same when treating DDH in patients younger than 8 years old? A prospective cohort study.

BACKGROUND: The primary objective was to report our early results after a one-stage procedure [open reduction (OR), Dega pelvic osteotomy (DPO), and femoral osteotomy (FO) when needed] for surgical management of a cohort of patients with developmental dysplasia of the hip (DDH). The secondary objective was to compare the functional, radiological, and complications among patients younger and older than 30 months. MATERIALS AND METHODS: This prospective cohort study included 71 hips with DDH in 61 patients with a mean age of 34.3 ± 19.5 months. All patients underwent one-stage surgical procedures, including OR + DPO and FO, if needed. Functional and radiographic assessment at the last follow-up was conducted using the modified Severin grading system and the Severin classification system, respectively, in addition to assessing the acetabular index (AI), osteotomies healing, and presence of complications. We divided patients into two groups, younger than 30 months (group I) and older than 30 months (group II). RESULTS: We included 35 hips in group I and 36 in group II. All hips received OR + DPO, while 25 (69.4%) hips in group II had FO. The operative time was significantly longer in group II (103.19 ± 20.74 versus 72.43 ± 11.59 min, p < 0.001). After a mean follow up of 21.3 ± 2.3 months, the functional outcomes were satisfactory in 62 (87.3%) hips (94.3% in group I and 80.6% in group II, p = 0.35). There was a significant improvement in the AI in all patients compared with preoperative values (27.2° ± 2.9 versus 37° ± 4.2, p < 0.05). Furthermore, 63 (88.7%) hips had satisfactory radiographic outcomes (94.3% in group I and 83.3% in group II, p = 0.26), and all osteotomies showed radiographic healing. The overall complications incidence was significantly lower in group I compared with group II (5.7% versus 30.6%, p < 0.05), and avascular necrosis occurred in 4 (5.6%) hips, all in group II (p = 0.06). CONCLUSION: One-stage procedure entailing open reduction, Dega pelvic osteotomy, and femoral osteotomy when needed for managing DDH in patients younger than eight years old revealed acceptable clinical and radiological outcomes. However, there was a higher need for a concomitant femoral osteotomy in patients older than 2.5 years, and complications were more frequent.

Management of anterior associated types of acetabular fractures utilizing the modified Stoppa and the pararectus approaches: a prospective cohort study and early experience from a level one Egyptian trauma centre.

PURPOSE: This study aimed to report the early experience (radiographic, functional, and complications outcomes) from an Egyptian (North African) level one trauma centre after utilizing the modified Stoppa and the pararectus approaches to manage anterior-associated types of acetabular fractures. PATIENTS AND METHODS: Between January 2014 and April 2018, 63 patients (40 males and 23 females) with a mean age of 33 ± 11.5 were included, 45 patients were treated through the modified Stoppa (group A), and 18 through the pararectus approach (group B). RESULTS: At a mean follow-up of 32.11 ± 15.36 months (range 12 to 64), 56 patients (43 group A and 13 group B) were evaluated. The post-operative anatomical reduction was achieved in 44 (78.6%) patients. At the last follow-up, Matta radiological outcome grades were excellent and good in 50 (89.2%) patients, fair and poor in six (10.8%). The mean Harris Hip Score (HHS) was 92.6 ± 7.6; the mean modified Merle D'Aubigné (MMD) score was 16.5 ± 1.5. Excellent functional outcome was reported in 42 (75.0%) and 25 (44.6%) patients according to HHS and MMD scores, respectively. There are four (7.1%) intra-operative iatrogenic complications (two in each approach), three (5.3%) vascular injuries (two in group B and one in group A), and one (1.8%) bladder injury in group A. CONCLUSION: Employing less-invasive anterior approaches for managing anterior associated types of acetabular fractures proved efficiency and safety. Good to excellent radiological and functional outcomes were achieved, with no significant difference between both approaches.

Surgical management of paediatric pelvic fractures: a prospective case series and early experience from a level one Egyptian trauma centre.

PURPOSE: We aimed to report our early experience treating paediatric pelvic fractures (PPF) surgically, reporting on indications, outcomes, and complications. METHODS: Patients aged 0-15 with PPF treated surgically at a level I trauma centre were included prospectively between 2016 and 2018. Fractures were classified according to AO/OTA classification system. Functional evaluation was performed using a modification of the Majeed functional scoring system. Radiological evaluation of vertical and posterior displacement was performed according to Matta and Tornetta criteria and the method described by Keshishyan et al. for assessing pelvic rotational asymmetry. RESULTS: We included 45 patients (77.8% males and 22.2% females), with a mean age of 9.53 ± 3.63 and 19.87 ± 8.84 months of mean follow-up. The functional outcome was excellent in 42 (93.3%) patients, good in two (4.4%), and fair in one (2.2%). Radiologically, the vertical displacement improved from 5.91 ± 4.64 to 3.72 ± 2.87 mm (p-value 0.065), the posterior displacement improved from 7.87 ± 8.18 to 5.33 ± 13.4 mm (p-value 0.031), and the symphyseal diastasis improved from 9.88 ± 7.51 mm to 7.68 ± 3.18 mm (p-value 0.071). Residual pelvic asymmetry improved from 1.2 ± 0.61 to 0.8 ± 0.7 (p-value 0.001). Complications occurred in 21 (46.7%) patients, 11 (24.4%) pin tract infection, six (13.3%) limb length discrepancy, two (4.4%) prominent metals, one (2.2%) subcutaneous haematoma, one (2.2%) infected ISS. CONCLUSIONS: We achieved acceptable functional and radiological outcomes after surgically treating a group of patients with PPF, which was relatively safe with minimal complications. The proper approach and fracture fixation tool should be tailored according to the fracture classification and the presence of associated injuries.

Management of femoral head fractures through surgical hip dislocation (SHD): a demanding but safe technique.

INTRODUCTION: Femoral head fractures considered to be rare injuries. Surgical intervention is indicated for major fragment displacement or in the presence of instability. Surgical management can be achieved through either Anterior, posterior, and trans-trochanteric surgical approaches. Surgical hip dislocation (SHD) has been advocated by many authors to be a safe and effective alternative way of management. The aim of this study was to report on the accuracy of fracture reduction, procedure safety, and outcomes of using SHD in the management of femoral head fractures. PATIENTS AND METHODS: Between 2011 and 2017, 31 patients presented with femoral head fracture were treated through SHD. At a mean follow-up of 48 months, 27 patients were available for the study with a mean age of 33.8 years. Patient demographics, clinical evaluation according to modified Harris hip score and modified Merle d'Aubigne and Postel score, radiographic fracture reduction according to Matta's criteria, and any complications were reported. RESULTS: Excellent and good clinical outcomes were reported in 25 (92.6%) and 24 (89%) patients according to the modified Harris hip and modified Merle d'Aubigne and Postel scores, respectively. Anatomic fracture reduction was achieved in 21 (77.8%) patients. Two (7.4%) patients developed AVN, one (3.6%) patient developed hip OA (grade 3 according to Tönnis classification), and five (18.5%) patients developed asymptomatic Brooker stage I heterotopic ossification. No infection or trochanteric flip osteotomy fragment non-union was reported. CONCLUSIONS: SHD offers a safe and efficient approach for femoral head fractures management with acceptable clinical outcomes as well as complication rates. Giving the advantage of fully exposing the femoral head and the acetabulum which enables the surgeon to anatomically reduce the fracture and treat any associated injuries, SHD is recommended besides other approaches for the management of femoral head fractures.

Prediction of leg length change (LLC) after correcting varus and flexion deformity in patients undergoing TKA.

PURPOSE: Patients with varus and fixed flexion deformity (FFD) undergoing TKA may have a significant leg length change (LLC) after surgery. We aimed to determine the correlation between changes in HKA or FFD and leg length in patients undergoing TKA, the combined effect of coronal and sagittal plane deformity correction on LLC, and the possibility of estimating LLC mathematically. MATERIALS AND METHODS: This was a prospective radiographic evaluation of 242 knees, which had undergone primary unilateral TKA for advanced OA with varus and FFD. Full-length standing calibrated anteroposterior radiographs were used to measure the hip-knee-ankle axis (HKA) and functional leg length after adjusting for magnification. Clinical evaluation of FFD was done using a handheld goniometer. RESULTS: 224 knees (92.6%) showed increased limb length after TKA averaging 10.7 mm (SD 9.5 mm, P = .000). There was a significant correlation between the change in HKA and FFD from preoperatively to postoperatively with the amount of LLC (ρ 0.326 and 0.346, respectively, P = .000). FFD improvement from preoperatively to postoperatively was 8.1° to 1° (P = .000), respectively. A linear relationship was established between LLC and changes in HKA and FFD, where 10° improvement in HKA would result in an LLC of nearly 4 mm, and 10° improvement in FFD would result in a LLC of nearly 8 mm. CONCLUSION: LLC may be substantial after correcting varus and FFD with unilateral TKA, it correlates with the change in HKA and FFD and can be mathematically estimated. CLINICAL TRIALS . GOV IDENTIFIER: NCT03502382.

Post-operative hip centre restoration and migration after impaction bone grafting in revision and complex primary hip arthroplasty.

INTRODUCTION/OBJECTIVES: Although impaction grafting proved efficacy in the reconstruction of acetabular defects in primary and revision hip arthroplasty, its role in large segmental defects is still debatable. Our objective is to determine hip centre restoration and last follow-up migration after acetabular reconstruction with impaction grafting in different types of acetabular defects. METHODS: This is a single-centre retrospective radiographic study of (107) total hip arthroplasty (42 primary and 65 revision) in (104) patients using impaction grafting. The available radiographs were examined for normal, preoperative, immediate postoperative, and last follow-up vertical (Y) and horizontal (X) hip centre. Maximum acetabular defect distance (MADD), presence, and size of the mesh were recorded. RESULTS: In type I and II AAOS defects, the post-operative hip centre was not significantly different from the normal hip centre on the contralateral healthy side. In type III defects, there was a significant variation between the normal hip centre and the post-operative hip centre (P value 0.034 and 0.001 for Y and X, respectively). At 44-month follow-up of 36 hips, 31 (86%) hips migrated. The mean migration ± SD was 5.72 ± 3.7, 2, 4.15 ± 1.2, and 11.26 ± 3.9 mm for types I, II, and III, respectively (P value 0.211). Hips with MADD > 15 mm, especially with large mesh sizes migrate significantly more (P value = 0.042, 0.037, and 0.039, respectively). CONCLUSION: Hip centre restoration was better, and migration was less for type I and II AAOS rather than for type III. Other options for reconstruction should be considered.

Unusual Pattern of Osteochondral Marginal Impaction in Acetabular Fractures: A Report of Two Cases.

Acetabular fractures could be accompanied by articular impaction injuries, affecting the outcomes if missed or treated less than optimally. Marginal impaction detected either in preoperative or intraoperatively imaging studies should be anatomically reduced using the femoral head as a template and augmenting the defect with bone graft if needed. The impacted segment articular surface looks enface during surgery, which is the classic description of such injuries. In the present report, we describe an unusual pattern of marginal impaction injuries appearance in two patients, in which the impacted fragment articular surface is facing toward the joint cavity, which is the reverse of the classic description, alluding to the probable mechanism of its occurrence, the technique for reduction, and the consequences of missing such injuries. Marginal impaction injuries should be diagnosed and treated correctly to preserve joint congruency; however, the surgeon should be aware of the possibility of an unusual pattern of marginal impaction in which the fragment could be reversed, and keeping this possibility in mind would make its diagnosis and management easier.

Locally obtained autologous bone grafts are effective for achieving arthrodesis while managing foot and ankle charcot's neuroarthropathy: short to mid-term results from a specialized north African foot and ankle surgery unit.

PURPOSE: We aimed to report the union rate after only utilizing a locally obtained autologous bone graft while correcting the deformity and performing joint arthrodesis in patients with foot and ankle Charcot neuropathy (CN) and to report on the radiographic, functional, complications incidence outcomes at a minimum of two years of follow up. METHODS: We included 24 patients having a mean age of 55.4 ± 10.1 years diagnosed with CN of the foot, ankle, or both. Seven (29.2%) cases were classified as Brodsky type 1, 11 (45.8%) as type 3 A, and six (25%) were type 4. Hindfoot and Midfoot bi-columnar arthrodesis was performed in 70.8% and 29.2% of the patients, respectively. Eight (33.3%) cases had preoperative ulcers. Functional outcomes were evaluated using a modified AOFAS score. Arthrodesis site union was assessed clinically and radiographically. All patients were available for a mean follow up of 35.7 ± 9.5 (24-54) months. RESULTS: Arthrodesis site union was achieved in 23 (95.8%) cases after a mean of 4 ± 1.7 (2-7.5) months. The mean modified AOFAS score was 72.4 ± 10.41 (46-83) points; 79.2% achieved excellent and good scores. Ulcers healed in 87.5% of the patients. Twenty-two (91.7%) patients were satisfied with their functional results. Infection incidence was 12.5%, and no patients required revision or amputation. CONCLUSION: Foot and ankle Charcot neuroarthropathy deformity correction by arthrodesis of the affected joint as a salvage management option resulted in acceptable clinical and radiological outcomes. To enhance the local environment for arthrodesis consolidation, locally obtained autografts led to higher union rates and avoided the drawbacks of using other graft types.

Total knee arthroplasty post-high tibial osteotomy, results of an early experience from a North African arthroplasty unit, and a comprehensive review of the literature.

PURPOSE: To report an early experience after converting HTO to TKA by reporting the incidence of functional, radiological, and complications in a single surgeon case series from a North African specialized arthroplasty unit. METHODS: Between 2010 and 2020, 33 knees in 31 patients (two bilateral) were operated upon, 24 females and seven males, had a mean age of 65 ± 4.5 years; 17 (51.5%) knees had medial wedge opening (WMO), while 16 (48.5%) had lateral wedge closure (LWC) osteotomies. The mean time from HTO to TKA was 8.1 ± 3.3 years. A posterior stabilized (PS) implant was used in 31 (93.9%), while in 2 (6.1%), a varus-valgus constrained (VVC) implant was used. A tibial stem was needed in 13 (39.4%) knees. The functional assessment was performed according to the Knee Society Scoring System (KSS). The radiographic assessment included the anatomical femorotibial angle (aFTA) for alignment, the medial proximal tibial angle (MPTA), and the tibial slope (TS). RESULTS: After a mean follow-up of 4.3 ± 1.1 years, the KSS knee and function sub-scores improved from a preoperative mean of 41 ± 8.9 (26 to 57) and 37.7 ± 9.2 (25 to 55) points to 91.3 ± 3.8 (81 to 94) and 85.5 ± 5 (80 to 95) points at the last follow-up, respectively (P < 0.05). The preoperative knee flexion improved from a mean of 84.5° ± 15.9 (55 to 110) to 110.6° ± 9.3 (95 to 125) (P < 0.05). The aFTA improved from a preoperative mean of 182.2° ± 10.3 (164 to 205) to a postoperative mean of 186° ± 2.6 (179 to 190) (P < 0.05). The MPTA changed from a preoperative mean of 88.4° ± 6.7 (77 to 102) to a postoperative (tibial component alignment) mean of 90° ± 1.7 (85 to 94) (P < 0.05). The mean preoperative TS changed from 80.9° ± 7.3 (68 to 96) to a mean postoperative of 86.9° ± 1.3 (83 to 89) (P < 0.05). Non-progressive radiolucent lines were detected at the tibial component in four (12%) knees. Complications were reported in seven (21.2%) knees; no revision was needed in any knee. CONCLUSIONS: The authors' early experience showed improved functional and radiological outcomes; however, the complication incidence was relatively high, but no knees required revision. A longer follow-up is mandatory to prove the consistency of the results.

Interposition Arthroplasty in an Acute Setting to Treat Unexpected Denuded Distal Humerus Articular Cartilage After AO 13C2.2 Distal Humerus Fracture, Surgical Technique, and a Case Report.

Restoring elbow joint motion is paramount for upper extremity optimum function. In end-stage elbow disease and stiffness, total elbow arthroplasty is the recommended option for older patients; however, for younger, highly demanding patients, interposition arthroplasty (IPA) is the management option of choice. We report a case of an 16-year-old female patient who presented after she had an open-grade IIIA, type AO 13C2.2 distal humerus fracture, which was managed initially by debridement and a cross-elbow external fixation. The decision was made to manage the fracture by open reduction and internal fixation through a posterior approach, and after performing an olecranon osteotomy, the surgeon found that the distal humerus segment was denuded of articular cartilage, so a decision was made after consulting the patient's parents to perform an IPA using fascia lata. At the final follow-up after 16 months, the fracture united completely, and the elbow ROM was from 15° to 120°. Interposition arthroplasty is a valid option to manage unexpected denuded distal humerus articular cartilage while managing distal humerus fractures.

The promising role of bacteriophage therapy in managing total hip and knee arthroplasty related periprosthetic joint infection, a systematic review.

PURPOSE: Total hip and knee arthroplasty periprosthetic joint infection (PJI) poses a management dilemma owing to the emergence of resistant organisms. A promising option is Bacteriophage therapy (BT) was used as an adjuvant for PJI management, aiming at treating resistant infections, decreasing morbidity, and mortality. The current review aimed to demonstrate the role and safety of using BT as an adjuvant to treat PJIs. METHODS: A systematic search was performed through four databases (Embase, PubMed, Web of Science, and Scopus) up to March 2022, according to the predetermined inclusion and exclusion criteria. RESULTS: Our systematic review included 11 case reports of 13 patients in which 14 joints (11 TKAs and three THAs) were treated. The patients' average age was 73.7 years, underwent an average of 4.5 previous surgeries. The most common organism was the Staphylococcus aureus species. All patients underwent surgical debridement; for the 13 patients, eight received a cocktail, and five received monophage therapy. All patients received postoperative suppressive antibiotic therapy. After an average follow-up of 14.5 months, all patients had satisfactory outcomes. No recurrence of infection in any patient. Transaminitis complicating BT was developed in three patients, needed stoppage in only one, and the condition was reversible and non-life-threatening. CONCLUSION: BT is a safe and potentially effective adjuvant therapy for treating resistant and relapsing PJIs. However, further investigations are needed to clarify some BT-related issues to create effective and reproducible therapeutics. Furthermore, new ethical regulations should be implemented to facilitate its widespread use.

Safety and efficacy of a modified WALANT technique using undiluted adrenaline during open surgical carpal tunnel release: a prospective report of 308 procedures.

PURPOSE: The current study aimed to report on the safety and efficacy of utilizing a modified WALANT (mWALANT) technique during open surgical carpal tunnel release (CTR), where we used undiluted epinephrine compared to the originally described WALANT technique. METHODS: From January 2015 till the end of June 2021, 200 patients (175 (87.5%) were females) who presented with carpal tunnel syndrome, either bilateral (108 (54%) patients) or unilateral (92 (46%)) were included, formulating a total of 308 procedures. Open surgical CTR was performed as a daycare procedure by the same surgeon. The mWALANT injectable mixture was prepared by mixing 8 CC of 2% lidocaine HCl + 1 CC of 0.25 mg/1 ml epinephrine without dilution (2.5 times the concentration used in the original WALANT technique). The injection was performed before draping. RESULTS: The patients' average age at surgery was 42.88 ± 13.03 years old; they were followed up for an average of 31 ± 17.17 months. The average operative time was 9.5 ± 1.87 min. None (0.0%) of the patients needed top-up of local anesthesia or shift into general anesthesia, and no (0.0%) patients needed postoperative hospital stay. The average VAS during the surgical procedure was 2.5 ± 2.1, mainly reported during infiltration of the local anesthesia; no patients reported discomfort during the surgical procedure itself. 180 (90%) patients reported a full return to their usual preoperative ADL after an average of 4.7 ± 1.2 weeks. No (0.0%) postoperative fingers ischemic or temperature changes. Two (1%) patients experienced an adrenaline rush in the form of tachycardia that needed sedation and close monitoring by the anesthesiologist; they were discharged on the same day. One (0.5%) patient (who had uncontrolled diabetes mellitus) showed a superficial wound infection which resolved after conservative management. CONCLUSIONS: Using undiluted epinephrine during the mWALANT technique is safe and effective. There is no need to wait until the drugs fully function, and no epinephrine-related complications were encountered apart from occasional adrenaline rush symptoms.