Association of vitamins B12 and D3 with Balance and Falls in a sample of Greek older people.

OBJECTIVES: Balance disorders and falls are common in the elderly and have a multifactorial etiology. The purpose of the present cross-sectional study is to evaluate a possible association between vitamins D3 and B12 and impaired balance and falls. METHODS: Ninety patients, females and males, were evaluated, from December 2019 to December 2020 during their first ambulatory visit at the Prevention of Falls Clinic of the General University Hospital of Patras. Vitamins B12 and D3 levels were measured. The number of falls during the last 12 months was recorded and patients were assessed using Mini-Balance Evaluation Systems Test (Mini-BESTest), Fried Phenotype, Walking Speed, Hand Grip Strength, Short Physical Performance Battery. RESULTS: A multiple linear regression analysis showed that Mini-BESTest are statistically significantly predicted, F(10,79)=18.734, p<0.001, adj. R2=0.70 from Vit-B12 and FRIED Phenotype (pre-frail vs non-frail). Similarly, in the multiple binary logistic regression analysis, falls were statistically significantly predicted from FRIED Phenotype (pre-frail vs non-frail) χ2(5)=63.918, p<0.001, Nagelkerke R Squared=0.68. CONCLUSIONS: Higher levels of vitamins B12 but not of D3 are associated with better balance but not with less falls in a sample of community-dwelling older people.

Outcome Predictors in Civilian and Iatrogenic Arterial Trauma.

BACKGROUND: Our aim was to identify predictors of mortality and limb loss in iatrogenic and civilian arterial trauma. METHODS: Cases were identified by searching prospectively maintained registries. Multivariable logistic regression was used to identify independent outcome predictors. RESULTS: During the study period, 285 patients with arterial trauma were managed with endovascular (n = 20) or open (n = 265) repair. Iatrogenic injuries increased in frequency during the course of the study, from 23.9% during the first decade to 35.9 and 55.7% during the second and third decade, respectively (p < 0.001). Endovascular management increased in frequency during the course of the study, from 0% during the first decade to 5.1 and 11.1% during the second and third decade, respectively (p = 0.005). Mortality was 9.8%, and limb loss (in cases with injury of the aorta or limb arteries, n = 259) was 6.2%. Independent predictors of mortality included increased age (odds ratio, 95% confidence interval [OR, 95% CI] 1.05 (1.02-1.07), p < 0.001), blunt trauma (OR [95% CI] 4.8 (1.9-12.2), p = 0.001) and the number of RBC units transfused intraoperatively (OR [95% CI] 1.25 (1.1-1.4), p = 0.001). Independent predictors of limb loss included the first half of the study period (OR [95% CI] 3.9 (1.1-14.1), p = 0.04), lower extremity arterial trauma (vs upper extremity, aortic, common or external iliac artery trauma, OR [95% CI] 8.3 (1.9-35.7), p = 0.004), bone fracture (OR [95% CI] 16.9 (4.7-62.5), p < 0.001) and the number of RBC units transfused intraoperatively (OR [95% CI] 1.16 (1.02-1.33), p = 0.024). CONCLUSION: Increasingly iatrogenic in cause and managed by endovascular methods, arterial trauma remains a problem associated with significant mortality and limb loss. Identification of unfavourable outcome predictors may help clinicians involved with arterial trauma to escalate the level of care.

Arthroscopic reduction and fixation of greater tuberosity fractures of the humerus.

BACKGROUND: The optimal technique for the displaced greater tuberosity (GT) fractures remains unclear; those in favor of arthroscopic techniques emphasize on the feasibility of arthroscopic reduction and fixation, while others report that anatomic reduction and osteosynthesis of the fracture are optimal through open surgery. Therefore, we performed this study to evaluate the clinical results of arthroscopic fixation for displaced and/or comminuted GT fractures using a bridging arthroscopic technique. MATERIALS AND METHODS: We studied the files of 11 patients (4 men, 7 women; mean age, 55 years; range, 28-74 years), with an isolated, displaced GT fracture treated with arthroscopic reduction and double-row suture anchor fixation technique from December 2016 to October 2018. All patients were operated at a mean time from their injury of 23 days (range, 1-85 days) using an arthroscopic technique. Any concomitant pathology that was arthroscopically identified was identified and repaired after arthroscopic fixation of the GT fracture. The mean follow-up was 12 months (range, 6-18 months). We evaluated pain using a 0-10 point visual analog scale (VAS), shoulder range of motion, fracture healing, Constant-Murley Shoulder Outcome Score, and patients' satisfaction from the operation. RESULTS: Postoperative radiographs showed anatomic reduction without any displacement of the GT fracture in eight patients and residual displacement of < 3 mm in three patients. All patients significantly improved in VAS score from 8.4 points (range, 7-10 points) preoperatively to 0.9 points (range, 0-3 points) postoperatively. Range of motion was 153 degrees forward flexion (range, 130-170 degrees), 149 degrees abduction (range, 120-170 degrees), 42 degrees external rotation (range, 20-70), and internal rotation between T10 and L3 spinal level. The final mean Constant-Murley Shoulder Outcome Score was 85.8 points (range, 76-94 points); correlation analysis showed that the patients with the higher greater tuberosity fracture displacement had the worst postoperative score (Pearson correlation coefficient -0,85; p = 0.0009), and the patients with nonanatomic reduction had close to average score. All patients were very satisfied with the end result of the operation, even the 3 patients with residual fracture displacement. No patient experienced any postoperative complications. CONCLUSIONS: Arthroscopic reduction and fixation of displaced GT fractures is a feasible minimally invasive procedure for optimal fracture healing and patients satisfaction.

Intraneural ganglion cysts of the peroneal nerve.

BACKGROUND: Intraneural ganglion cysts of the peroneal nerve are rare, and there is lack of evidence for the surgical management of this entity. We performed this study to evaluate the imaging, diagnosis, treatment and outcome of seven patients with intraneural ganglion cysts of the peroneal nerve. MATERIALS AND METHODS: We retrospectively studied the files of seven patients with intraneural ganglion cysts of the peroneal nerve, diagnosed and treated from 2016 to 2019. Diagnostic approach included clinical examination of the leg and foot, magnetic resonance imaging, nerve conduction studies, surgical excision of the cyst and histological examination. The mean follow-up was 2 years (range 1-3.5 years). We evaluated the time and methods for surgical treatment, and the clinical outcomes of the patients. RESULTS: All patients presented symptoms of peripheral compression neuropathy; three patients presented with foot drop. The intraneural ganglion cysts were excised in all cases in addition to knee articular nerve branch transection to avoid cysts recurrence. Postoperatively, all patients experienced complete neurological recovery without clinical evidence of intraneural ganglion cysts recurrences. CONCLUSION: The treating physicians should be aware of intraneural ganglion cysts of the peroneal nerve in patients presenting with limb weakness, sensory deficits at the lateral and anterior side of the leg and foot, paresis or paralysis of the foot and ankle. MR imaging is the imaging modality of choice for a clear and accurate preoperative diagnosis to avoid misdiagnosis and wrong treatment. In case of doubt, these patients should be managed in an orthopedic oncology setting with microsurgery facilities available for complete excision of the intraneural ganglion cyst.

Lateral arm flap: indications and techniques.

The lateral arm flap (LAF) is a popular flap transfer, which can be applied in many procedures. It was first described in 1982, and till then, even more clinical applications are suggested. It can be used as a free fasciocutaneous or fascial flap to cover small- to medium-sized soft tissue defects in head and neck but also in upper and lower extremity reconstruction, or as an osteocutaneous flap when vascularized bone graft is needed. We present the indications and contraindications, the advantages and disadvantages, as well as the step-by-step technique of harvesting a fasciocutaneous and an osteocutaneous flap and its complications. We conclude that the LAF is a reliable and versatile tool for reconstructive surgery, due to its anatomical characteristics and the low complication rate.

Microvascular reconstruction of pediatric lower extremity trauma using free tissue transfer.

While free tissue transfer has long been established as a reliable microsurgical technique in the adult population, its application in pediatric reconstruction is a relatively recent phenomenon. Despite initial concerns regarding minute vessel diameters, increased propensity for vasospasm, and limited tissue availability, pediatric free tissue transfer is now a widely used technique that has demonstrated an acceptable level of donor and recipient site morbidity in children. Five flaps commonly used in the reconstruction of lower extremity trauma are discussed in this paper: the latissimus dorsi, rectus abdominis, anterolateral thigh, gracilis, and the subscapular and parascapular flaps. The indications, blood supply, advantages, and disadvantages of each are detailed. Incredible progress has been made in the application of microsurgical techniques to the pediatric population over the last several decades. With a healthy understanding of the anatomy and functionality of the donor site, the reconstructive surgeon can repair a variety of complex injuries with an acceptable morbidity and mortality rate.

Reduction techniques for difficult subtrochanteric fractures.

Subtrochanteric fractures can result from high-energy trauma in young patients or from a fall or minor trauma in the elderly. Intramedullary nails are currently the most commonly used implants for the stabilization of these fractures. However, the anesthetic procedure for the patients, the surgical reduction and osteosynthesis for the fractures are challenging. The anesthetic management of orthopedic trauma patients should be based upon various parameters that must be evaluated before the implementation of any anesthetic technique. Surgery- and patient-related characteristics and possible comorbidities must be considered during the pre-anesthetic evaluation. Adequate fracture reduction and proper nail entry point are critical. Understanding of the deforming forces acting on various fracture patterns and knowledge of surgical reduction techniques are essential in obtaining successful outcomes. This article discusses the intraoperative reduction techniques for subtrochanteric fractures in adults and summarizes tips and tricks that the readers may find useful and educative.

The relationship between isokinetic strength and functional performance tests in patients with knee osteoarthritis.

[Purpose] The main purpose of the study was to examine the relationship of a battery of frequently used functional assessment tests with quadriceps and hamstrings isokinetic strength in Knee-osteoarthritis (OA) patients. Secondarily, the predictability of isokinetic strength on these performance variables was also assessed. [Subjects and Methods] Seventeen males and 23 females with Knee-OA, were assessed via a) the common functional tests: 6-minute walk test, Timed up-and-go test, 30-second chair test and 12-stair test and b) isokinetic concentric extension-flexion at 120°/s and 180°/s. [Results] Both Knee Extension and Flexion Peak Torque per Body weight showed moderate to strong, statistically significant correlation, with all 4-functional performance tests, for both velocities. Both 12-stair test and 30-second chair test were significant predictors in all analyses, while the 6-minute walk test was an additional significant predictor of the 120°/s knee flexion. [Conclusion] Thigh muscle strength in both tested velocities proved to be significantly correlated with functional performance. The 12-stair test and 30-second chair test results were significant predictors for isokinetic extension and flexion in both velocities. It appears that those two tests challenge the knee and the surrounding musculature in a manner that reflects muscle strength.

Posterior shoulder fracture-dislocation: an update with treatment algorithm.

Posterior shoulder fracture-dislocation is a rare injury accounting for approximately 0.9 % of shoulder fracture-dislocations. Impression fractures of the articular surface of the humeral head, followed by humeral neck fractures and fractures of the lesser and grater tuberosity, are the more common associated fractures. Multiple mechanisms have been implicated in the etiology of this traumatic entity most commonly resulting from forced muscle contraction as in epileptic seizures, electric shock or electroconvulsive therapy, major trauma such as motor vehicle accidents or other injuries involving axial loading of the arm, in an adducted, flexed and internally rotated position. Despite its' scarce appearance in daily clinical practice, posterior shoulder dislocation is of significant diagnostic and therapeutic interest because of its predilection for age groups of high functional demands (35-55 years old), in addition to high incidence of missed initial diagnosis ranging up to 79 % in some studies. Several treatment options have also been proposed to address this type of injury, ranging from non-surgical methods to humeral head reconstruction procedures or arthroplasty with no clear consensus over definitive treatment guidelines, reflecting the complexity of this injury in addition to the limited evidence provided by the literature. To enhance the literature, this article aims to present the current concepts for the diagnosis, evaluation and treatment of the patients with posterior fracture-dislocation shoulder, and to present a treatment algorithm based on the literature review and our own experience.

Tumors of the hand.

Tumors of the hand comprise a vast array of lesions involving skin, soft tissue and bone. The majority of tumors in the hand are benign. Malignant tumors, although rare, do occur and frequently have unique characteristics in this specific anatomic location. Careful staging, histological diagnosis and treatment are essential to optimize clinical outcome. However, straightforward most of the time, hand tumor management does have pitfalls; caution is advised, as a missed or delayed diagnosis or an improperly executed biopsy may have devastating consequences. This article reviews the clinical spectrum of the most common benign and malignant bone and soft tissue tumors of the hand and discusses the clinicopathological findings, imaging features and current concepts in treatment for these tumors.

Low-energy femoral shaft fractures after long-term alendronate therapy: report of seven cases.

BACKGROUND: There is increasing evidence suggesting a high incidence of low-energy fractures of the diaphysis or the proximal femur in patients receiving bisphosphonates for a long time. Bisphosphonate-related femoral fractures occur after low-energy trauma and have a typical simple transverse or oblique radiographic pattern, with focal or generalized increased cortical thickness, cortical beaking, and medial spiking. MATERIALS AND METHODS: This article presents six female patients who experienced seven transverse femoral diaphysis and subtrochanteric fractures with cortical thickening and beaking; all patients had alendronate treatment for 4-10 years (average, 9 years) before their fracture. RESULTS: The typical radiographic findings, long-term administration of alendronate, low-energy mechanism of fracture, and related literature support the fact that the fractures in the patients presented in this series should be related to alendronate treatment. CONCLUSION: Until definite evidence is available, alendronate treatment in patients with osteoporosis is not now prohibited by the healthcare authorities, probably because its beneficial influence outweighs the adverse effects. However, this adverse effect deserves attention of medical practitioners; physicians should be alert on alendronate's possible suppressive effect on bone turnover, which in turn may be responsible for the occurrence of femoral fractures.

Ultrasound-guided anterior axilla musculocutaneous nerve block.

PURPOSE: This paper presents a technique of ultrasound-guided localisation and block of the musculocutaneous nerve through the anterior wall of the axilla. MATERIALS AND METHODS: Twenty patients (7 males and 13 females; mean age, 35 years) had axillary nerve block for upper extremity trauma. With the arm adducted, the ultrasound probe was positioned on the anterior axillary wall; the axillary artery, coracobrachialis and pectoralis major muscles and lateral cord of brachial plexus were visualised in cross section. With continuous imaging of the axillary artery in cross section, the ultrasound probe was slowly moved towards the biceps muscle until the musculocutaneous nerve appeared crossing the coracobrachialis muscle. After ultrasound localisation of the musculocutaneous nerve, the arm was abducted and externally rotated, and the nerve was identified with nerve stimulation and blocked. The quality of sensory and motor nerve block, as well as of ultrasound imaging were evaluated. RESULTS: Ultrasound-guided block of the musculocutaneous nerve was excellent and complete in 18 of the 20 patients. In two patients, the musculocutaneous nerve was fused with the median nerve and the nerve block was repeated successfully with the same technique. The quality of ultrasound imaging was excellent in all patients. No patient experienced pain or tourniquet discomfort during surgery, or any other nerve block-related complication. CONCLUSION: The anterior axillary ultrasound view provides for complete nerve block and imaging of the entire course of the musculocutaneous nerve and its relations with adjacent structures with excellent quality.

Ball-joint versus single monolateral external fixators for definitive treatment of tibial shaft fractures.

PURPOSE: To compare modular monolateral external fixators with single monolateral external fixators for the treatment of open and complex tibial shaft fractures, to determine the optimal construct for fracture union. MATERIALS AND METHODS: A total of 223 tibial shaft fractures in 212 patients were treated with a monolateral external fixator from 2005 to 2011; 112 fractures were treated with a modular external fixator with ball-joints (group A), and 111 fractures were treated with a single external fixator without ball-joints (group B). The mean follow-up was 2.9 years. We retrospectively evaluated the operative time for fracture reduction with the external fixator, pain and range of motion of the knee and ankle joints, time to union, rate of malunion, reoperations and revisions of the external fixators, and complications. RESULTS: The time for fracture reduction was statistically higher in group B; the rate of union was statistically higher in group B; the rate of nonunion was statistically higher in group A; the mean time to union was statistically higher in group A; the rate of reoperations was statistically higher in group A; and the rate of revision of the external fixator was statistically higher in group A. Pain, range of motion of the knee and ankle joints, rates of delayed union, malunion and complications were similar. CONCLUSION: Although modular external fixators are associated with faster intraoperative fracture reduction with the external fixator, single external fixators are associated with significantly better rates of union and reoperations; the rates of delayed union, malunion and complications are similar.

Acrometastases.

Metastases distal to the elbow and the knee (acrometastases) are rare, accounting for approximately 0.1 % of all cases. Acrometastases can appear in patients of every age, with men being twice as likely as women to be affected. The most common primary cancer site is the lung (>50 %), followed by the colon, breast and genito-urinary tract. They mainly appear in cancer patients with wide-spread disseminated disease. Rarely, they may be the first presentation of occult silent cancer, mimicking a benign condition. Current evidence supports that the tumor cells reach the bones of the hands through the circulation and not the lymphatic system; the malignant cells from the lungs have an easy access through the arterial circulation of the arms. The rare incidence of foot acrometastases is believed to be due to the lack of red marrow in these bones, a further distance from the primary cancer site, and the valveless paravertebral venous plexuses (Batson's plexuses), which allow retrograde tumor cell embolization through the iliofemoral venous system. Treatment depends on staging and tumor extent. Amputative surgery is the more common approach, especially for cancers with poor response to radiation therapy and chemotherapy. In the majority of cases, disarticulation of the ray is required to achieve wide margin resection. In the foot, amputation can be that of a ray, midfoot or transtibial, depending on the location and spread of the tumor. If unresectable, palliative treatment with radiation therapy, bisphosphonates and chemotherapy is recommended. The prognosis of the patients with acrometastatic cancer is poor; the mean survival time after diagnosis is <6 months. An exception seems to be the patients with renal cell carcinoma, if treated with radical surgical resection, and a long latency period between nephrectomy and metastasis has occurred.

When and how to operate on thoracic and lumbar spine fractures?

PURPOSE: To discuss when and how to operate on thoracic and lumbar spine fractures. PATIENTS AND METHODS: We retrospectively studied 77 consecutive patients with thoracic and lumbar spine fractures treated from 2000 to 2011; 28 patients experienced high-energy spinal trauma and 49 low-energy spinal trauma. Mean follow-up was 5 years (1-11 years). Surgical treatment was done in 15 patients with neurological deficits, and in 16 neurologically intact patients with fractures-dislocations, burst fractures and fractures with marked deformity. Non-surgical treatment was done in 46 neurologically intact patients with simple fracture configurations. Clinical and imaging examination and the Oswestry Disability Index (O.D.I.) questionnaire were obtained. RESULTS: All patients treated surgically maintained spinal alignment; patients with long fusion maintained the best alignment; however, they experienced back stiffness and moderate low back pain. Patients with combined posterior fusion and kyphoplasty experienced earlier recovery and improved sagittal correction. Mean O.D.I. was 22.4 and 14.2% at 3 and 12 months postoperatively. Thirty six (78%) patients treated non-surgically were asymptomatic, 22 (48%) experienced mild residual kyphosis, 10 (22 %) developed marked deformity during their follow-up and were finally operated; mean O.D.I. was 28.6 and 12.1% at 3 and 12 months. No difference in O.D.I. was observed between patients who had surgical and non-surgical treatment. CONCLUSIONS: Progressive neurological deficits and/or mechanical instability of the spine are absolute indications for early surgical treatment. Younger patients with high-energy spinal trauma, unstable fractures and neurological deficits should be treated surgically in order to provide optimum conditions for neurologic recovery, early mobilization and possibly ambulation. Most cases can be adequately operated through a posterior only surgical approach; an anterior or combined approach is usually indicated for burst and thoracic spine fractures. Postoperative complications, more common infection and neurological deterioration may occur. Elderly, neurologically intact patients with low-energy, stable spinal fractures without marked spinal deformity may be successfully treated conservatively. Most of these patients will do well; however, follow-up for progressive posttraumatic deformity is required.

Neglected Bicondylar Fracture of the Distal Humerus Treated With Total Elbow Arthroplasty.

A 69-year-old woman suffered a distal humerus fracture including the medial and lateral condyles. She received conservative treatment with a posterior arm splint at a local healthcare center where she was evaluated by a non-specialist physician. Eight months later, she presented to our department complaining about severe instability. An upper limb specialist examined the patient at the time, and after thoroughly explaining the condition, he suggested a surgical approach with total elbow arthroplasty (TEA), which was then performed. At the one-year follow-up, the patient had a full range of motion without any complications or pain complaints. TEA in neglected fractures of the distal humerus is a poorly researched topic in the field of upper limb surgery with only scarce literature available. In this case report, we present the excellent outcomes of the procedure performed on an elderly patient after non-union regaining her quality of life and suggest that TEA can be a viable solution in elderly patients with complicated or non-united elbow fractures.

Capitate Proximal Fragment Migration Compressing the Median Nerve in Scaphocapitate Fracture: A Case Report.

BACKGROUND Scaphocapitate syndrome is a rare clinical entity consisting of a combined scaphoid and capitate fracture along with a 90- or 180-degrees rotation of the proximal capitate fragment. The syndrome is scarcely described in the literature, with proximal migration of the capitate fragment being reported only by Mudgal et al in 1995. Concurrent compression of the median nerve is a highly unfortunate event, suggesting a unique case presented here. CASE REPORT We present a unique case of scaphocapitate fracture-dislocation in a 25-year-old man with volar dislocation of the capitate's fragment deep to the median nerve. X-rays and CT scan were performed and the patient was treated few hours after the injury by a hand specialist, in order to prevent median neuropathy and avascular necrosis of the fragment. Open reduction and internal fixation utilizing a Herbert screw for the scaphoid fracture and 3 additional K-wires was performed. Immediately post-operatively, the acute neurological symptoms had subsided and good reduction was acquired radiologically. One year post-operatively the patient had regained good hand and wrist functionality, with no extension or flexion ROM deficits. CONCLUSIONS Immediate intervention in a specialized center with reduction and fixation utilizing a Herbert screw and K-wires showed favorable 1-year results in our case of scaphocapitate syndrome. The impending complications of median neuropathy and capitate avascular necrosis were avoided despite the high-risk injury pattern.

Pigmented Villonodular Synovitis of the Shoulder: A Case Report and Literature Review.

BACKGROUND Pigmented villonodular synovitis is a rare clinical entity, with 2-3% of all PVNS cases affecting the shoulder. Diagnosis is challenging and can elude clinicians for years, with definitive treatment involving arthroscopic or open synovectomy. CASE REPORT A 50-year-old woman presented with left shoulder pain persisting for 2 years. She was initially conservatively treated by a rheumatologist, with corticosteroid schemes intra-articularly injected and per os, but no improvement of her symptoms was noted. Two years later, she was referred to the Orthopedics Department of our hospital with constant pain in her left shoulder, refractory to the conservative measures. Physical examination revealed tenderness of her shoulder on palpation and limited range of motion. The diagnosis of PVNS was established by preoperative magnetic resonance arthrography (MRA) and confirmed by biopsy from intra-operative tissue sampling. Arthroscopic debridement and synovectomy were performed, yielding good surgical results, and she now reports pain relief, improved function, and no recurrence of symptoms at 1-year follow-up. CONCLUSIONS The diagnosis of PVNS can be elusive for years. MRI and clinical suspicion along with tissue biopsy can set the diagnosis. Shoulder PVNS follows a similar natural history as knee PVNS, with conservative treatment failing and arthroscopic excision providing definite relief. We report a rare case of shoulder PVNS, underscoring the importance of considering PVNS in cases of shoulder pain refractory to conservative treatment.

Double approach operation for large extracompartmental proximal thigh tumors.

Resection of large femoral triangle tumors that invade the bone (or vice versa) still remains a challenge. A lateral-only approach would hinder dissection of the mass, away from the femoral vessels, while an iliofemoral-only type of approach would make bone resection and megaprosthetic reconstruction very arduous. The authors describe a two-stage, one-position operation via a double surgical approach: the first stage is comprised by an iliofemoral approach and dissection of the femoral vessels, followed by proximal femoral resection and reconstruction stage. One illustrative case is presented along with the authors overall experience. We believe that this operation facilitates wide tumor resection in a safe and step-wise manner, as not to add to the morbidity of the procedure.