Results and Outcomes of Combined Cross Screw and Ilizarov External Fixator Frame in Ankle Fusion.

Ankle fusion is a treatment option for end-stage ankle arthritis. Fusion site stability and optimal foot positioning are crucial parameters. We present the results of our double fixation technique, combining both cross-screw fixation and Ilizarov external fixator frame via transmalleolar approach. We reviewed the files from 52 patients operated for ankle fusion in our center. In our technique, we use a transmalleolar approach, initial stabilization with 2 cannulated, half-threaded cross screws, and final stabilization with an Ilizarov external fixator frame. Fusion stability, weightbearing time, complication rates, and final functional scores were recorded and evaluated. Mean frame removal time was 11.2 ± 2.1 weeks, and 71.6% of patients were fully weightbearing at that time. Absolute fusion stability was reported in 88.46% of patients at that time, while no pseudarthrosis was noted in final follow-up at 12 months. According to the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot-ankle score evaluation at 12 months, 90.4% of patients reported excellent and 9.6% good results. None of the patients was referred for symptomatic forefoot arthritis, and there were no cases of deep infection or deep vein thrombosis. Material-related complications were reported in 1 patient who was treated with implant removal after 1 year. Ankle fusion is a salvage procedure that offers optimal results in end-stage ankle arthritis. Our technique offers absolute fusion site stability with excellent functional results, minor complications, and the advantages of early protected weightbearing. Careful patient selection in addition to fine foot positioning should be regarded as crucial for the final outcome.

Similar thromboprophylaxis with rivaroxaban and low molecular weight heparin but fewer hemorrhagic complications with combined intra-articular and intravenous tranexamic acid in total knee arthroplasty.

PURPOSE: To evaluate the efficacy of the combined intravenous and intra-articular administration of tranexamic acid (TXA) to control the collateral effects and complications of rivaroxaban (RIV) after total knee arthroplasty (TKA) and to compare thromboprophylaxis schemes with and without TXA, RIV and low molecular weight heparin (LMWH). MATERIALS AND METHODS: We prospectively studied 158 TKA patients from 2014 to 2018. The patients were randomly assigned into three groups. Group A (46 patients) was administered intravenous and intra-articular TXA and RIV postoperatively; group B (58 patients) was administered TXA as in group A and LMWH postoperatively; and group C (54 patients) was administered saline as in group A and RIV postoperatively. We evaluated blood loss, transfusion requirements and hemorrhagic complications. RESULTS: Hct and Hb values significantly decreased in group C compared to groups A and B, without any difference between groups A and B. Suction drain blood volume output was significantly higher in group C compared to group A and B, without any difference between group A and B. Hemorrhagic complications were more common in group C. No patient experienced clinical findings of VTE. CONCLUSION: Combined intravenous and intra-articular administration of TXA is safe and effective in TKA, with fewer hemorrhagic complications compared to placebo. Thromboprophylaxis with RIV and LMWH is similar.

Biologic treatment of mild and moderate intervertebral disc degeneration.

Disc degeneration is the most common cause of back pain in adults and has enormous socioeconomic implications. Conservative management is ineffective in most cases, and results of surgical treatment have not yet reached desirable standards. Biologic treatment options are an alternative to the above conventional management and have become very attractive in recent years. The present review highlights the currently available biologic treatment options in mild and moderate disc degeneration, where a potential for regeneration still exists. Biologic treatment options include protein-based and cell-based therapies. Protein-based therapies involve administration of biologic factors into the intervertebral disc to enhance matrix synthesis, delay degeneration or impede inflammation. These factors can be delivered by an intradiscal injection, alone or in combination with cells or tissue scaffolds and by gene therapy. Cell-based therapies comprise treatment strategies that aim to either replace necrotic or apoptotic cells, or minimize cell death. Cell-based therapies are more appropriate in moderate stages of degenerated disc disease, when cell population is diminished; therefore, the effect of administration of growth factors would be insufficient. Although clinical application of biologic treatments is far from being an everyday practice, the existing studies demonstrate promising results that will allow the future design of more sophisticated methods of biologic intervention to treat intervertebral disc degeneration.

Papineau debridement, Ilizarov bone transport, and negative-pressure wound closure for septic bone defects of the tibia.

PURPOSE: Ilizarov pioneered bone transport using a circular external fixator. Papineau described a staged technique for the treatment for infected pseudarthrosis of the long bones. This article presents a single-stage Papineau technique and Ilizarov bone transport, and postoperative negative-pressure wound dressing changes for septic bone defects of the tibia. MATERIALS AND METHODS: We studied the files of seven patients (mean age, 32 years) with septic bone defects of the tibia treated with a Papineau technique and Ilizarov bone transport in a single stage, followed by postoperative negative-pressure wound dressing changes. All patients had septic pseudarthrosis and skin necrosis of the tibia. The technique included a single-stage extensive surgical debridement of necrotic bone, open bone grafting with cancellous bone autograft and bone transport, and postoperative negative-pressure wound dressing changes for wound closure. The mean time from the initial injury was 6 months (range, 4-8 months). The mean follow-up was 14 months (range, 10-17 months). RESULTS: All patients experienced successful wound healing at a mean of 29 days. Six patients experienced successful bone regeneration and union at the docking side at a mean of 6 months. One patient experienced delayed union at the docking site, which was treated with autologous cancellous bone grafting. Two patients experienced pin track infection, which was successfully treated with antibiotics and pin site dressing changes. All patients were able to return to their work and previous levels of activity, except one patient who had a stiff ankle joint and had to change his job. No patient experienced recurrence of infection, or fracture of the regenerated or transported bone segment until the period of this study. CONCLUSION: The combined Papineau and Ilizarov bone transport technique with negative-pressure wound closure provides for successful eradication of the infection, reconstruction of the bone defect, and soft-tissue closure. A single-stage surgical treatment is feasible, without any complications.

PEEK rod systems for the spine.

Traditional materials for the spine such as titanium and stainless steel have produced satisfying long-term fusion rates, mainly due to their strength and stiffness. However, although fixation with titanium rods leads to high fusion rates, increased stiffness of titanium constructs may also contribute to stress shielding and adjacent segment degeneration. Dynamic and flexible materials such as the Dynesys system allow better stress distribution to all of the spinal columns, but increase the rate of complications including screw loosening, infection, back and leg pain, and endplate vertebral fracture. Semi-rigid instrumentation systems using rods made from synthetic polymers such as the polyetheretherketone (PEEK) have been recently introduced as an alternative biomaterial for the spine. PEEK is a fully biocompatible and inert semi-crystalline thermoplastic polymer with minimal toxicity; it has a modulus of elasticity between that of cortical and cancellous bone, and significantly lower than titanium. However, there are very few clinical studies with small sample size and short-term follow-up using PEEK rod-pedicle screw spinal instrumentation systems. Additionally, their results are conflicting. To enhance the literature, this review discusses the effect of this medical for the spine and summarizes the results of the most important related series.

The Radiological Anatomy of the Distal Tibiofibular Joint: A Retrospective Computed Tomography Study.

Introduction Distal tibiofibular joint (DTFJ) injuries are commonly encountered in patients with ankle fractures. Achieving optimal fixation is mandatory, but it requires a thorough understanding of the local anatomical relationships. For this reason, we performed a retrospective CT study in healthy ankles to radiologically describe the normal anatomy of the DTFJ and the anatomical relationship of the fibula within the ankle joint. Materials and methods For this study, we retrospectively examined 60 CT scans of healthy, non-injured ankles in a plantigrade position. Patients with prior ankle surgery or systemic diseases with ankle involvement were excluded because we needed to describe the normal anatomy of the joint. The radiological evaluation included the position of the fibula in the fibular notch and the rotational relationship of the fibula with the talus and the medial malleolus. Results Our study included 60 healthy ankles. Thirty-three were right ankles, and 27 were left. The cohort included 36 females and 24 males with a mean age of 48.3 years old. We found that the fibular notch was retroverted on the transverse plane, with the tibiofibular engagement being 0.11 mm (SD=1.57 mm, SE=0.2 mm), at 1 cm proximally to the tibial plafond. Additionally, we observed that the fibula was internally rotated against the lateral talar facet, while the medial and lateral malleolus facets were externally rotated in between. Moreover, we found a strong positive correlation between the incisura retroversion and fibular engagement at 1 cm above the tibial plafond line (Pearson correlation=0.273, p=0.03). Conclusion Our study highlights the importance of gaining a comprehensive understanding of the inherent anatomy of the DTFJ to achieve reduction goals in ankle fractures. According to our results, in ankle fracture treatment, surgeons should aim for anatomical fracture and syndesmotic fixation, with the fibula in internal rotation against the lateral talar facet. Additionally, as normal tibiofibular engagement is borderline, we do not suggest that over-tightening the syndesmotic screws is essential. This study's findings can aid surgeons in reducing the malreduction rates in patients with ankle fractures.

Electrical Stimulation and Motor Function Rehabilitation in Spinal Cord Injury: A Systematic Review.

Spinal cord injury (SCI) often leads to devastating motor impairments, significantly affecting the quality of life of affected individuals. Over the last decades, spinal cord electrical stimulation seems to have encouraging effects on the motor recovery of impacted patients. This review aimed to identify clinical trials focused on motor function recovery through the application of epidural electrical stimulation, transcutaneous electrical stimulation, and functional electrical stimulation. Several clinical trials met these criteria, focusing on the impact of the aforementioned interventions on walking, standing, swimming, trunk stability, and upper extremity functionality, particularly grasp. After a thorough PubMed online database research, 37 clinical trials were included in this review, with a total of 192 patients. Many of them appeared to have an improvement in function, either clinically assessed or recorded through electromyography. This review outlines the various ways electrical stimulation techniques can aid in the motor recovery of SCI patients. It stresses the ongoing need for medical research to refine these techniques and ultimately enhance rehabilitation results in clinical settings.

The Effect of PRP Augmentation of Arthroscopic Repairs of Shoulder Rotator Cuff Tears on Postoperative Clinical Scores and Retear Rates: A Systematic Review and Meta-Analysis.

The aim of this review and meta-analysis is to assess recent clinical trials concerning the combination of operative treatment of rotator cuff tears and the administration of PRP and its effect on clinical scores and postoperative retear rates. The trials were used to compare the combination of PRP treatment and arthroscopic rotator cuff repair to arthroscopy alone. Twenty-five clinical trials were reviewed. A risk-of-bias assessment was made for all randomized clinical trials included, using the Cochrane collaboration's tool as well as a quality assessment for all non-randomized studies utilizing the Newcastle−Ottawa scale. The PRP-treated patients showed statistically significant improvement postoperatively compared to control groups concerning the Constant−Murley (mean difference 2.46, 95% CI 1.4−3.52, p < 0.00001), SST (mean difference 0.32, 95% CI 0.02−0.63, p = 0.04), and UCLA (mean difference 0.82, 95% CI 0.23−1.43, p = 0.07) scores. A statistically significant decrease of retear rates in the PRP-treated patients, with a risk ratio of 0.78 (95% CI 0.65−0.94, p = 0.01), was found. We believe that the results presented have positive aspects, especially concerning the retear risk, but are yet inconclusive concerning clinical results such as shoulder pain and function.

Elastic Reconstruction of Chronic Instability of the Distal Tibiofibular Joint in an Obese Patient: A Case Report.

An active, obese young patient was admitted to our clinic complaining of chronic ankle pain after fixation of his lateral malleolus fracture. His symptoms consisted of intermittent pain after prolonged walking, swelling, and feeling of instability. His clinical and radiological evaluations indicated chronic mechanical instability of his distal tibiofibular syndesmosis that remained unresponsive to conservative treatment. Considering his age and activity level, we proceeded to a global syndesmotic reconstruction of the three major syndesmotic ligaments with split-thickness peroneus longus graft. According to this technique, the graft was passed through specific tibiofibular tunnels restoring the native stability and elasticity of the region. The patient had an optimal postoperative function, with diminished symptoms and increased clinical scores. His late radiological evaluation revealed an anatomic ankle reduction with restoring his normal syndesmotic anatomy compared to his contralateral limb. Regardless of his high BMI, we noticed no further subluxation of his talus, while his general symptomatology was unremarkable at the 12-month follow-up. In conclusion, elastic reconstruction of the distal tibiofibular joint with split-thickness peroneus longus graft provides excellent results at 12 months regardless of the patient's BMI. To our knowledge, this is the only technique that restores the three main regional ligaments, simultaneously allowing for close-to-normal biomechanics and providing excellent short-term clinical outcomes.

Bone Mineral Density Post a Spinal Cord Injury: A Review of the Current Literature Guidelines.

BACKGROUND: Spinal cord injury (SCI) causes rapid osteoporosis below the level of injury in a multi-factorial manner. This literature review focused on the early diagnosis of low bone mass (LBM) in SCI patients and aimed to summarize all the available recent data on the diagnosis and treatment of osteoporosis in this unique patient population.  Materials and Methods: Advanced literature research was conducted in the online PubMed database using the keywords 'bone mineral density, 'spinal cord injury, 'skeletal fragility', and 'osteoporotic fractures'. Out of the initial 430 articles, duplicates were removed and the remaining studies were assessed for eligibility. Two reviewers independently extracted data from each study and assessed variable reporting of outcome data. The exclusion criteria were: studies not measuring bone mineral density (BMD), studies comparing SCI to other diseases, animal studies, molecular studies, studies including children, and studies not written in English. The 83 remaining papers were divided into studies focusing on treatment and studies investigating LBM in SCI. Following this step, studies with small patient samples set at 20 patients with SCI for the treatment group and 30 patients for the diagnosis of the LBM group, were also excluded. RESULTS: In the remaining 32 studies, 18 focused on the diagnosis of LBM in SCI and 14 focused on the various treatment options to address this phenomenon. Most of these studies (n=13) used the dual-energy X-ray absorptiometry (DXA) method to evaluate bone mass while five studies preferred quantitative computed tomography (QCT) measurements and one evaluated LBM using calcaneal qualitative ultrasound. In the treatment group of studies, seven papers administered medication to address LBM and four clinical protocols used physiotherapy methods to reduce bone loss post-SCI while three studies combined medical treatment with physiotherapy. CONCLUSION: The unawareness of the unique mechanism through which bone is rapidly lost in the first months post-SCI led to initial scientific confusion. In this review, we summarize information to increase physicians' awareness of the dangers of 'silent' osteoporosis progression post-SCI. We have also provided information on the best timing to evaluate bone loss as well as treatment options that could prevent fragility fractures in this population.

The Role of Sclerostin in Bone Diseases.

Sclerostin has been identified as an important regulator of bone homeostasis through inhibition of the canonical Wnt-signaling pathway, and it is involved in the pathogenesis of many different skeletal diseases. Many studies have been published in the last few years regarding sclerostin's origin, regulation, and mechanism of action. The ongoing research emphasizes the potential therapeutic implications of sclerostin in many pathological conditions with or without skeletal involvement. Antisclerostin antibodies have recently been approved for the treatment of osteoporosis, and several animal studies and clinical trials are currently under way to evaluate the effectiveness of antisclerostin antibodies in the treatment of other than osteoporosis skeletal disorders and cancer with promising results. Understanding the exact role of sclerostin may lead to new therapeutic approaches for the treatment of skeletal disorders.

A Systematic Review of the Diagnosis and Treatment of Non-Typhoid Salmonella Spondylodiscitis in Immunocompetent Children.

The aim of this systematic review is to distinguish the clinical features of immunocompetent children with non-typhoid Salmonella spondylodiscitis and summarize the diagnosis, diagnostic tools, and treatment methods to guide clinicians. The review was conducted according to the preferred PRISMA guidelines. We conducted a literature search in the PubMed, Embase, and Cochrane Library databases. Article screening, data extraction, and study evaluation were performed by two independent reviewers. A total of 20 articles, published between 1977 and 2020, were selected, which included 21 patients with average age of 12.76 years (range, 2-18) without comorbidities; in total, 19% of the patients had positive blood cultures for non-typhoid Salmonella, and 80.9% underwent either CT-guided or open biopsy, which were positive for NTS. All infections were monomicrobial, and 11 different serotypes of non-typhoid Salmonella were identified. Analyzing the reviewed cases, 52.4% of the patients presented with fever, 90.5% had localized pain, and only 19% had gastroenteritis. The most common level of discitis was the lumbar region, especially the L4/L5 level. Primarily, third-generation cephalosporin was administered, and antibiotic treatment was given for an average of 9.6 weeks. Non-typhoid Salmonella spondylodiscitis is a rare clinical entity in healthy and immunocompetent children. The identification of the responsible organism is essential to guide antibiotic therapy and define the treatment duration. A significant limiting factor in this systematic review was the lack of published research articles and case series due to the rarity of the disease.

Angiogenesis in Spinal Cord Injury: Progress and Treatment.

Traumatic spinal cord injury (SCI) provokes the onset of an intricate pathological process. Initial primary injury ruptures local micro-neuro-vascularcomplex triggering the commencement of multi-factorial secondary sequences which exert significant influence on neurological deterioration progress. Stimulating by local ischemia, neovascularization pathways emerge to provide neuroprotection and improve functional recovery. Although angiogenetic processes are prompted, newly formed vascular system is frequently inadequate to distribute sufficient blood supply and improve axonal recovery. Several treatment interventions have been endeavored to achieve the optimal conditions in SCI microenvironment, enhancing angiogenesis and improve functional recovery. In this study we review the revascularization pathogenesis and importance within the secondary processes and condense the proangiogenic influence of several angiogenetic-targeted treatment interventions.

Enlarged Reactional Periostitis of the Peroneal Tubercle Mimicking Osteochondromatosis of the Calcaneus: A Case Report.

Foot and ankle tumors are relatively rare. Nevertheless, the calcaneus is a prevalent location accommodating various lesions. Reactional periostitis of the lateral wall is rarely encountered but can potentially mimic a wide variety of tumors. We present a case of excessive proliferation due to chronic compression of the peroneal tendons against the calcaneus in a female patient with a history of diminished foot control, treated successfully by tumor excision and peroneal restoration via the tubularization technique. This study aimed to underline the mimicking potential of reactional periostitis and its effect on the peroneal tendons and hindfoot motion.

Application of Collagen-Based Scaffolds for the Treatment of Spinal Cord Injuries in Animal Models: A Literature Update.

SCI is regarded as one of the most devastating central nervous system (CNS) injuries, exhibiting an alarmingly rising incidence rate, indirectly connected with the expansion of the global economy. The consequences of SCI are multidimensional: SCI injuries may result in permanent voluntary motor dysfunction and loss of sensation while incurring heavy economic and psychological burdens as part of the treatment. Thus, it is crucial to develop effective and suitable SCI treatment strategies. Collagen-based scaffold application is one of the most promising methods of SCI treatment. This review compiles newer bibliographical data regarding the application of collagen scaffolds for the treatment of Spinal cord injury (SCI) in animal models. Recently, several relevant studies have been carried out using carefully selected animals with similar pathophysiology to humans. In mouse, rat and canine models that have undergone transection or hemisection, the stump connection, the transplanted cell differentiation, and the elimination of glial scar are promising. Also, encouraging results have been found regarding the increased neuronal growth, the decreased collagen deposition, the behavioral recovery, the improved electrophysiology, and the enhanced axonal regeneration.

Functional outcome and complications using the intramedullary hip screw for intertrochanteric fractures.

We prospectively studied 110 consecutive patients with intertrochanteric hip fractures treated with the 130 degree angle, 10-mm short IMHS intramedullary hip screw (IMHS, Smith & Nephew, Richards, Memphis, TN). Surgery was performed within 36 hours from admission; all patients were mobilized immediately postoperatively. Fracture union, pre- and post-operative mobility status and complications were evaluated. Eighty patients were included in the postoperative evaluation for a mean followup of 14 (range, 9 to 25) months. Mortality was 19%. Union occurred in 79 fractures within 6 months from surgery; there was one case of screw cut-out and one case of deep venous thrombosis. Periprosthetic femoral shaft fractures were not observed. At the latest examination, the mean mobility score decreased from 8.4 +/- 1.6 to 7.1 +/- 2.1 (p = 0.0001); 26 patients (32%) fully achieved the preoperative mobility score and 54 patients (68%) achieved more than 90% of the preoperative mobility score. The IMHS intramedullary hip screw represents a reliable method for the treatment of patients with intertrochanteric hip fractures, and provides for early mobilization and rehabilitation of the patients with acceptable complications.

Orthopedic Implant-Related Biofilm Pathophysiology: A Review of the Literature.

Orthopedic implant-related infections remain a major problem even nowadays. Bacterial resistance through biofilm formation, in addition to the limited treatment options available, has resulted in an increased effort to better understand pathophysiology mechanisms. We performed a review of the literature in order to identify major biofilm formation pathways through which possible treatment strategies could arise.

Chronic Undiagnosed Brucellosis Presenting as Sciatica.

Brucellosis is a common zoonotic disease in southern Europe. Although having the potential to harm several anatomic regions and systems, musculoskeletal manifestations are rare, usually involving the spine and the sacroiliac joints. In the literature, the reports of hip manifestations are sporadic. We present a case report of chronic, undiagnosed brucellosis indirectly affecting the hip joint. A 51-years-old male patient was admitted to our department with acute onset sciatica. His medical history was remarkable for incomplete cauda equina syndrome of unknown etiology and concomitant dura mater disruption, creating local sinuses resulting at the right buttock. On radiological evaluation, we demonstrated multiple abscesses of the lower lumbar spine and the ipsilateral sacroiliac joint, along with sinuses communicating with the right hip joint capsule. Soft and osseous tissue cultures obtained from the area of the lesion were negative for common bacteria. Considering the patient's history, chronicity of the disease, and the lesional pattern, we suspected brucellosis as a possible etiological factor. Laboratory evaluation with the serum agglutination test confirmed the diagnosis. The patient denied the surgical treatment, so we proceeded with chronic suppression antibiotics schemes. On 12-month follow-up, the patient has no clinical signs of infection relapse; he has reasonable pain control and a normal gait. Indirect hip infection due to chronic brucellosis is rare, and physicians should be very suspicious of the disease's characteristic radiological manifestations to reach a correct diagnosis.

Sclerostin and Its Involvement in the Pathogenesis of Idiopathic Scoliosis.

Idiopathic scoliosis is a disorder of unknown etiology. Bone biopsies from idiopathic scoliosis patients revealed changes at cellular and molecular level. Osteocytic sclerostin is downregulated, and serum level of sclerostin is decreased. Osteocytes in idiopathic scoliosis appear to be less active with abnormal canaliculi network. Differentiation of osteoblasts to osteocytes is decelerated, while Wnt/ß-catenin signaling pathway is overactivated and affects normal bone mineralization that leads to inferior mechanical properties of the bone, which becomes susceptible to asymmetrical forces and causes deformity of the spinal column. Targeting bone metabolism during growth by stimulating sclerostin secretion from osteocytes and restoring normal function of Wnt/ß-catenin signaling pathway could, in theory, increase bone strength and prevent deterioration of the scoliotic deformity.

One Year Later: What Was the Impact of the COVID-19 Pandemic on Orthopedic Practice?

The coronavirus disease 2019 (COVID-19) pandemic is an enormous challenge for health care systems worldwide. Although it is widely accepted that orthopedic service has been reduced during the COVID-19 pandemic, little is known about the magnitude and qualitative characteristics of this reduction. The aim of the present study is to quantify the impact of the COVID-19 pandemic on everyday orthopedic practice and to detect the qualitative details of this impact in order to provide data for appropriate planning of health care policy. Data from the year 2020, when the COVID-19 pandemic occurred, regarding the number of patients examined in the emergency department, outpatient clinics, as well as the number of hospital admissions, were recorded for each month. The number of surgical procedures per month was also recorded and evaluated in relation to the category and the anatomical region that these procedures pertained to. Similar data from the year 2019 were used as a control group. The mean number of patients who visited the emergency department, the outpatient clinics, and those who were admitted to the hospital per month decreased by 47.2%, 30.4%, and 9%, respectively. Overall, the mean number of orthopedic operations decreased by 11.7%, with trauma operations being reduced by 8.9% and elective operations by 13% per month. Based on the findings of the present study, the impact of the COVID-19 pandemic on orthopedic patients is definitely negative. The establishment of new guidelines and re-distribution of resources is required to return to a normal function of orthopedic practice within hospitals.